Keywords

Youth; Youth friendly services; Sexual and reproductive health; Utilization

Abbreviations

HCT: Human Immunodeficiency Virus Counselling and Testing; HIV: Human Immunodeficiency VIRus; HTPs: Harmful Traditional Practices; STIs/ Ds: Sexually Transmitted Infections/Diseases; WHO: World Health Organization; VCT: Voluntary Counselling and Testing; YFS: Youth Friendly Services; YFSRHS: Youth Friendly Sexual and Reproductive Health Services

Introduction

Though youths are faced with immense Reproductive Health (RH) problems, they have limited access to quality RH services and information that are specially designed to meet their needs. Available reproductive health services are adult-centred. Thus, they are less accessible to youths. Factors like non youth friendliness of the existing service outlets and the limited economic and physical access this group of the society has to the available services are among other factors contributing to their low access and utilization of existing services [1].

Recent estimates indicate that 17.0% of the global population, 20.0% of Sub-Saharan Africa and 17.9% of Ethiopian population is composed of youths aged 15-24 years. Globally youths are facing different sexual and reproductive health (SRH) problems like unwanted pregnancy, unsafe abortion, sexually transmitted infections (STI) including human immune deficiency virus (HIV). But they are usually mistakenly perceived as healthy and as if they are not in need of special health services [2,3].

In Ethiopia over 65% of its population is under the age of 25 years and the country’s youths have profound reproductive health needs. 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, STI, and acquired immune deficiencies (AIDS). Lack of education, unemployment, and extreme poverty exacerbates and perpetuate the reproductive health problems faced by Ethiopian youth [4].

The type of sexual and reproductive health services (SRHS) intended to be provided at Youth Friendly Service (YFS) outlets varies and involves service delivery points both within and outside the public health system. However, with the establishment of appropriate referral linkages between the different service outlets, it would be possible to ensure that youth get a combination of different primitive, preventive, curative and rehabilitative services rendered at the different service outlets [5,6].

The range of comprehensive youth friendly SRHS youth need to get should include the following: information and counselling on Reproductive and Sexual Health issues and sexuality, Promotion of healthy sexual behaviours through various methods including peer education, family Planning information, counselling and methods including emergency contraceptive methods, condom promotion and provision, testing Services: Pregnancy, HIV testing and counselling (HCT), management of sexually transmitted infections. Antenatal care, Delivery Services, Postnatal Care and prevention of mother to child transmission (PMTCT), abortion and Post abortion care, appropriate referral linkage between facilities at different [6].

Materials and Methods

Community based quantitative cross sectional study design was conducted among youths of Bale zone. Bale zone is found in Oromia Regional State at 430 kms away from Addis Ababa which is the capital city of Ethiopia in the south eastern direction. Agarfa, Goro, Jara and Gasera towns were among the towns with health centers that provide youth friendly services in the zone. In each town there is one public health center providing youth friendly services. According to the reports obtained from district health offices of each town these health centers are currently providing YFS like Information and Counselling on Sexual and Reproductive Health, Promotion of healthy sexual behaviours through various methods including peer education in schools, Family Planning information, counselling and methods including emergency contraceptive methods, condom promotion and provision, Pregnancy test and HCT, management of STIs, prevention of harmful traditional practices, Antenatal care, Delivery Services, Postnatal Care, PMTCT, safe Abortion and Post abortion care. The study was conducted in March, 2015. Youth who were the residents of the four towns and selected for the study were included in the study.

Sample size determination

A single population proportion formula was used to estimate the sample size.

The following assumptions were used to estimate the required sample size above:

P= 63.8% from the study conducted in Harar on YFS utilization [7].

α= 5% level of significance d= 5% maximum tolerable error

Considering ten percent non response rate the final sample size become 354+36=390

Sampling procedure

Four towns with health centers providing youth friendly sexual and reproductive health services were selected for the study. The total youth population of the four towns according to the information obtained from each districts health offices were around 17,812 that is (Agarfa town-6675, Goro town-4450, Gasera town-3570, Jara town-3116). The total sample size was proportionally allocated to each town based on the size of youth population of each town: Agarfa (146), Goro (98), Gasera (78) and Jara (68). The total house households in the selected four towns were 4887 (Agarfa town-1709, Goro town-1059, Gasera town- 1160 and Jara town-959). Systematic random sampling technique was used to select individual participants at house hold level with sampling interval of 12. Random selection was done in the case of households having more than one youth.

Data collection method and instruments

Structured, pre-tested and interview administered questionnaire which was developed by reviewing various relevant literatures to the topic was used. Four data collectors were involved in the pretesting and actual data collection process after training was given by the researchers.

Data processing and analysis

The data were entered into IBM statistics SPSS version 21.0. Then, the entire data were cleaned and edited for any factual errors. Descriptive, bivariate and multivariate logistic regression was used to assess the factors associated with YFS utilization. Those variables with p-value of ≤0.2 at bivariate analysis were taken for multivariate logistic regression analysis. p-value of <0.05 was considered as a cut off value to declare statistically significant association.

Data quality assurance

The questionnaire were prepared in English and translated to local language Afan Oromo and then retranslated to English language to check its consistency. Pre-testing was conducted on 5% of the sample size at Robe town before the actual data collection and then modification of the tool was made accordingly. To check an internal consistency of the questions prepared to measure attitude and knowledge Cronbach’s alpha coefficients was used. A 0.7 was considered for its lower limit. The data collectors were given training about data collection process. On top of this, supervisors followed the data collection process and the investigators were also followed the collected data at each step.

Ethical considerations

After obtaining ethical approval from Madda Walabu University research and community service directorate, a supportive letter was given to Agarfa, GoroJara and Gasera district health offices to get formal permission to conduct the research. Explaining the purpose of the study, verbal consent was obtained from each participant whose age is in between 18 and 24 years. However, for those whose age range is 15-17 years assent was obtained from their parents/guardians. The respondents were told that they have the right to respond fully or partially to the questionnaire or refuse to participate at all. All the information given by the respondents was used for research purposes only and confidentiality was maintained by omitting any personal identifiers of the respondents.

Results

Socio-demographic characteristics of study participants

A total of 382 youth were participated in the study making the response rate of 97.9% of which 213 (55.8%) were females. The mean age of the study population was 18.97 with standard deviation of 1.97 years. As to their marital status 327 (85.6%) of the participants were single. Majority 319 (86.5%) of youth belong to Oromo ethnicity followed by 42 (11%) Amhara ethnicity. With regard to youth living condition higher proportion 281 (73.6%) live with their parents. One hundred twenty two (31.9%) of the youth mothers were attended secondary and above level of education (Table 1).

Table 1: Socio demographic characteristics of youth in Bale zone Ethiopia March, 2015.

Past sexual history and awareness of YFSRHS

Regarding the past sexual history only 151 (39.5%) of the youth ever had sexual intercourse in the past. The mean age for sexual debut was 17.13 years with the standard deviation of 2.34 years

Among those who ever had sexual intercourse 88 (58.3%) started sexual intercourse before the age of 18 years and 21 (13.9%) reported that they had ever acquired STIs in the past.

According to this study majority 367 (96.1%) of youth had ever heard about youth friendly sexual and reproductive health services (YFSRHS). The most commonly mentioned source of information for YFSRHS was from the media 270 (73.6%) followed by from the health care professionals 167 (66.5%) (Table 2).

Table 2: The frequency of selected variables among youth in Bale Zone Ethiopia March, 2015.

Youth friendly sexual and reproductive health service utilization

From all youth who had ever heard about YFSRHS only 172 (46.9%) had ever been used youth friendly sexual and reproductive health service and the rest 195 (53.1) didn’t ever used YFSRHS (Figure 1).

Figure 1: Youth friendly service utilization among youth in Bale zone Ethiopia March, 2015.

The reasons for utilizing YFSRHS

According to this study from the users of YFSRHS the reasons for utilizing the services mentioned by 105 (20.6%) of youth was for treatment of all health problems and for perceived harmful traditional practices (HTPs) followed by for voluntary counselling and HIV testing service 102 (20%) (Table 3).

Table 3: The frequency of the reason to use YFSRHS among youth in Bale Zone Ethiopia March, 2015.

The reasons not to use YFSRHS

This study revealed that more than half of the study participants 195 (53.1%) not ever used YFSRHS. From all the non-users of YFSRHS, the paramount justification for not to use the services stated among 132 (67.7%) was because they were not ill to use the services followed by lack of information about the services 59 (30.3%) (Figure 2).

Figure 2: Reasons not to use YFSRHS among youth in Bale zone Ethiopia March, 2015. (Other reason mentioned - don’t want to go for such service).

Factors associated with YFSRHS utilization among youth in towns of Bale zone

As per multivariate logistic regression analysis, age category of the youth, ever have had sexual intercourse, age at first sexual intercourse, ever acquiring sexually transmitted diseases and attitude towards YFSRHS were found to be significantly associated with YFSRHS utilization.

YFSRHS utilization was more than 7 times higher among youth in the age category of 20-24 years than youth in the age category of 15-19 years (AOR (95% CI)=7.64 (1.36,15.02)). Those who ever had sexual intercourse were 5 times more likely utilized YFSRHS when compared with those who didn’t have had sexual intercourse (AOR (95% CI)=5.08 (7.04, 10.91)). Youth whose age category is in the range of 15-19 years at first sexual intercourse were more than 4 times likely use YFSRHS than youth whose age category is in the range of 10-14 years at first sexual intercourse (AOR (95% CI)=4.33 (3.36, 7.26)). Youth who ever acquired sexually transmitted diseases were more than five times more likely to use YFSRHS than their counterpart (AOR (95% CI)=5.08 (4.04,9.96))

Knowledge of YFSRHS was not significantly associated with the use in the multivariate logistic regression analysis. But, YFSRHS utilization was found to be statistically significantly associated with attitude of the youth towards the service. Those whose attitude was favourable were more than 6 times more likely to use YFSRHS when compared to their counterpart (AOR (95% CI) =6.491 (1.39, 30.49)) (Table 4).

Table 4: Factors associated with the use of YFSRHS among youth Bale Zone Ethiopia March, 2015.

Discussion

Youth tend to be less informed, less experienced, and less comfortable in accessing reproductive health services than adults. They often lack basic reproductive health knowledge and access to affordable and confidential health services [8]. This study tried to assess the level of youth friendly sexual and reproductive health service utilization and associated factors among youth in towns of Bale zone. According to this study majority 367 (96.1%) of youth had ever heard about youth friendly sexual and reproductive health services (YFSRHS). The most commonly mentioned sources of information about YFSRHS were from the mass media 270 (73.6%) followed by from the health care professionals 167 (66.5%). This finding is consistent with the finding of study conducted in Jimma town where the major sources of information for reproductive health were radio for (80.4%) and television (73%) and school teachers for (71.8%) of respondents [9]. The overall prevalence of youth friendly sexual and reproductive health service utilization among the study participants in this study was 172 (46.9%). When compared with the result of the study conducted in Harar which revealed youth friendly sexual and reproductive health service utilization prevalence of 845 (63.8%) it is lower, the possible explanation for the difference might be the study setting as Harar town is relatively more urban compared with the current study towns and the services accessibility, availability and delivery system might be better which in turn affects the services utilization [9].

The result of this study is comparable with the result of study done in West Hararghe where (42.1%) of the study participants were used YFSRHS in the existing health institutions at the time of the survey. It is higher when compared with the study conducted in the AAU students that showed YFSRHS utilization among youth of age (15-24) years of (14.6%). The reason for such higher prevalence in this study might be explained in terms of the difference in time gap between the two studies as there is progress in promotion and expansion of youth friendly services which possibly contribute for the higher utilization in the recent study [10,11]. In this study from the total study participants about 151 (39.5%) of the youth were already had sexual intercourse at the time of the survey. This result is in line with the result of the study conducted in republic of Vanuatu where around half (50.4%) youth reported ever having sex and from those who were sexually experienced, the majority had commenced sexual activity between the ages of 15-19, although 8.5% reported sexual debut before the age of 15 [12].

As to the reasons for using YFSRHS, majority of the youth 105 (20.6%) used for perceived (HTPs) and for treatment of all health problems followed by for the purpose of voluntary counselling and HIV testing service 102(19.4%). This result is in line with study done in Kiambu county district, in Kenya where the youth used the services for family planning (29.5%), used for voluntary counselling and HIV testing services (38.7%), and for STIs treatment (9%) and also in line with the study done in Vanuatu where (59%) of all youth attended YFS clinics for family planning and 26% for STIs treatment [13,14].

The result in this study is not in line with the report of Assessment of Youth Reproductive Health Programs in Ethiopia where youth centers in Addis Ababa were mostly visited by the youth for services like library, recreation and for sharing of information between the youth. The possible reason for the difference with this report might be the difference in the focus of the studies; this study was focused on SRHS [4].

This study revealed that more than half of the study participants 195 (53.1%) not ever used YFSRHS. The main reasons mentioned by study participants for not using the services includes they were not ill to use the services which accounts 132 (67.7%) followed by lack of information about the services 59 (30.3%). This result differs from the result of the study done in Harar where only 36.2% of the youth didn’t used YFSRHS and the reasons mentioned for not to use the services were the youth did not know where to go for such services(43%) followed by distance from the service site (18.7%) [7]. The possible explanation for the difference in reasons not to use might be the time lapse between the two studies which may be linked with current accelerated expansion and promotion of youth services than the previous period. Youth friendly sexual and reproductive health service utilization among youth in the age category of 20-24 years is more than 7 times higher compared with youth in the age category of 15-19 years [AOR (95% CI)=7.64 (1.36, 15.02)].

This finding is not in line with the result of the study in AAU where age group of the youth was not significantly associated with YFSRHS utilization [11]. The possible explanation for the difference might be due to age grouping difference. Youth who ever had sexual intercourse were also more than 5 times more likely to use YFSRHS than those who didn’t have had sexual intercourse [AOR (95% CI)=5.08 (7.04, 10.91)]. The possible reason for this might be those who ever had sexual intercourse may expect unwanted outcomes of sexual intercourse that push them to seek for health services in general and for YFSRHS in particular.

In this study youth who ever acquired sexually transmitted diseases were more than five times more likely to use YFSRHS than youth who didn’t acquired [AOR (95% CI)=5.08 (4.04,9.96]. This might be due to the fact that youth who acquired STDs are more likely search for treatment of their health problems compared with their counterpart. Knowledge of the youth about YFSRHS was not significantly associated with the use of YFSRHS whereas, attitude towards YFSRHS was found to be significantly associated with YFSRHS utilization. Those whose attitude was favourable towards YFSRHS were more than 6 times more likely to use YFSRHS when compared to their counterpart [AOR (95% CI) =6.491 (1.39, 30.49)].

Conclusion

Nearly all of the study participants were ever heard about youth friendly sexual and reproductive health services. More than half of the study participants were already sexually active before the age of 18 years and had not ever used YFSRHS. The paramount justification for not to use stated were because they were not ill to use the services and lack of information about the services. Ever have had sexual intercourse, age at first sexual intercourse, ever acquiring sexually transmitted diseases and attitude towards YFSRHS were found to be significant predictors of YFSRHS utilization. Hence, interventions targeting the youth have to be implemented.

Author’s Contributions

AA has taken a leading role in writing the proposal, submission and follow up for ethical review, data collection, data entry, and writing of the preliminary results. TB, KA and RA participated in the planning of the study and critically reviewing the manuscript. TB, KA and RA have also involved significantly in the analysis and writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgments

First and for most we are indebted to Madda Walabu University for funding this research. We would like also to thank all youth who participated in this study by scarifying their valuable time to respond to questions and for their cooperation. We are also grateful to all staffs of Madda Walabu University for their constructive comments and suggestions starting from proposal to this final paper.

References

1. Ministry of Health (2006-2015) National Reproductive Health Strategy: Federal Democratic Republic of Ethiopia, Ministry of Health, Addis Ababa, Ethiopia.
2. Fonds C (2005) Training in Sexual Health Research. GFMER /WHO, Geneva.
3. Mesganaw F (2001) Notes on maternal and child health-reproductive health for master of public health students.
4. FHI/USAID (1991) Assessment of Youth Reproductive Health Programs in Ethiopia, Youth Net Institute of Development Research: Lecture papers on population and development, Addis Ababa, Ethiopia.
5. Valentina, B, Alex P (2009) M Youth-friendly health policies and services in the European region, Europe.
6. UNICEF, UNFPA, WHO (2009) Standards and minimum service delivery package on youth friendly reproductive health Services.
7. Aboma M (2012) Youth-friendly Health Services Utilization and Factors in Harar, Ethiopia. Harar Bulletin of Health Sciences in 2012, Extracts number p. 4.
8. World Health Organization (‎2003)‎ Adolescent friendly health services: An agenda for change.  World Health Organization, Geneva.
9. Ayalew T, Meseret Y, Yeshigeta G (2008) Reproductive Health Knowledge and Attitude among Adolescents: A community based study in Jimma Town, Southwest Ethiopia. Ethiop J Health Dev 22: 3.
10. Ahmed A (2004) Youth reproductive health problems and service preferences, Assebe Teferi West Hararghe.
11. Yordanos B (2008) Reproductive health needs and service utilization of Addis Ababa University Students, Ethiopia.
12. Kennedy EC, Bulu S, Harris J, Humphreys D, Malverus J, et al. ( 2013) Be kind to young people so they feel at home: A qualitative study of adolescents’ and service providers’ perceptions of youth-friendly sexual and reproductive health services in Vanuatu. BMC Health Services Research 13: 455.
13. Obonyo P (2009) Determinants of utilization of youth friendly reproductive health services among school and college youth in Thika West District, Kiambu County, Kenya.
14. Joe K (2007) Utilization of Adolescent Reproductive Health Services by Young People in Vanuatu. UNFPA Office for the Pacific. p: 41.