Utilization status of sexual and reproductive health services among high school students in assosa zone; western ethiopia, 2021.


 Introduction: - Sexual and reproductive health service is critical for youths; because it does not only set the stage for health beyond the reproductive years; it also affects the health of the next generation. Youth is one of life’s most fascinating and complex life stages and accompanied by special sexual and reproductive health needs.Objective: - This study was aimed to determine; utilization status of sexual and reproductive health services and associated factors among high school students in Assosa Zone Western Ethiopia. Methods: - School-based quantitative cross sectional study was carried out among all students from systematically selected in high school of Assosa Zone. Total of 400 samples were proportionally allocated for the stratum and eligible students in were interviewed. Pretested structured questionnaires were employed to obtain quantitative data. The collected data was interred into Epidata version 3.1 and analysed using SPSS version 25 software.Results: - Over all utilization of sexual and reproductive health services by youth students was 32% in the past six months. Counseling services was the major (33.6%) service utilized and Private clinic was the major 73% place of sexual and reproductive health service utilized. Having pocket money [95 %CI (AOR=2.81(2.35, 5.09)], being sexually active [95 %CI (AOR=1.82(1.25, 3.26)], parental discussion [95 %CI (AOR=2.78(1.59, 4.67)], peer education was also significantly associated with utilization of sexual and reproductive health services. Conclusions: - Over all utilization of sexual and reproductive health service among youth students in the past six months was 32%. To improve youth’s sexual and reproductive health service utilization; increasing accessibility, awareness creation at all levels as well as making the service confidential should be interventional areas.


Introduction
Youths begin to de ne and clarify their sexual values and often begin to experiment with sexual behaviour. These typical characteristics of adolescents lead to an increased risk of various sexual and reproductive health problems, particularly in sub-Saharan Africa including Ethiopia(1).
Young people from sub-Saharan Africa are more at risk of sexual and reproductive health problems than young people around the world (2).Each year, an estimated 1.7 million adolescents lose their lives prematurely due to preventable or treatable problems such as accidents, violence, pregnancy complications and other illnesses. For these reasons, adolescent sexual and reproductive health (YSRH) is becoming an increasingly important part of global health strategy (3).
Evidence suggests that investing in the health of young people is critical to a country's socio-economic development (4).Sexual and reproductive health service is a crucial, as it is not only creates the conditions for health beyond the reproductive years; it also affects the health of the next generation (5).Youth Sexual and reproductive health services are ; access to SRH education ,information and counselling contraceptives ,Abortion services and treatments of STIs, that all people can safely reach services provided in an atmosphere of trust and con dentiality to make every contact a milestone visit. This makes it possible to successfully win, support and retain the young customers(6).Sexual and reproductive health service is fundamental human rights to which adolescents and youths are entitled, and care providers and planners should understand this adolescent's right to access SRH information and services in order to make an informed decision (7).Young people often do not have access to information about sexual and reproductive health services and how to use health services. Worldwide, around 45% of all new infections with the human immunode ciency virus (HIV) occurred in people aged 1524 years. In Africa, an estimated 1.7 million young people have been exposed to many reproductive health problems, and 60% of all new HIV infections occur in adolescents 1,519 years and older (8,9). In Ethiopia alone, there are about 87,000 young population living with HIV and 8,700 new cases among young population across the country (10).A study by the Ethiopian Ministry of Health found that 17% of young women and 14% of young men aged 20 to 24 were sexually active by the age of fteen years. The risks of neglecting YSRH are great; painful or damaging transition to adulthood can result in a lifetime of ill effects. Girls exposed to early pregnancy / motherhood can pose a physical risk and the potential can affect educational achievement and economic growth (11,12).
The incidence of premature births varies greatly from region to region. Recently it has ranged from 9.6% in Addis Ababa to 59% in Benishangul-Gumuz (13).Indeed, adolescent pregnancy is dangerous, with serious long-term and wide-ranging consequences from health complications to broader economic concerns (14).
Prevalence of sexually transmitting infections among Gonder university students was found to be 18.20% North West Ethiopia. STIs can result in long life disabilities and burdens on countries economy by increasing loss of youth lives (15).According to a study in northeast Ethiopia, 23.5 unwanted pregnancies are a leading cause of unsafe abortions. Unsafe abortions are an important contributor to maternal mortality, with an estimated 22 million cases annually and between 4.7-13.2% of maternal deaths globally (16).The study conducted in North west Ethiopia identi es that knowledge status of liberalized safe abortion among Debra Markos female students' is 41.2% only. More over Low knowledge status of abortion legality enforces the students to attempt unsafe abortion and increase mortality rates (17).Thirty four (83.9%) adolescents of 15 to 19 years and 46 (46%) 20 to 24 years old women underwent unsafe abortion(18).In Benishangul-Gumuz region, health care systems is weak and school based education and information provision of youth health was fragmented with the poor coordination between health and education sectors(19).Efforts have been made to address youth Sexual and reproductive health service problems at different levels. Ethiopia ministry of health (FMOH) launches several strategies to promote adolescents and youth reproductive health services National Adolescent and youth Reproductive Health Strategy 2007-2015 and, Standards on YFRH Services and tools for planning, implementation and monitoring of the health care system (6, 20).Irrespective of those above efforts utilization of youths SRH service is 21.21% in Nekemte town high school youth students which was below the target of Ethiopian federal ministry of AYRH strategies developed in 2016 (21) and also literatures on youth students utilization of SRH services was rare in Ethiopia.
Throughout sub-Saharan Africa countries level of SRH service is different. In Ghana 55.8% the youth had utilized at least one or more of a sexual and reproductive health service in life time (22). Malawi contraceptive Unmet Need was19% among 15-24 years in 2014 (23).Even across the regions in Ethiopian utilization of YSRH services has great variation, 32.1% in Bahirdar (24),to 69.1.1% in Mekelle town, Utilization of Youths sexual reproductive health services not only differs from one country to other, but also varies within a single country (25)(26)(27).
Some local studies that have been carried out in Ethiopia show that young people pocket a lot, residences, family life, parents' educational and economic level, unfavourable attitude and negative perceptions of parents towards health behaviour of young people, age and gender differences, marital status, death of the family, certain social cultures, taboos and other socio-economic factors have a direct and indirect impact on the use of YSRH services (25,28).
Many studies have attempted to identify factors contributing to poor YSRH service. These are: -source of information, knowledge about SRH services, sexual behaviours, self / partner trust, embarrassment, attitudes towards the SRH service, discussions about sexual and reproductive health with their family members have a signi cant in uence on the level of SRH services for adolescents (21,24,27). History of sexual practices, exposure to SRH problems were, peer education and youth preference of place, time and Health care providers (28, 29).
In Ethiopia, parents were often ignorant, preferring their children to learn from teachers, peers and healthcare professionals; Parents 'discussion of sexual and reproductive health issues in order to improve adolescents' knowledge is also signi cantly linked; The parents' discussion on issues of sexual and reproductive health in order to improve the knowledge of young people is also signi cantly linked(26, 30).
Reproductive health services can play an important role in both health promotion and prevention. However; According to the study carried out in South Africa, the existing health services in various countries are not fully accessible, affordable and acceptable for young people (31).
Obstacles to the use and access to sexual and reproductive health (SRH) services for young people are: -Lack of well-trained health care providers, costs of services and goods, service privacy, absence of YFS, inconvenient operating hours of health facilities, Low accessibility to SRH services are the main drivers of low use of SRH services, such as the studies conducted in Awabel District, Northwest Ethiopia and Woreta City, Northwest Ethiopia, and attitudes of health professionals towards AYSRH services (30,32)

General objectives
To assess utilization and factors associated with sexual and reproductive health services among high school students in Assosa western Ethiopia, 2020.

Speci c objectives
To determine utilization of sexual and reproductive health service among in high school youth students in Assosa western Ethiopia/2020.
To identify factors associated with utilization of sexual and reproductive health service among in high school youth students in Assosa western Ethiopia, 2020.

Study area
This study was carried out in the Assosa Zone in western Ethiopia. This zone has a city administration and a total population of 89,232, of which 44,906 men and 44,326 women, and is located 670 km southwest of the Ethiopian capital Addis Ababa. According to reports from the Benishangul Gumuz Zone Education Bureau, there were 16 high schools in the Assosa Zone, with an estimated number of 50 students per class. In terms of health facilities in the Assosa region, there were 1 general hospital, 2 health canters, 6 private clinics and 5 health stations(33).

Study periods
The study was conducted from March 2-13/2020 among high students in high schools in Assosa Zone western Ethiopia.

Study Design
School-based quantitative cross sectional study was carried out among selected students in high school of Assosa Zone administration western Ethiopia.

Source population
Students In high schools found in Assosa zone administration registered for 2019/2020 academic year.

Study population
All students from randomly selected sections

Study participants
Eligible students from randomly selected students of the high schools 3.5 Inclusion and exclusion criteria 3.5.1 Inclusion criteria All students attending high school education during study period were included.

Exclusion criteria
Students those declare illness during data collection period were excluded 3.6 Sample size determination The required sample size was determined by using single population proportion formula by considering the following assumptions-P= 38.5% (as an estimated prevalence of sexual and reproductive health service utilization in the past one year among high school youths taken from the study conducted in Hadiya Zone(34) southern nation and nationalities and peoples State of Ethiopia. By considering 95% con dence level = 363.8 = 364 By adding 10% of non-response rate the nal sample size was400

Sampling techniques
After stratifying eight high schools into grades (9th, 10th, 11 th, 12th ) the total of 400 samples were allocated proportional to the size of the student they have. Grades were heterogeneous and students in the same grades were homogeneous; by considering that until allocated sample were gained the required students selected from each stratum by lottery methods and self-administered questionnaires were distributed for eligible students

Operational de nitions
Use of Sexual and Reproductive Health Services: -Was assessed based on student practice, one or more components of the SRH service (contraception, treatments for STIs, VCT of HIV, abortion service, SRH information education and counselling, and pregnancy test for the last six months (21,30).
Youth students -students those in between 15-24 years age group and enrolled in high schools.
Sexually active -having a previous history of sexual intercourse.
Knowledgeable: -Students' knowledge of sexual reproductive health was determined by the average score of six knowledge questions created by true or false dictation answers. Teens who scored lower than the mean were inexperienced and those who were knowledgeable were scored higher than or equal to the mean of the knowledge questions (21,30,34).
Favourable attitude: -The attitudes of students to sexual and reproductive health were determined using six attitude questions, which were created with a Liker-Scoring-System. Adolescents with positive attitudes scored greater than or equal to the average liker score points, and those who scored less than the average liker score on the attitudes questions had an unfavourable attitude(21, 28, 35).

Data collection instruments
For data collection, a structured, self-administered questionnaire was adopted in English after reviewing various literatures and modi ed depending on the local situation and research objective. It was rst developed in English and then translated into Amharic and translated back into English to check its consistency. The questionnaires contain questions about demographic and socio-economic factors, individual factors, health institutions and family-related factors.

Data collectors
Two Supervisors with back grounds of MSC maternity and reproductive health and four data collectors of two BSC nurses two BSC midwifes were trained to assist students and monitor overall data collection process. In order to identify the clarity of questions and their sensitiveness, pre-testing of the instrument will be done on 5% of the students among non-selected students. During the pre-test; discussion was held with the students on any problem they encountered during lling of the questionnaire.

Data quality management
Data quality was assured through careful design of the questionnaire. Data collectors and supervisors were trained in one day about the purpose of the study, the questionnaire in detail, the data collection procedure and the rights of study participants. Pre-test was done prior to the actual data collection. The collected data were checked for completeness and consistency after each day of data collection by holding a meeting with the data collectors.

Data processing and analysis
Data was coded, cleaned and entered into Epidata version 3.1 and analysed by SPSS Version 25 for the analysis and collinearity check by SPSS. Variable with P-value <= 0.25 in bivariate logistic analysis were transferred into multivariate logistic analysis .Frequency, percentages, proportions, odds ratios, were computed. Adjusted odds ratios with the 95% con dence interval and p-value of less than 0.05 were considered to be signi cant

Ethical Consideration
Ethical approval was obtained from Bahirdar University, institutional review board, Research ethics and letter of permission was obtained from Benishangul Gumuz Regional educational bureau. The purpose of the study was explained to youth students and a written informed consent was obtained from the participants. Con dentiality of information was maintained by omitting any personal identi er from the questionnaire.

Socio demographic Characteristics of participants
A total of 375 students were participated in the study which makes response rate of 94%. One hundred sixty eight (44.8%) females and (55.20%) were males. Over all participants age fall in age 20-24 one hundred ninety seven (52.5%). Three hundred thirteen (83.5%) single and one hundred fourteen were Oromo (30.4%) followed by Amhara (25.3%) and the three smallest ethnic groups were Mao and Komo and Tigre(7.2%) grouped under other by ethnicity. Based on religious; majority of them (31.54%) were Orthodox religious followers.

Characteristics of youths' families
Regarding to youth families characteristics; from the total respondents, 36% were living with their friends/peer, followed by 33.86%living with both parents and the rest were either with father only or mother only. Regarding educational status of their parents, 36.5%of their fathers were secondary and above and maximum numbers of their mothers (29.6%) were attended primary education. The higher proportion of the youths stated as they discussed sex related issues with their mothers 56.8% than they discussed with their fathers 36.8%.Small number of the students 14.1% described as their family monthly expenditure <=2000 and majority of them described as 70.4% as monthly expenditures 2001-4000 of their families.

Knowledge, attitudes towards SRH services and sexual practices
All study participants were asked to select services they know provided under youth SRH and two hundred nineteen 58.4% and one hundred eighty 48% of them knows Voluntary counselling and testing of HIV and contraceptives/condom as service given under youth SRH services consecutively. The other less known components were Pregnancy test 11931.7% and One hundred ten 29.3%abortion services followed by the least known services was treatment of sexually transmitted infections by 99 25.5% of youth students.

Source of SRH information
Two hundred fourteen 62.7% of the students knows STIs as HIV/AIDS only. Fifty ve students 14.6% fail to state any sexual and reproductive health services. Friends and teachers were reported by 54.2% as time main source of information related to reproductive health services and posters6.9%was the least .The majority of the participants eighty two (67.8%) responds as private clinic as the likely place to receive SRH services followed by 24.8%as governmental health facilities. For the purpose of knowledge assessments out of six questions on SRH services with the score out of six with dichotomous forms yes or no response provided. One hundred fty six (41.6%) were knowledgeable and two hundred nineteen 58.4% were not knowledgeable of SRH service areas.
Regards to attitudes of youths towards SRH services six attitude questions with ve liker scale from strongly agree to strongly disagree ranging from a minimum score of 6to 30 maximum were provided. Two hundred fty four (67.7%) of the students have favourable attitude towards youths sexual and reproductive health services (32.3%) have no favourable attitude. Majority of the participants agreed on the statements SRH service is important for youths; youths have a right.

Sexual behaviours of participants
Out of the 375 participants26.4% of them already sexually initiated and the rest were not and61, 6% were premarital sexual practices .Due to different reasons more than fty percept of 60(73.3%) them didn't use contraceptive during the rst sexual events. Didn't perceive sexual and reproductive health problems 44.4%,fear of family and community 35.4% and 20.2% of them missed due to unavailability of service facility near to living areas. The mean age of rst sexual intercourse was at 14.5 with a standard deviation of 2.0 years.

Youth preference of Place, time and health care provider
Regarding to youth preferences of health facility SRH services, majority of the 66.1% prefer youth center and 5.9% of them prefers anywhere with privacy. In addition special service hour youth prefers was during the time when there is no more patients 360 (96%) and usual working hours 3.7%. Youths also prefers Health care providers for SRH services deviates to Young providers of the same sex 44.5%, followed by Young and any sex were prefers 32.8% health care providers.

Utilization of Sexual and reproductive health Services
This study reveals that 32% [95% CI (26.9, 36.8)] of the participants had utilized at least one component of sexual and reproductive health services in the past six months. The SRH service they received were SRH information, education andCounselling22%, contraceptive/ or condom17.6%, and the least service utilized was abortion services by2%of students. The rst place of SRH services utilized was private health facilities 51.2%followed by governmental health facilities26.5%), family guidance association 17.5% and 5% students respond that they utilized from traditional healers.

Reasons of youth students not used SRH services
The main reasons of youths not utilized SRH services were lack of separate room 21.3% and Judgmental attitude of health care providers 16.8%, too young to get the services 12.2%, no awareness of service 11.8%, fear of parent 11%,cost of service and commodities 7.1%,inconvenient service location and lack of youth clinic 11.8%, distance of the facility and inconvenient service hours 8.5%were common reasons of youths not utilized SRH services.

Factors associated with use of Sexual and Reproductive Health Service
The effects of different independent variables were tested for utilization of sexual and reproductive health services using logistic regression analysis. With an intention of controlling confounding effect, variables that were statistically signi cant with sexual reproductive health service utilization on bivariate analysis were interred in to multivariable in logistic regressions.
During multivariate logistic analysis Age, discussion with mother, peer education, pocket money, and distance of the facility were signi cant. The likely hood of SRH service utilization was 2.

Discussion
Utilization of sexual and reproductive health services among youth students of highs schools in Assosa zone was found to be 32% with 95% CI (26.9, 36.8), elicited by asking the past six months use of SRH services before the date of data collection. This nding is similar with study done in Bahir Dar city Ethiopia had reported (24).The possible justi cations for this similarity might be due to the educational level of participants and socio demographic characters. In other way report of this study is lower than the study done in Mekelle town North Ethiopia (25) which was 69.1% of youths used youth friendly services in the past one year.
On the other hand this nding is greater than study conducted in Nekemte town North east Ethiopia (21) which was 21.21%, and in Machakel district 21.5%, Northwest Ethiopia(36) of youth utilize SRH services. For these possible discrepancies, it might be due to differences in the availability and accessibility of youth friendly sexual and reproductive health facilities or the availability of youth canters, and/or difference in individual /socio-demographic characteristics of the study participants.  (40,41).Possible explanation of this discrepancy is Still the observed proportion is not adequate to say youths are knowledgeable in sexual and reproductive service areas.
This study also identi ed that history of sexual initiation was signi cantly associated with SRH service utilization. In which the students those ever had sexual intercourse were 1.8 times more likely to utilize SRH services than their counter parts [(95% CI) AOR= 1.8 (1.25,3.26)]. This is in line with the study done in Southwest Oromia, Ethiopia(28).Possible justi cation of this may be sexually active respondents were more exposed to SRH problems thus they were concerned about their sexual and reproductive heaths than responds those never sexually initiated.
Having pocket money also signi cant predictor of SRH service utilization in this study, Those had pocket money for daily expense were 2.8 time more likely to utilize SRH service than those had no pocket money [(95% CI) AOR= 2.81 (2.35, 5.09)]. This nding is in line with the study conducted in Woreta town, North West Ethiopia (32).The possible explanation of this association is, since sexual and reproductive health problems necessitates privacy thus youths with pocket money can use services like treatments of STI and condoms without asking help from others.

Limitations of the study
Since this study examines personal and sensitive issues, obtaining honest responses among youth students might have been di cult. Therefore researchers better focus on qualitative study on such sensitive study.

Conclusions
This study identi ed that utilization of sexual and reproductive health services was low to achieve 2016 strategies of Ethiopian ministry of health developed on youth's reproductive health. Youths who had pocket money for daily expense, had a parental discussion on sexual and reproductive health issues, peer education and knowledge status ofyouth on sexual and reproductive health services were predictors of youth sexual and reproductive health service utilization.
Abbreviations OR: odds ratio; CI: con dence interval; NOS: Newcastle-Ottawa Quality Assessment Scale; SNNPR: Southern Nations Nationalities and People Region; AIDS: Acquired immunode ciency syndromes; AY: Adolescence and Youth; EDHs: Ethiopian Demographic and Health Survey; YSRH: youth sexual and reproductive health; WHO: World Health Organization. Declarations 1. Hunduma Dina: -Developing proposal, analysis, and interpretation of the result, manuscript writing and summation.
2. Simachew Kassa:-Proposal evaluation, analysis and interpretation of the results 3. Shumiye Shiferaw :-Proposal evaluation, interpretation of the results and support me manuscript preparation All the authors read and approved the nal manuscript

Funding information
There was no funding source for this study Availability of data and materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
Ethics approval and consent to participate Not applicable.

Consent for publication
Not applicable.