Abstract
Contraceptives are among the most effective strategies to prevent unwanted pregnancies and their consequences. Understanding the intention to use contraceptives is crucial to implementing family planning; however, there is an evidence gap in the Gambia. Therefore, this study aimed to identify the intention to use contraceptives and determinants among married women in the Gambia. This study was based on an extensive national survey, the Gambian Demographic and Health Survey. A total weighted sample of 6085 married women of reproductive age was included. A logistic regression model was used, and a p-value of <0.05 for multivariable logistic regression with a 95% CI was used to declare statistical significance. The overall intention to use contraceptives was 29.72%. Age, education, region, occupation, wealth, family hearing from friends/relatives, family planning hearing from a health professional, ever use of contraceptives, number of children, visits by field workers, and number of visits to health facilities were significant factors associated with the intention to use contraceptives in the future. The proportion of women who have the intention to use contraceptives remains very low. The intention to use contraceptives was affected by numerous individual attributes. Therefore, efforts to increase the uptake of contraceptives should focus on improving education and economic opportunities for married women, particularly those have never used contraceptives. Policymakers and stakeholders should solicit the support of health facilities in designing contraceptive education programs, expanding through friends/relatives, health professionals, and making contraceptives freely accessible to all married Gambian women.
Plain Language Summary
Background: Contraceptives are the most effective strategies to prevent unwanted pregnancies and their consequences. Realizing the intention to use contraceptives is crucial to drafting and implementing a successful family planning program, however, there is an evidence gap in the Gambia.
Objective: This study aimed to identify determinants affecting womens intention to use contraceptives in the Gambia.
Method: This study was based on an extensive national survey, Gambian Demographic and Health Survey. A total weighted sample of 6,085 married reproductive-age women was included. A logistic regression model was used to study determinates that may influence intention to contraceptive use. A p-value of <0.25 for binary logistic regression with a 95% confidence interval and a p-value of less than 0.05 was used to declare statistical significance.
Results: The overall intention to use contraceptives was 29.72. Participants age range 25 to 34 years and 35 to 49 years, primary and secondary educational levels and, women from Basse region heard from friends/relatives and health professionals and ever use of contraceptive women who had 3 to 5, and six or more children have shown visited by field workers and health facilities richest women, and currently are determinate variables that was associated with intention to use contraceptive.
Conclusion: Nearly two-thirds of married women were not intended to use contraceptives. Intention to use contraceptives was affected by plenty of individual attributes. Thus, public health interventions mainly that could increase information dissemination regarding contraceptive education among the community and enhance contraceptive utilization rates are required at the national level to improve contraceptive utilization.
Introduction
Utilization of contraception is a major indicator of avoiding unintended births, lowering maternal and infant mortality, and enhancing the quality of life for women and their families (Cleland et al., 2006; Singh & Darroch, 2012). Likewise, it is leading the charge in the battle to achieve the Sustainable Development Goals (SDGs) by 2030 (Starbird et al., 2016).
In 2019, the United Nations (UN) reported that approximately 1.1 billion reproductive-age women needed to use contraceptive methods; however, around 270 million of them had faced the unmet need for contraceptive methods (Bongaarts, 2020). The SDG and the UN world family planning report indicated that the total rate of satisfaction of mothers in family planning (FP) is stopped at around 78%; nevertheless, due to several hindering factors, the rate of satisfaction in African regions has shown the lowest rate (56%) (United Nations, 2017).
In the present scientific fact, the world has reached consensus agreements regarding FP by reducing the number of women's exposure to pregnancies, limiting more than four births (Cleland et al., 2012; Stover & Ross, 2010), reducing unsafe abortion from unintended pregnancies (Bearak et al., 2018; Sedgh et al., 2016), declining newborn and infant mortality rates (Darroch et al., 2017), preventing the transmission of HIV/AIDS from the mother to the child by 93% (Singh et al., 2014), empowering mothers and girls by keeping them in school (United Nations Educational, Scientific and Cultural Organization, 2014), and improving adolescents’ reproductive health, social and economic wellbeing (Darroch et al., 2016). The task of FP is exponentially tricky and daunting in sub-Saharan Africa (SSA); hence, according to the World Bank project report, the number of populations in SSA has shown an increment of about ten times between 1990 and 2050 (Institute for Health Metrics and Evaluation (IHME), 2020). This, in turn, shows that population growth is fast in Africa (United Nations, 2020). The SSA has demonstrated a few declines from 6.3 to 4.6 births per woman from 1990 to 2019 (United Nations, 2020).
FP services have been provided free of charge in all public health facilities in Gambia since 1975. Despite this, the prevalence of contraception is declining among married women aged 15 to 49 years due to a variety of factors, including low educational attainment and religious barriers (The Gambia Bureau of Statistics (GBOS) & ICF International, 2014; Gambia Bureau of Statistics, 2021). The lower use of contraceptives has been attributed to several reasons, including side effects and fear of contraception (Barrow et al., 2021; Staveteig, 2017), culture and traditions (Kriel et al., 2019), resistance from husbands (Kriel et al., 2019), education, wealth, parity, religion, and place of residence (Jammeh et al., 2014; L’Engle et al., 2013).
In the Gambia, 16.3% of married women use modern contraceptives nationwide, with urban regions having a greater rate of use than rural areas (17.7% vs. 13.5%, respectively; UNICEF, 2019). Therefore, using contraception will have many benefits for the mother, child, and her family as a whole, including preventing hazards associated with pregnancy and the needless deaths of women (Dansou, 2019; Sileo et al., 2015; World Health Organization, 2007), reduction of infant mortality, control of sexually transmitted diseases, and protection against HIV transfer from mother to child (Gambia Bureau of Statistics, 2021; Jammeh et al., 2014; World Health Organization, 2007), preventing teenagers from dropping out of school by lowering their pregnancy rates and improving opportunities for girls to attend school (Rosenberg et al., 2015), and improving the economics of the family (Gribble, 2012). Conversely, from 8,000 in 2013 to 10,000 in 2016, the number of births was prevented because of modern contraception methods (Family Planning, 2020; New et al., 2017). Modern contraceptive methods have reduced the number of maternal deaths from 40 in 2012 to 60 in 2016 (Family Planning, 2020). To give women the chance to have the desired number of children with the desired spacing between them, contraception was developed (New et al., 2017).
Studies on contraceptive methods in the Gambia are very limited, and their limited size of study population made them difficult to determine for the general population of the country. Second, these studies did not include several factors that may affect the intention to use contraception methods. Therefore, this study aimed to determine the intention to use contraceptive methods and its determinants among married women of reproductive age. By identifying essential determinates that affect the intention to use contraceptive methods in the county, this study contributes to the Gambia and would have paramount importance to increase birth control by controlling birth rates. Policymakers and other stakeholders working on family planning for women’s and children’s health will access the findings of this study to develop, improve, and implement their plans accordingly.
Methods and Materials
Study Design and Setting
This descriptive cross-sectional study used the 2019 to 2020 Gambia Demographic and Health Survey (GDHS). The GDHS is a nationally representative population-based survey that is conducted periodically to collect health indices and served as the foundation for this investigation. The United States Agency for International Development and the government of the Republic of Gambia funded the 2019–2019 GDHS with assistance from the Inner-City Fund through the Demographic and Health Survey Program. The Gambia is a country in West Africa. The Atlantic Ocean and the Republic of Senegal form their western and northern borders, respectively. The nation experiences two distinct seasons: the rainy season (June to October) and the dry season (November to May).
Source Population, Data Collection and Sampling Technique
A stratified two-stage cluster sampling technique was used for the survey. Enumeration areas were chosen in the initial step with a probability inversely correlated with their size within each sampling stratum. In the second step, the households were carefully sampled. All mothers in the reproductive age range made up the source population. Only married mothers were included, and all were excluded from the study. In the estimation, the sample weightings for women were employed to help correct the unfair sample allocations made during data collection. As a result, 6,805 weighted samples of mothers were used in this study.
Variables of the Study
Dependent Variable
The outcome variable of this study was the intention to use contraceptives among contraceptive nonuser women. The variable was dichotomized into
Independent Variables
Plenty of independent variables were included in this study. These are the ages of women and husbands, religion, educational status of women and husbands, type of residence, region, working status of women, household income, mass media exposure, whether they heard family planning text messages by phone, and whether they heard about family planning from friends/relatives. Peer health education, health professionals, radio, television, traditional communicators, knowledge of modern contraceptives, ever use of contraceptives, fertility preference, desire for more children, the desire of husbands for children, visits by a field worker in the last 12 months, visits to a health facility in the last 12 months, and number of children. The frequency of radio listening, television viewing, and magazine/newspaper reading was generated as variables, and their dichotomous responses were used to determine the variable mass media exposure. Any participant who experienced at least one of these three media exposures at least once a week deemed to have media exposure. All other remaining variables were calculated directly, except for recording as given in the tables, and no statistical computations were performed.
Data Analysis
The statistical program STATA version 14.1 was used to extract and analyze the data. For categorical data, descriptive studies such as frequency count and proportion were used to summarize the descriptive data. Bivariable logistic regression was used to select candidate variables for multivariable logistic regression. A p-value cutoff of .25 was used in the Bivariable logistic regression to determine which variables would be included in the multivariable analysis. Multivariable logistic regression was used to find independent determinants of the intention to use contraceptives in the Gambia while adjusting for confounders. Statistical significance was assessed using the 95% confidence interval (CI) and a p-value of .05. The variance inflation factor was used to construct a pseudo-linear regression to examine the multicollinearity among the independent variables. In addition, the overall fitness of the final regression model was evaluated using the Hosmer and Lemeshow test.
Result
Sociodemographic and Other Individual-Related Characteristics of the Participants
A total of 6,085 weighted samples of married contraceptive nonusers were included in this study. The majority of women and their husbands were 25 to 34 and 35 to 44 years old, with a proportion of 2,488 (40.89%) and 2,086 (34.28%), respectively. Nearly all the 5,958 (97.92%) women were Muslims. Nearly half of the women, 2,910 (47.84%) and more than half, 2,955 (48.56%) of the participants and their husbands did not attend formal education, respectively. About 1,265 (20.79%) of the participants were from households with the poorest wealth.
Regarding the type of residence and region, 4,093 (67.26%), and 2,433 (39.98%) participants were from the urban and Brikama regions, respectively. About 4,083 (67.10%), and 4,166 (68.46%) participants work currently and have mass media exposure, respectively. Regarding ever use of contraceptives, a desire more children did not visit by the field worker and visited health facilities by themselves in the last 2 months 4,221(69.37%), 5,076 (83.42%), 5,190 (85.29), and 4,758 (78.19%), respectively. More proportion of women 3,792 (62.32%), heard about family planning from friends/relatives; however, 3,679 (60.46%) did not hear about family planning from health professionals. Most of them have cohabitation in at the range of 10 to 19 years 3,906 (64.20%). Regarding fertility, approximately 4,863 (79.93%) participants had another desire to have children in the future (Table 1).
Sociodemographic and Other Individual Characteristics of Married Women in the Gambia (n = 6,085).
Determinants Associated With the Intention to Use Contraceptives
In the logistic regression analysis: age, education, region, occupation, wealth, FP heard by friends/relatives, FP heard by a health professional, ever use of contraceptives, number of children, number of visits by field workers, and rate of visits to health facilities were significant determinants of participants’ intention to use contraceptives in the future.
Participants within the age range of 25 to 34 years (AOR = 0.78, 95 CI% [0.65, 0.93]) and 35 to 49 years (AOR = 0.36, 95% CI [0.29, 0.46]) were less likely to be intended to use contraceptives in the future compared to participants with the age range of 15 to 24 years. Participants who had completed their primary and secondary educational attainment were 1.44 (AOR = 1.44, 95% CI [1.23, 1.68]) and 1.45 (AOR = 1.45, 95% CI [1.04, 2.03]) times more likely to use contraceptives in the future than participants who did not have formal education. Women from the Basse region were 39% less likely to be intended to use contraceptives than women from the Banjul region (AOR = 0.61, 95% CI [0.46, 0.82]). Mothers who are currently working and have the richest household income have revealed that (AOR = 0.76, 95% CI [0.66, 0.86]) and (AOR = 0.66, 95% CI [0.51, 0.86]) are less likely to be intended to use contraceptive, respectively. Participants who heard of contraceptives from their friends/relatives and health professionals (AOR = 1.26, 95% CI [1.10, 1.44]), and (AOR = 1.56, 95% CI [1.32, 1.78]) were more likely to be intended to use contraceptives shortly. Similarly, ever-used contraceptives (AOR = 4.55, 95% CI [3.99, 5.18]) were approximately, five-fold more likely to be intended to use contraceptives in the future than their counterparts. In addition, women who had 3 to 5, and six or more children have shown (AOR = 1.22, 95% CI [1.03, 1.44]), and (AOR = 1.72, 95% CI [1.36, 2.16]) were more likely to be intended to use contraceptives compared to women who have 0-2 children respectively. Regarding visits by field workers and visited health facilities in the last 12 months, those mothers who have the exposure have shown (AOR = 1.32, 95% CI [1.13, 1.53]), and (AOR = 1.38, 95% CI [1.18, 1.61]) times higher chance of being intended to use contraceptive than their counterparts respectively. Mothers currently working and the richest household income have revealed that (AOR = 0.76, 95% CI [0.66, 0.86]) and (AOR = 0.66, 95% CI [0.51, 0.86]) are less likely to be intended to use contraceptives, respectively (Table 2).
Determinants Associated with the Intention to Use Contraceptives Among Reproductive Age Married Women in the Gambia (n = 6,085).
significant statistically at p-value of < .05
Discussion
This study aimed to assess future intention to use contraceptives and determinants among married women who were not current contraceptive users. The proportion of participants who intended to use contraceptives in the future was 29.72 (28.6, 30.82). This figure is less than that of studies conducted in Indonesia (63%; Utomo et al., 2021), Ghana (70%, 69.3%; Der et al., 2021; Eliason et al., 2013), Uganda (60%; Lutalo et al., 2018), Malawi (69.1%; Forty et al., 2021), and Ethiopia (84.3%; Abraha et al., 2018).The possible reasons for the empirical findings of this study being lower than those mentioned above may include differences in countries’ FP experiences, participants’ attitudes, knowledge and educational backgrounds regarding FP intentions, the number of determinants considered, and other methodological variations that could have contributed.
Based on our findings: age, education, region, occupation, wealth, FP heard by friends/relatives, FP heard by a health professional, ever use of contraceptives, number of children, number of visits by field workers, and rate of visits to health facilities were significant determinants of participants’ intention to use contraceptives in the future.
This study discovered that age was one of the main determinant variables. Participants aged 35 to 34 years and 35 to 49 years were less likely to use contraceptives in their future FP than the younger participants. This finding agrees with those of many other studies conducted at various sites, such as Cameron (Rai, 2015), Zambia (Lasong et al., 2020), Uganda (Lutalo et al., 2018), Malawi (Forty et al., 2021), and Ethiopia (Oumer et al., 2020). This is related to the fact that older women may be less likely to need contraceptive methods (Endriyas et al., 2017). This can also be explained by the fact that as mothers get older, their ability to give birth may decrease, and they may experience health problems, sometimes due to pregnancy or related reasons. On the other hand, due to their age, they may think they are infertile and may have a negative view of modern contraceptives.
Women with primary and secondary educational attainment have shown a more positive tendency to use contraceptives in the future than those without formal education. Studies conducted in Rwanda (Habyarimana & Ramroop, 2018), Ethiopia (Alemayehu et al., 2016), five east African countries (Bakibinga et al., 2016), and 11 low- and middle-income countries (Blumenberg et al., 2020) shown similar findings regarding the association between maternal education, and contraception utilization. The low prevalence of contraception use among uneducated women can be attributed to misinformation, myths, and cultural norms that promote high fertility (Ankomah et al., 2011; Nalwadda et al., 2010). This suggests that as women’s education levels rise, so will their ability to assess the future costs of having more children in terms of finances, health, and other social dimensions. Having more freedom to make their own decisions and being better able to obtain high-quality medical services. Therefore, they intend to use contraceptive techniques to lessen the burden of childbirth and childcare. Positivity also increases the understanding of how to handle side effects and where and how to receive the service.
Individuals who have placed their residence in the Basse region have a lower tendency to use contraception compared with residents of the Banjul region. Although there is no previous literature to compare it to, a descriptive statistic from the Gambia shows that family planning was lower in the Basse region than in the remaining regions (Gambia Bureau of Statistics, 2021). Other invisible hands, such as husband opposition and the implementation of contraception services in the region in cooperation with essential stakeholders, might affect the acceptance of the intention to use contraception. The possible reasons might be from the cultural and traditional as well as the knowledge and attitude of women toward contraception; as a result, they may also be using contraceptive methods are offensive and forbidden in their religion and cultural practices (Agha, 2010). Those participants might have also faced geographic challenges and resource unavailability.
The males who are the primary decision-makers in the home also strongly oppose these issues (since most of the Basse region is not urban; UNFPA in The Gambia, 2022). Other difficulties include a lack of health professionals, a lack of resources for services, and inadequate infrastructure and supplies, particularly in remote and hard-to-reach places in the region (UNFPA in The Gambia, 2022; UNFPA, 2022). Some wealthier women also mentioned that using contraceptive methods has health concerns issues and infrequent sex (Moreira et al., 2019). Investigating the root causes in both quantitative and qualitative approaches and strengthening the systems of the service in the region are needed.
This study discovered that women who are currently at work have a low intention to use contraception in the future compared to their counterparts. This could be explained by the fact that women with occupations are more likely to be independent and have their own sources of income. Given the fixed difficulties that could result from having as many children as feasible, they are encouraged to have children. Studies revealed that wealthy and working women commonly mentioned health issues, infrequent sex, method-related adverse effects, being overbooked owing to a busy schedule, and greater responsibility as justifications for not using contraceptives. Plenty of studies have found odd results with this study regarding the working status of women (Budu et al., 2022; Kuug et al., 2024).
In this study, participants from wealthiest households revealed a higher probability of not being intended to use contraception than their counterparts. These findings are in agreement with other studies conducted in 11 low- and middle-income countries (Blumenberg et al., 2020) and Ethiopia (Alemayehu et al., 2016). Because more affluent women may not feel the need to use any form of contraception because of their intense concern over how it will affect their health, they may not be inclined to do so. As a result, their inability to use all available ways could provide a challenge. On the other hand, wealthy women may be less inclined to use contraception because they can hire a helper to carry their child. Other various studies have found odd results with this study regarding the richest women.
The other exciting variable was that those participants who had heard from their friends/relatives and health professionals about FP had more intention to use contraceptives. This finding is supported by several studies conducted in low- and middle-income countries (Moreira et al., 2019), Ghana (Seidu et al., 2022), Ethiopia (Abate & Tareke, 2019), SSA (Zimmerman et al., 2019), Rwanda (Habyarimana & Ramroop, 2018), and Nigeria (Ejembi et al., 2015). This shows that favorable person-to-person information about contraceptives was a significant determinant of the intention to use modern contraceptive methods and should be considered during the development of Gambian FP programs. The increase in the number of people who have heard of the positive benefits of contraceptives in the community and health facilities is one indication that mothers are ready to do whatever is best for the community.
Individuals who have ever used FP at least once in their lifetime have a more favorable interest in using the contraceptive methods once again in their future life. These participants who have ever used contraceptives at least once may increase their awareness and knowledge about the service over time. Their understanding and knowledge, in turn, might increase the intention to use contraceptives through the exposure and counseling received from health care providers. This idea is supported by studies conducted in Ethiopia (Abraha et al., 2018; Oumer et al., 2020), Yemen (Masood & Alsonini, 2017), and Malaysia (Elkalmi et al., 2015).
Women who have given birth to 3 to 5 and more than 5 have also shown a lower likelihood of intending to use contraceptives compared with those who have given 0 to 2 births. This result is concurrent with studies conducted by SSA (Boadu, 2022), Zambia (Lasong et al., 2020), Ethiopia (Abate & Tareke, 2019), and Tanzania (Kidayi et al., 2015). The desired number of children is not achieved among nulliparous women, who also have a strong intention to become pregnant and are less likely to use contraception. Women increasingly use contraception because they know they will have their chosen number of children as the numbers increase. Conversely, these multiparous women may have a better opportunity for a learning experience about the challenges of having a large number of children.
The other interesting associations were observed between the outcome variable and visited by a field worker and visited a health facility in the last 12 months. Participants who have visited field work sites and visited health facilities by themselves have scored a higher odds ratio of using contraception than their counterparts. studies from Zambia (Lasong et al., 2020), Nigeria (Ajayi et al., 2018), Ethiopia (Olika et al., 2021; Tiruneh et al., 2016), and sub-Saharan Africa (Boadu, 2022). The women would have developed greater confidence and started using contraception if the field workers had provided clear explanations of its benefits. Similarly, if women frequently visit their health facilities, the health professionals will be in a better position to promote the use of FP. Therefore, to reach the Sustainable Development Goal of universal access to sexual and reproductive health services, including family planning, by 2030, it is crucial to expand access to health care facilities in medically disadvantaged settings.
Implications for Future Studies
This study's results have substantial consequences for future research by identifying specific pathways for more in-depth examination. Future investigations should shift their focus from merely identifying the determinants to understanding the mechanisms and motivations behind them via in-depth, multi-faceted research. Conducting in-depth interviews and focus groups would entail understanding the complex cultural, religious, and gendered beliefs that shape intentions, with a specific focus on the impact of male partners, community elders, and religious leaders. Having a contextual understanding is essential for developing impactful interventions.
Moreover, the research highlights the necessity of conducting longitudinal studies to monitor the translation of intentions into actual contraceptive usage over time, and to identify the obstacles that emerge between intention and action. Implementation science research should focus on developing and testing targeted community-based strategies, including programs that engage men or culturally sensitive counseling models, informed by these specific national-level factors. This study ultimately offers a crucial body of evidence to steer future research away from general monitoring and towards focused, actionable investigation, which can directly inform and enhance family planning programs in the Gambia.
Strength and Limitations of the Study
This study’s employment of a sizable sample size with a nationwide representative is one of its strengths. The likelihood of departures from the actual population declines as the sample size grows closer to the population as a whole. The cross-sectional nature of the study precludes concluding the causes of the observed relationships; hence, this study should be regarded with some caution. Moreover, because all of the data were self-reported, a social desirability bias could have been introduced.
Conclusion
The proportion of women who have the intention to use contraceptives remains very low. Age, education, occupation, income, region, information to get family planning, ever use contraceptive, number of children, and supervisions were determinants that affected the intention to use contraceptives. Therefore, efforts to increase the uptake of contraceptives should focus on improving education and economic opportunities for married women, particularly those ever use contraceptives. Policymakers and other key stakeholders should solicit the support of health facilities in designing contraceptive education programs expanding through friends/relatives and health professionals and making contraceptives freely accessible to all Gambian married women.
Footnotes
Acknowledgements
The authors acknowledge the DHS program office to take ethical consideration of this study.
Author Note
We hereby declare that this study represents our work which has been done after registration and reception for the accessing of data at 
and confirms that all methods were carried out following relevant guidelines and regulations. We have attempted to identify all the risks related to this research that may arise in conducting this research, obtained the relevant ethical and/or safety approval (where applicable), and acknowledged my obligations and the rights of the participants by the demography and health survey program authorities. The research is conducted following the declaration of Helsinki.
Ethical Considerations
Ethical approval and permission letter were requested online from the DHS program at and received permission letter with the reference number (AuthLetter_218190) to access the data for this study, and the DHS program was granted permission through email. The data used in this study was freely available and did not contain any personal information.The research is done based on secondary data from Gambian demography health survey (GDHS). Issues of informed consent, confidentiality, anonymity and privacy of the study sample were already done ethically by the GDHS authority and we did not manipulate and use the data for other issues. There was no patient or public involvement in this study. Therefore, there is no direct contact with the study participants and consent information’s is only the source of DHS dataset that we obtained by permission letter.
Consent to Participate
This study uses anonymized data from the 2022/23 Gambian National Survey. The data were collected under a separate informed consent process by the Demographic and Health Surveys (DHS) Program, and all ethical approvals were obtained from The IRB-approved procedures for DHS public-use datasets. The data we are using have been de-identified, meaning that individual participants cannot be identified. Our analysis focuses solely on aggregate data to explore the “intention to use contraceptives and determinants among married women in The Gambia.” No individual-level data will be reported, and all results will be presented in a manner that protects participant confidentiality.
This research is being conducted by Engidaw Fentaun Enyew, Mahlet Moges Jembere, and Bewuketu Terefe. Our goal is to identify the intention to use contraceptive and determinants among married women in the Gambia. Participation in this study is implied by the inclusion of our data in the publicly available dataset. This Data used only for the purpose of statistical reporting and analysis, and only for our registered research. However, given the data’s anonymized and aggregated nature, such exclusion is not practically feasible, and our data will be stored securely and protected in accordance with the data protection regulation of DHS law
Author Contributions
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Data for this study were obtained from the DHS Program as well as obtained the extract data from the principal investigator by requesting.