Youth’s Sexual and Reproductive Health Service Utilization and Associated Factors in Addis Ababa: Community Based Cross-sectional Study

: Background: youth is a period of change and adjustment. It is a period of life in which an individual display significant physiological, psychological and social changes that expose them at high risk of reproductive health problems. Consequently, many youth are less informed, less experienced and less comfortable in utilizing reproductive health services. Objective: this study assessed reproductive health service utilization and associated factors among youths in Addis Ababa, Yeka Sub city (Woreda one), Ethiopia. Methods: a community based cross-sectional study was conducted from September 13, 2020 to October 25, 2020. Three hundred seventy eight youths were selected by systematic random sampling technique and interviewed using structured self-administered questionnaire. Data were analyzed using SPSS windows version 24.0. Multiple logistic regression was run to identify variables that predict RHS utilization. P-values <0.05 were taken as a decision line to consider a variable is statistically significant or not. Results: Three hundred thirty nine (89.4%) respondents were properly filled and returned the questionnaire. One hundred sixty two (47.8%) of them were female and 177 (52.2%) of them were male participants. Two hundred fifty two (74.3%) of the respondents had heard about reproductive health services and 87.3% had knowledge about sexually transmitted infection and 42.8% of the respondents utilized RHS. Age (AOR=0.342, 95% CI: 0.124-1.942), marital status (AOR=3.420, 95% CI: 1.088-11.065), living arrangement (AOR=0.142, 95% CI: 0.032-0630), father education (AOR=6.613, 95% CI: 2.363-18.505), mothers education (AOR=0.334 95% CI: 0.133-1.936) and self-determination (AOR=0.294 95% CI: 0.149-0.581) were predictors of youth reproductive health service utilization. Conclusion: irrespective of the youth knowledge/information about reproductive health service (sexually transmitted diseases and family planning), youths reproductive health service utilization is low. Therefore, life skill training for youth, parental scaffolding and communication with youth, and training and updating care providers in the youth center, capacitating the youth center in terms of resources helps to enhance youth reproductive health service utilization.


Introduction
Youths are those populations whose age are ranged from 15 years old to 24 years old [1]. This group of population constitutes 20% of the world total population, of whom 85% are living in developing countries and identified as the most vulnerable group for risky sexual and reproductive health problems [1]. Being youth is the most unstable period. They are in enormous physiological, psychological, and social changes. It is the time for discovery and experiment for the new development.
There are 1.2 billion youth in the world by 2015, which accounts one out of every six people worldwide. In Africa, there is 226 million youths which accounts 19 percent of the global youth population [2]. Ethiopia is the country of youths which accounts 20.4% of the total population [3]. Youth is the healthiest, productive and reproductive stages of life as obviously understood. However, it is the critical period in which young people are facing with peculiar and critical sets of threats that risks their survival. They are novel for the adult doings and lack experiences, negotiation skills, and communication skill and confronted with decisions which have vital implications for their future. Instability in emotion leads to fast and short sighted decisions which will hamper their future goal.
Youths are at risk of unplanned and unprotected sexual activity. This leads them to Sexually Transmitted Infection, HIV/AIDS, unintended pregnancy, unsafe abortion, unmeet of family planning and frustration which leads them to stress and anxiety in turn leads to excessive consumption of alcohol and other drugs [4].
Youths sexual and reproductive health issues should be prioritized and addressed through the promotion of responsible and healthy reproductive and sexual behavior [5]. This can be done using voluntary abstinence, delivery of services, age group suitable counseling, encourage programs, improve health care providers attitude that restrict the access and utilization of the service and provide necessary information for youth when they need it. Youth sexual and reproductive health services are services that are accessible, equitable, comprehensive, efficient, acceptable and appropriate for the youth. The service is provided at the right place with the right price and delivered in the right style acceptable and comfortable to young people in an effective, safe and affordable manner. Youth Sexual and Reproductive Health Service (YSRHS) includes counseling, family planning, promotion of health sexual behavior, condom provision, voluntary counseling and testing, treatment of STI, testing pregnancy, ANC, delivery service, PNC, abortion and post abortion care and referral linkage [6].
Youths' sexual and reproductive health service utilization is the concern for the government and the researchers. Youths are the current workforce and the future responsible citizen of a country. It is both the productive and reproductive age which a country aimed to get a lot from them. They are expected to be healthy and free from any physical and psychological aliments. Their sexual and reproductive health, which is the basic concern of the youth has to be taken in to account seriously. It has to be prioritized and addressed through the promotion of responsible and healthy reproductive and sexual behavior [5].
To this end there are various national youth reproductive health service policies, strategies and sector development plans. However, the national health strategy and sector plans are not widely disseminated and implemented. Moreover, the existing reproductive health (RH) services for youth are not well organized to meet youths need and much has not been done to make the health services youth friendly [6]. Adolescence/youth birth is the risk factor for maternal mortality and contraceptive prevalence is only 20% in Ethiopia [7]. Consequently, there are evidences on the low and improper utilization of the RH service and are different associated factors for it.
Young people whose age ranged from 15-24 years old accounted for 42%, which is almost half of the infection reported worldwide of whom 80% are living in sub-Saharan Africa. Among these youth only 28% woman and 36% of men have knowledge about HIV in the Sub-Saharan region [8,9]. The Ethiopian demographic health survey [3] revealed that 39% of men and 24% of women have knowledge about HIV/AIDS and 22% of them have unmeet family planning need. The prevalence of sexually transmitted disease including HIV/AIDS is relatively high among young people in Ethiopia.
Moreover, youth's problem of utilizing sexual and reproductive health service is related to unsafe sexual activity, unplanned pregnancy and unsafe abortion. More than 4.4 million young people between the ages of 15-24 years have abortion every year and 56% of which is unsafe abortion. According to HIV sentinel surveillance young girls attending antenatal care, the prevalence is 26 percent for girls 15-24 years of age [10]. Thirteen million young aged girls of 15-19 years have unintended birth each year. Moreover, the presence of unmet need for contraceptive exists among both married and unmarried individuals in the developing world.
In Sub-Saharan Africa, forty one and fifteen percent of unsafe abortion takes place among young women age of 15-19 and 15-24 years respectively [11]. There is an estimation of over 40% unintended pregnancy worldwide resulting from non-use, ineffective use or method failure of contraceptive [22]. Youth sexual and reproductive health services like access to contraception, HIV testing and counseling or treatment is severely hampered in East Africa. Consequently, 19% of girls in developing countries become pregnant by age 18 and 3% by age 15 [12,13].
On one hand research works on the issue have been done on adolescence in other regions of the country [7,14,15]. On the other hand researches done in regions were also focused on females [16,17]. Moreover, the present research is peculiar by taking the community and care takers. A study takes place on a community on youths sexual reproductive health service utilization is not found in Addis Abba as far as the researcher's knowledge is concerned except a study in Debrbirhan city. Consequently, the presence of these gaps together with the need of the researcher to work on this issue initiates to conduct this study. Therefore, the purpose of this study is to assess the RHS utilization and associated factors in care takers and care givers perspective.

Methods and Materials
A community based cross-sectional study was conducted to generate quantitative and qualitative data through assessing youth sexual and reproductive health service utilization and associated factors among youths in Yeka sub city (Woreda One). Woreda one is geographically located in the North-East of the Sub City. It accommodates about 10.7% of the total population in Yeka Sub City in 2,060 households. In the old lower level administration system, three Kebeles (Kebele 06, Kebele 07 and Kebele 22) are included in Woreda one. It has a total population of 38,647 with 49% (18,937) males and 51% (19,710) females (Woreda Health Office, 2020). Among these around 20,433 (52.9%) of the populations composed of children and youths below 25 years old. Youths in the Woreda constitute 11,171 (28.9%) of the total population of the Woreda [20], which is the focus of the present researcher. The study was conducted from September 13, 2020 to October 25, 2020.
A single population proportion formula was used to estimate the sample size. A study conducted in Debre Birhan was taken as parameter to determine sample size for this study, since it is a community based study while others were institution based study. Therefore, 33.8% was used as proportion to determine the sample size with a confidence level of 95%, marginal error of 5%, and adding 10 percent non-response rate. The total sample size was 378. Key informants from health centers in the Woreda was taken purposively.
A structured self-administered questionnaire was used to collect data. The questionnaire is adapted from John Cleland's illustrative questionnaire for interview survey with young people's [18] and combined with several literatures reviewed to achieve the research objectives. The main points included in the questionnaire were socio demographic characteristics, youths' individual attributes regarding sexual and reproductive health, service accessibility and four main aspects of RH services (sexual and RH information and education, modern contraceptives, voluntarily counseling and testing for HIV, STI diagnosis and treatment).
Verbal consent was obtained from the participant youths whom information was obtained. Ethical clearance was from Addis Ababa Public Health Research and Emergency Management Directorate. Respondents were informed that participating in the research is not harming them instead helps to create awareness about the issue. The right to withdraw the consent whenever they want was also assured and respected.
After checking for its completeness, the data was processed and analyzed by SPSS version 24.0. Descriptive and analytical statistics including percentage (frequency) and graphs, were used for describing different variables. Moreover, bivariate and multivariate logistic regression was run to identify factors that predict reproductive health service utilization. All variables with p<0.05 in regression analysis was fitted in to the multiple variable logistic regression models to identify factors associated with RH service utilization. P values less than 0.05 was considered as a level of significance.

Result
A total of 378 participants were involved in the study and among them 339 (89.4%) participants were filled and returned the questionnaire properly. Two key informants who are providing youth reproductive health service were purposely selected (one from a health center and one other form youth center) because of their experience in dealing with YRHS issues. Out of the total respondents, 162 (47.8%) were females and 177 (52.2%) were males. One hundred seventy nine (52.8%) of the respondents were aged between 15-19 years old while 198 (29.0%) of the respondents were aged between 20-24 years old. The remaining 60 (18.0%) of the respondents were aged between 25-29 years old, where the mean and median age of the respondents were 17.6 (SD=.771) and 18.8 respectively. The majority of the respondents 243 (71.7%) were single. Regarding their education status, 122 (36%) participants were attended their education in preparatory school and 101 (29.8%) of the respondents have education level of college/university and above. The remaining 77 (22.7%) and 39 (11.5%) of the respondents have attended secondary education (9-10 grade) and primary education (1-8 grade) level respectively.
Among the participants who were participated in the study, majority, 253 (74.6%) of them were living with their family while 34 (10%) of them were living alone. About respondents parental education, 146 (43%) of fathers and 104 (37%) mothers had education level of Diploma and above respectively. In contrast, 69 (20.4%) of fathers and 91 (26.8%) mothers never attend formal education respectively. One hundred eighty two (57.3%) of the respondents replied, they could not get pocket money for their daily expenses. As it is observed in table 2, most of the youths were familiar with reproductive health service. Two hundred fifty two (74.3%) of the respondents replied that they have heard about or have knowledge about RHS. Among those who have knowledge of RHS, the sources of information were; mass media 203 (80.6%), websites 173 (68.8%), and schools 172 (68.7%). Whereas parents 91 (36.5%) and peers 108 (42.9) were the other sources of information which is perceived less valuable source of information for youths to have knowledge on RHS. These respondents were also asked about "where do you think reproductive health service is provided?". Respondents replied that health centers, youth centers, hospitals and schools were the places where RHS is given which accounts 221 (82.2%), 119 (47.2%), 109 (43.2%) and 102 (42.5%) respectively.
Regarding the participants' knowledge about the types of RHS given to youth, 246 (70.6%) of the respondents replied that services related to VCT for HIV/AIDS and 161 (47.5%) of them replied family planning. Moreover, 132 (38.9%), 127 (37.5%), 117 (34.5%) and 95 (28%) of the respondents knew that the type RHS service provided to youth includes condom use, sexually transmitted infections, antenatal care and abortion services respectively.  Table 3, moreover, tries to present whether youths know about sexually transmitted infections or not. To this regard 321 (95.5%) of the respondents replied that they knew about sexually transmitted infections. They listed HIV/AIDS, Syphilis, Gonorrhea, and Cancroids which accounts 280 (87.2%), (71.7%), and 148 (46.1%) respectively. In relation to this participants were asked about the ways of transmission and symptoms of sexually transmitted infections. Majority 232 (72.3%) of the research participants knew that unsafe sexual practice is the most common way of transmitting sexually transmitted infections. Second blood contamination which accounts 200 (62.3%) was indicated as a means to transmit sexually transmitted infections. Moreover, participants knew that mother to child transmission and communal use of sharp materials were known by the respondents as a means of STIs transmission 148 (46.1%) and 154 (41.7%) respectively. Knowledge of the symptoms of sexually transmitted infections were asked. Considerable number of participants 172 (53.6%) replied that genital ulcer is the symptom of sexually transmitted infections. Moreover, burning sensation during urination, genital discharge and itching were known by research participants, 136 (42.4%), 129 (39.3%) and 114 (35.5%) respectively. The overall utilization of youth sexual and reproductive health services was 145 (42.8%) out of this utilization of services by male and female was 85 (58.6%) and 60 (41.4%) respectively. Research respondents were asked about the service type they utilized. Alternatives including family planning, treatment of sexually transmitted disease, voluntary counseling and testing for HIV/AIDS, abortion services, post abortion services, antenatal care and condom use. To this end 113 (79%), 111 (77.6%), 97 (67.8%), and 95 (65%) of the research participants replied they utilized family planning, treatment of sexually transmitted infections, condom use and voluntary counseling and testing for HIV/AIDS respectively. Moreover, 45 (31.5%), 37 (28.9%) and 32 (22.4%) of the respondents replied they utilized abortion service, antenatal care and post abortion care services in the same order.
Moreover, the issue "where did you get the service?" was raised for those who utilized any of the above services. Alternatives including youth center, health center, hospital and family guidance was presented. Health center 112 (78.3%) and youth center 63 (44%) were the major institutions where participants got RH services.
On the other hand, more than half 194 (57.2%) of the research participants could not utilize any of the RH services in the last twelve months. A question "Why not you used reproductive health service?" was presented for them with alternatives. Distance from the service providing institution, lack of knowledge, fear of getting RHS, cost of the service, no permission from parents, shame/embarrassment, culture and COVID-19 were listed as alternatives. However, distance, service cost, parental permission and cultural influences were not frequently indicated as a reason for not utilizing RHS. The reasons presented frequently by research participants were COVID-19 122 (62.2%), shame/embarrassment 115 (56.6%), other reasons not listed in the alternatives 92 (46.9%), and fear 62 (31.6%). Research participants put their answer which is different from the alternatives given. The reason why they did not utilize RH service includes; they do not need (found unnecessary), it is not my plan, my religion does not allow, I think I am not at age to use it, I do not have active sexual life and I have no time and plan to use it. In multivariate analysis, from total candidate variables, only age, marital status, living arrangement, father education level, mother education level and self determination to get RHS were found to be statistically significant association with youth reproductive health service utilization. Age of participants was found to have statistically significant association with youth reproductive health service utilization. Youths of age 20-24 years old utilized RHS 1.342 times more likely than those of age 15-19 years old (AOR=0.342, 95% CI: 0.124-1.942). Marital status of youth had statistically significant association with youth reproductive health service utilization. Married youths utilized RHS 3.420 times more likely than single youth (AOR=3.420, 95% CI: 1.088-11.065). Living arrangement of the youth had statistically significant association with utilization of RHS. The likelihood of RH services utilization of spouses was 0.142 times less likely than youths who live with their family (AOR=0.142, 95% CI: 0.032-0630).
Moreover, father education was found to be statistically significant association with youths reproductive health utilization. Youths who have fathers education level of college and above utilized RHS is 6.613 times more likely than no formal education (AOR=6.613, 95% CI: 2.363-18.505). Mother education was found to statistically significant association with youths reproductive health service utilization. Youths who have mothers education level of secondary education utilized RHS 1.334 times more likely than no formal education (AOR=0.334 95% CI: 0.133-1.936). Self-determination to get RHS was also statistically significant association with RHS utilization. Youths who said yes to get RHS without the permission of their family are 0.294 times less likely than those who wait for parental permission (AOR=0.294 95% CI: 0.149-0.581).

Discussion
In the present study 42.8% of the respondents utilize at least one reproductive health services. This result is relatively consistent with research reports done and reported in different places. For instance, a study conducted in Sodo and out of the total respondents 40.6% reported that they have ever used YRHS service in the past twelve months [20]. A study conducted in Goba town taking youth friendly sexual and reproductive health service utilization as 37.2% [21]. A study conducted in Debre Birhan reported that the overall reproductive health service utilization in twelve months was 33.8% [14].
The study considers a model that takes in to account the individual, social and institutional factors which affects the utilization of reproductive health service of youths. In this study the individual factors include socio-demographic factors (age, education level), knowledge (RHS, STIs, VCT) and shame/embarrassment. The socio-cultural factors including sex, parental education, pocket money, living arrangement, marital status and stigma & discrimination. Institution factors which is related to the health institution where RHS is provided includes availability of health institutions, cost of the service, convenient working time and health care providers attitude are discussed.

Conclusion and Recommendation
Most research participants have knowledge about reproductive health service, family planning and sexually transmitted infections. The findings of the study indicate that 42.8% of the respondents utilize at least one reproductive health services and it is low utilization. To this end among research respondents who utilized RHS, more than 50% of the respondents replied that they utilized family planning, treatment of sexually transmitted disease, voluntary counseling and testing for HIV/AIDS.
Most respondents replied that they know the presence of health institutions which provide RHS, which has separate room for the service and the time is convenient for them to get the service. Moreover, majority of the respondents replied that distance and waiting time was not problems to utilize reproductive health survive. Care providers have also positive attitude towards youth during their service provision.
The author of this research conclude that, youth have ample of information about reproductive health services (family planning and sexually transmitted infections). However, it is behind the expected level in terms of use of reproductive health services. It lacks practicability in terms of utilizing reproductive health services. As a result, programmers should think and act beyond information delivery and creating awareness for young people. Age, marital status, living arrangement, father education level, mother education level and self determination to get RHS were found to be statistically significant association with youths reproductive health service utilization.
Hence focus should be done on building skill or help youths to change their knowledge in to practice. Moreover, facilitating parent child communication, building the capacity of youth centers and increasing their decision making capacity to utilize reproductive health service is needed.