Youth Friendly Reproductive Health Service Utilization and Associated Factors Among School Youths in Ambo Town, Oromia Regional State, Ethiopia, 2018

Background: Youth is a period of life in which an individual passes from significant physiological, psychological and social changes that expose them at high risk of reproductive health problems. The reproductive health problems in this period are preventable provided that youth utilize quality reproductive health services. The aim of the study was to assess the extent of youth friendly reproductive health services utilization and the associated factors among secondary and preparatory school youths in Ambo Town. Methods: Institutional based cross-sectional study was conducted among 376 youths who were attending the secondary and preparatory school in Ambo town from March, 1-30 /2018. Simple random sampling method was used to select the study participants from each grade. Data were collected by trained data collectors using a pre-tested structured questionnaire. The collected data were entered into SPSS version 20 for analysis. Multiple logistic regression analyses were performed to identify the strength of association between dependent and independent variables at 95% confident interval and P value < 0.05. Results were presented using tables and figures based on the nature of the variables. Result: About 20.7% of the youths had utilized youth friendly reproductive health services at least once in the last twelve months prior to the study. On a multivariable logistic regression analysis variable such as age [AOR=0.38, 95% CI=0.176-0.819], student grade [AOR=3.0, 95% CI=1.499-6.230], previous residence status [AOR=0.53, 95% CI=0.300-0.926] and the existence of youth friendly reproductive health service facility around living area [AOR=7.700, 95% CI=2.931-20.423] were significantly associated with youth friendly reproductive health service utilization. Conclusion: Youth friendly reproductive health services utilization among secondary and preparatory school youths in Ambo town was low. Age of the respondents, student grade, and previous residence status of the respondents & existence of youth friendly reproductive health service health facilities were among predictors of youth friendly reproductive health services utilization. Therefore the Ambo town and, Ambo district health offices, Ambo town education offices and other organizations working in area of youths reproductive health services are recommended to give awareness on youth friendly service utilization through provision of training for youths.


Introduction
Youths are persons between 15 to 24 years of age and accounts about 20% of the world's population, of whom 85% live in developing countries [1]. In Ethiopia there are about 21 million, youths and adolescents ages 10 to 24 years which accounts approximately 20% of the total population in the country [2,3].
Youth friendly reproductive health services are services that are: accessible, acceptable, and appropriate for adolescents and youths. It is comprehensive essential services packages which includes provision of family planning and relevant SRH information, STI syndrome management, pregnancy test, provision of medical care service, provision of VCT/PITC, psychological support and counseling of GBV and sexual abuse, and referral linkage for services like ART, HIV/AIDS care and support of services to the whole target group [4,5].
The onset of adolescence brings not only changes to their bodies but also new vulnerabilities to human rights abuses, particularly in the area of sexuality, marriage and child bearing. Millions of girls are coerced into unwanted sex or marriage, putting them at risk of unwanted pregnancies, unsafe abortions, sexually transmitted infections (STIs) including HIV, and complication of child birth. Young people both boys and girls are disproportionately affected by HIV [6]. An estimated 1.3 million adolescent girls and 780,000 adolescent boys are living with HIV worldwide [7]. In Sub-Saharan Africa, slightly more than half of all people living with HIV are women and girls and young women aged [15][16][17][18][19][20][21][22][23][24] years are as much as eight times more likely than men to be HIV positive [8].
Among the many sexual and reproductive health problems faced by youth in Ethiopia are gender inequality, sexual coercion, early marriage, polygamy, female genital cutting, unplanned pregnancies, closely spaced pregnancies, abortion, sexually transmitted infections (STIs), and AIDS. Lack of education, unemployment and extreme poverty exacerbate and perpetuate the reproductive health problems of Ethiopian youth [9].
Throughout the world youths are exposed to health risks because they often do not have adequate knowledge and guidance about sexual and reproductive health (SRH) [10]. They tend to be less informed, less experienced, and less comfortable in accessing reproductive health services than adults. In addition most of them do not feel comfortable in discussing reproductive health issues with their parents [11,12] and access and utilization of youth friendly reproductive health services is limited due to socio-demographic, judgmental attitude of service providers, lack of confidentiality and privacy, costs and an unfavorable attitude of parents and negative community perceptions towards health seeking behaviors of adolescents and youths [13].
Globally many reproductive health services challenges confront young people and more pervasive in developing countries where the services and facilities are absent [14]. Youths in Ethiopia face many Reproductive health problems including gender inequality, sexual coercion, early marriage, unplanned pregnancies, abortion and sexually transmitted infections, including AIDS. Lack of education, unemployment, and extreme poverty exacerbates the reproductive health problems faced by Ethiopian youth [15].
According to demographic health survey 13% of girls aged 15-19 in Ethiopia have begun child bearing. This is associated with low use of modern contraceptives and limited access to youth friendly services [16] which in turn contributes to high rates of maternal mortality and morbidity [17]. Unmet need for contraceptives among sexually active unmarried young women is still as high as 26%. On top of this only a quarter of young women and 39% percent of young men aged 15-24 had comprehensive knowledge of HIV and its transmission [16]. Therefore, the purpose of this study is to assess utilization of youth friendly reproductive health services and identify the gap in provision of the services in the study area.

Study Design and Setting
Institution based cross sectional study was conducted among secondary and preparatory school youths, in Ambo town from March, 1-30/2018. Ambo town is located in West Shewa zone, Oromia regional state at a distance of 114 km to the west of Addis Ababa, the capital city of Ethiopia. According to the report obtained from Ambo town office, the total population of the town is estimated to be more than 83,053 of which around 16,611 are between the ages of 15 -24 years. The town has four government schools of which three of them are secondary schools and one is preparatory school. In these schools there were 7,041 students whose ages were between 15-24 during the study period. In the town there are two hospital, (one referral and one general hospitals), 2 public health centers, 27 clinics and three health posts rendering heath services for the community [18]. According to Ambo town Health office report, only one public health center was providing youth friendly reproductive health services in the town and about 3,349 of youths utilized YFRHS in 2017 [19].

Study Participants
Youths attending regular program in Ambo secondary and preparatory schools were included in the study while students who were unable to see or hear and critically ill were excluded from the study.

Sample Size and Sampling Techniques
In calculating the sample size, single proportion formula was utilized by taking P=37.2% from study conducted in Bale zone, Goba town [20], 95% confidence interval, α=0.05 margin of error and d=5% degree of precision. Since the source population is less than 10,000 the population correction formula was utilized. Finally, adding 10% of nonresponse rate 376 was sample size calculated.
All of the government schools in the town were included in the study. Proportional sample size allocation was used in selecting and including respondents, both male and female from each grade. Then simple random sampling was used to select study participants using their ID numbers as a sampling frame.

Data Collection
Four diploma nurses and two BSc were recruited as data collector and supervisors respectively. Prior to data collection, one day training was given for both data collectors and supervisors.

Measurements
The mean for knowledge about YFRHS was calculated based the knowledge questions and the calculated mean was considered as the cut-off point. Values below the mean were considered as poor knowledge while values above the mean were considered as good knowledge.

Data Analysis
The collected data were coded, cleaned and entered into Epi Data 3.1 software and exported to SPSS computer software version 21 for analysis. A binary logistic regression was done to identify associations between the dependent and independent variables and P-value of <0.25 was taken to include the variable as candidate for multivariable logistic regression model. Multivariable logistic regression analysis was done to determine the association between dependent and independent variables using adjusted odds ratio with 95% confidence interval at significance level of ≤ 0.05.

Ethical Consideration
Ethical clearance was obtained from Ambo University College of medicine and health sciences Ethical Review Committee. Supportive letters were obtained from the town education office and school administrations. Permission was also obtained from individual respondent for age greater than 18 and from their parents for these respondents whose age was less than 18 years of age.

Socio-demographic and Economic Characteristics of Respondents
A total of 376 students' age between 15-24 years participated in the study with 100% response rate. More than three-quarter (83.8%) of the respondents belong to age group between 14-19 years with mean age of 17.39 and SD of ±4.17 of years. About 97.1% of the respondents are Oromo by Ethnicity and 50.3%were protestant followers by religion. The large proportion (95.7%) of the respondents were single by marital status and 34.3% of them were grade nine by education level.
Regarding youth's parent occupation, 56.9% of youth's mothers were housewives and 47.3% of their fathers were farmers. About 34.6% of the respondent's father and 39.6% of the mothers attended primary education. From the total study participants, 1.9%of the respondents had pocket money of less than 50 ETB per month, (Table 1).

Reproductive Health Information and Youth Friendly Reproductive Health Service Utilization
About 82% of the respondents reported that they knew about youth friendly reproductive health services. More than half (56.6%) of the respondents knew about VCT followed by 51.1% family planning. About 62.8% of the study participants knew the place where youth friendly reproductive services are available and 74.2% of them responded that they had the right to use the youth friendly reproductive health services. Only 26.1% of the study participants reported that they had a parental discussion about the issue of reproductive health service. Out of the total respondents 88% reported that they knew methods of preventing pregnancy. Among these 37.9% knew one type pregnancy prevention methods while the remaining 47.5% knew more than one type of pregnancy prevention methods. The most known pregnancy preventing methods by the respondents was pills 60.4% followed by 51.9% injectables.
Regarding the sources of information 54.5% heard from school, 48.9% from health care providers, 27.9% from peers, 23.1% from Radio, 18.6% from parents, 4.8% from posters and 2.4% get information from internet about youth friendly reproductive health services. Among the total respondents 59.4% had only one source of information and 40.6% had 2 and above source of information about youth friendly services. From the total respondents 64.6% of them had knowledge on youth friendly reproductive health services (table 2).

Availability and Utilization of Youth Friendly Reproductive Health Service
About 71.5% of the respondents had awareness about the presence of the Youth friendly reproductive health services in their surroundings. Regarding the distance to health facility majority of respondents (54.2%) responded it is preferable if it is available within the distance of less than 30 minutes for a single journey to reach the health centers to utilize Youth friendly reproductive health services by walk from residence.
Out of the total respondents only 20.7% the study participants reported that they ever used at least one youth friendly reproductive health service in the past twelve months. Out of 20.7%, respondent who utilized the services in the last 12 months prior to the study, 82.1% of them received the services from government health centers, 12.8% of received the services from hospital and 5.1% of them received the services from private clinics.
Among the respondents who utilized the services, 65.5% of the study participants said that they were requested to pay for the service and 38.5% were not requested. About 25.6% of the respondents said that the health facility working time was convenient and for 74.4% the time was was not convenient to use youth friendly reproductive health services. Among those who were asked the option of their convenient time to use the service, 24.1% mentioned that weekend as a convenient time followed by 17.3% early in the morning, 51.7% after noon and 6.9% public holly day.
Regarding health providers approach in providing the services (44.9%) of them reported that they were handled in good friendly way and about 42.3% rated they are very with services given to them (Table 3).

Types of Youth Friendly Reproductive Health Services Utilized by Respondents
Regarding the utilization of youth friendly reproductive health services, 13.8% utilized VCT followed by 10.9% IEC. All of the study participants who have utilized the youth friendly services had used more than one type of service ( Figure 1). AOR-Adjusted OR: odds ratio by multiple logistic regression. 95% CI: confidential interval. **: p-value <0.05.

Reasons for Not Utilizing Youth Friendly Reproductive Health Services
The result of this study revealed that three-fourth (79.3%) of the study participants did not use YFRHS. The reason mentioned for not utilizing YFS was in about 35.9% they did not want the services or they were not ill followed by 25.8% do not know where to go to get the services, 11.8% because of distance of the health services and had no money for the services, 8% inconvenient working hours and 6.7% fear of being seen by families or peoples whom they know (figure 2).

Factors Associated with Youth Friendly RH Service Utilization
From nine variables which entered into multivariate logistic regression model only variables: age of the respondents, grade of the students, previous residence status and existence of youth friendly service facilities were found as predictors of outcome variable. were the variables that showed the significant association with youth friendly RH service in this study (Table 4).

Discussion
The findings of this study revealed that about 20.7% of the respondents every utilized youth friendly Reproductive health service in the last 12 months in the study area. This was almost similar with the result of study done in East Gojjam, Machakel district which was 21.5% [21].
But the result from the current study was lower when compared to the other studies conducted in different part of Ethiopia which was 69.1% in Mekelle town, 63.8% in Harar 38.5% in Hadiya 32.2% in Bahir dar, 34.3% in Albukoworeda and 37.2% in Goba town [22][23][24][25][26][27][28] respectively. The difference might be due to the difference in socio-cultural and openness of the study participants in Harar and Mekellein comparison with this study area [22,23].
The prevalence of youth friendly reproductive health service utilization in this finding is also lower than the institutional based study conducted in Malawi (62%), in Nigeria (51%) and Bureti city, Kenya (38.5%) [29,30]. This higher in utilization of YFRHS in those areas than the result of this study was probably the foreign countries might have more advanced in health care delivery than that of Ethiopia in having availability and accessibility of health facility, urbanrural residence and transportation difference between the countries and with better infrastructures.
Among those youths ever utilized youth friendly reproductive health services, the study showed the main services utilized 13.8% used VCT service making it the most utilized followed by IEC 10.9%. It is consistence with many studies in Harar, Metekel and Albukoworeda. In this study the most frequently visited health facilities by the respondents were government health centers (14%). This is less when compared with findings from studies conducted in Awabel district, Goba and sodo town [31,28,32]. Contrarily to these findings, respondent at Jimma (26.7%) and Harar (64.5%) reported that family guidance association of Ethiopia was frequently visited health institution [10,23]. This is, may be, due to poor collaboration with stakeholders, even though government health center had privacy and confidentiality, accessibility to trained health provider and affordability of cost in the study area.
In this study youths in the age groups of 15 -19 years were 0.38 times less likely to use youth friendly reproductive health services than youth of age 20-24 years [AOR=.380, 95% CI=(0.176 -0.819)]. This finding is consistent with the study conducted in Bahirdar, Jimma and Metekelin which youths within age groups of 20 -24 years were 2.31 times more likely to use services than youth of age 15 -19 years [11,30,31]. This is probably due to the fact that the older youths apply what they heard about youth reproductive health services and more likely to utilize the service when compared to youths of age 15 -19 years old..
The finding of this study also showed that grade nine students were 3 time more likely utilized youth friendly reproductive health services as compared to the other group. Butthis finding is inconsistent with the study conducted in Bale zone, Goba town in which Grade nine students were 91% less likely to use YFSRHS compared to grade eleven and twelve students [27]. This difference is probably due to the time to start for reproductive health information and secondary behavioral change and when they come to high school to the new environment, youths vulnerable to reproductive health problems that enforces the utilization.
Another predictor variable that shown significant association in this study was student's previous residence status. Accordingly, students who were living in urban were 0.53 times less likely to utilize YFRHS as compared to students when previously living from rural [AOR=.527, 95% CI=(0.3-0.926)]. This finding is not line with a survey report of EDHS in which Urban youths were more likely to utilizes YFRHS than rural youths [25]. This is most probably due to the fact that student who had used youth friendly reproductive health services have got new knowledge, adequate information, and more access to proper counseling offered from health professionals while they came to urban area.
This study also indicated that utilization of the youth friendly reproductive health services was high in respondents who had youth friendly reproductive health service facility around their living area were as those who had the services in their living area were 7 times more likely utilized youth friendly reproductive health service as compared to those who had no youth friendly service facility in their living area [AOR=7.1, 95% CI=(2.676-19.015)]. This is probable due to the reason that those respondent who have the opportunity to access health facility around their living can get exposure to health education related to youth friendly reproductive health services at the time of visit and thus get access to learn about the types, benefits and availabilities of youth friendly reproductive health service facility around their living.
In this study more than half 54.5% of the respondents heard about YFRHS from school followed by health care provider 48.9%. The finding was similar with study finding conducted in Harar which shows majority of respondents 72.4% heard information about YFRHS from school 31.5% followed by 22.8% from radio broadcasts [23]. The probability may be due to school teachers had better knowledge about youth friendly reproductive health services to provide the information in the study area.
Among those who did not use the service about 107 (35.9%) of the respondents reported that the reason not to use YFRHS was because they do not want the services or they were followed by do not know where to get the services 77 (25.8%) and distance of the health services 35 (11.8%). This result is almost similar with the result of study done in Harar were the reasons mentioned for non-use were the youths did not know where to go for the services (43%) followed by distance (18.7%) [23]. Another reason mentioned by the study participants for not to utilize the services in this study were, inconvenient working hours 24 (8%), fear of being seen by families or peoples whom they know 20 (6.7%). This is consistent with the studies in Harar, Bahir dar and Albuko Woreda that the Study participants claimed that: youth friendly reproductive health service working hours were inconvenient (31.8%); there is payment for the services (28.4%) and fear of being seen by parents or people [23,25,26]. This is also consistent with the study done in Kenya on the barriers of utilization of reproductive health services which indicated that 31% of the students mentioned inconvenience hours as one of the reasons as barriers to utilizes the reproductive health services [30].

Limitation of the Study
Since study was conducted on school youths the generalization of the result for out of school youths may not possible. In addition collecting data through selfadministered questionnaire by itself has subjectivity and not involving quantitative methods also its own limitation to the data.

Conclusions
Generally the utilization of youth friendly reproductive health services among secondary and preparatory school students in Ambo town was low. Lack of information where to get the service, distant to youth friendly service delivery institution, and fear of parents are barriers of utilization of youth friendly reproductive health services. Age, grade of the students, previous residence status and existence of youth friendly reproductive health services were factors found to be associated with youth friendly reproductive health services.