This study aimed to compare differences in SRH services utilization among high school adolescents from youth friendly service implemented and non-implemented areas, and to identify independent factors for SRH service utilization.
In the study, adolescents from high schools where health facilities had not yet implemented YFS had a lower utilization of SRH services compared with health facilities which implemented YFS. This can be justified as having access to various SRH services in an environment that is tailored to adolescent’s age, sociocultural and economic contexts would increase the utilization of the services [11]. Furthermore, adolescents living in YFS implemented areas have higher probability of getting information regarding SRH services and health professionals working in the YFS centers may have brought change in norms of the community living around the centers [23]. The finding highlights a need for scale up of the existing YFS sites to non-implemented sites so that SRH services can be promoted to all adolescents and youths.
Majority of the respondents in the present study had not utilized SRH services owing to varied reasons. Lack of privacy was the most commonly reported reason for not using SRH services. Health professionals’ attitude, embarrassment in receiving the services and perceived inadequacy of medical equipment were also the reasons listed by the participants. This finding was consistent with findings from studies conducted in East Gojam, Nekemte, and Tanzania [6, 21, 24]. Mostly, they feared that their parents would find out their visit to the clinic. This implies that there is a need of tackling the barriers by dealing with health professionals, community leaders and with the adolescents themselves. Due emphasis should be given to increase the capacity of health care providers so that they can deliver services without imposing their own and socially endorsed moral frameworks on the adolescents’ sexual behavior. In addition, there is a need to address the cultural, religious and traditional value systems that prevent health professionals from providing a better quality and comprehensive SRH services to the adolescents. The current study showed that adolescents’ whose mother’s attended secondary and higher education were having higher odds of utilization of SRH services. This finding is in agreement with a study conducted in Asgede-Tsimbla district, East Gojam and Gondar [1, 6, 22]. This can be explained that women at higher level of education might have been more open to discuss SRH issues with their children. It might have also been related to the fact that women at higher level of education would have a better access to SRH messages and would be more flexible to deal with their children or investigate for any problems their children encounter regarding SRH services use. In contrary, studies from Debre Berhan and Woreta towns showed no association between maternal education and adolescents’ SRH service utilization [5, 10]. The variation might have been emanated from socio-cultural differences in the Northern and Southern Ethiopian regions. In the current study, knowledge and attitude of adolescents on SRH services showed a significant relationship with the presence or absence of YFS centers in their locality. Positive attitude and good knowledge was higher among adolescents from schools where YFS centers were established in the health centers. It is plausible that adolescents living in areas where youth friendly services were established would get appropriate information from their in-school and out of school peers through the organized peer education delivered in the YFS centers. The presence of the peer support system could be a source of attraction to the youngsters and might have resulted in having a good knowledge and favorable attitude since trained health care providers and the peers provide health education to youths in the YFS implemented areas [14-16].
Likewise, the odds of utilizing SRH services were higher among adolescents’ having good knowledge than their counterparts. This finding is consistent with the studies conducted in East Gojam, Harar town, Lao PDR and North Shewa zone [6, 13, 25, and 26]. This can be justified as adolescents with good knowledge had adequate information regarding the consequences of SRH problems. It is better to use YFS sites as a learning center for adolescents as lack of knowledge makes them vulnerable to unsafe reproductive health behavior and inappropriate choices. Some of these choices may have undesirable effects on their reproductive health in the future such as unplanned pregnancy, STI infection, HIV/AIDS and other sexual and reproductive health problems. The effects of these wrong choices are manifold with some capable of lasting for a lifetime. These potential human resource and future leaders end up as school dropouts. Additionally, these would have social and economic implications to their households and the nation as a whole.
The current study assured that adolescents with favorable attitude towards SRH services were more likely to utilize SRH service as compared to their counterparts. This could be explained by the fact that having a positive feeling towards the services derives initiation to seek SRH services. The finding is supported by the study conducted in Lao PDR [25] which reported that the prevailing negative cultural attitudes were the main barrier for Lao youths to access SRH services.
Moreover, this study showed that adolescents who ever discussed on SRH issues with their families were more likely to utilize SRH services than adolescents who never discussed on SRH issues with anyone. This finding is analogues with other studies elsewhere, which reported ever discussion on SRH issues was an independent predictor for SRH service utilization among adolescents [1, 5, 27]. Communicating SRH issues with parents is very crucial for adolescents so as to advance their awareness of SRH issues. Moreover, such discussions (especially if the family members have good knowledge on reproductive health problems and reproductive health services) increase adolescents’ feeling of self-trust and there by urge their SRH seeking behavior. This implies that adolescents who discuss SRH issues with their family would have a better knowledge and awareness about SRH services and thus would be motivated to use the services [28]. In contrary, finding of this study is not supported by the study conducted in North Shewa which reported that adolescents who never discussed on VCT services were significantly more likely to use the service than adolescents who had discussed on the service [26]. This difference can be justified by adolescents who have information and have discussed SRH services with different individuals may not think they need SRH service because they perceive a low risk, which shows there is a gap in continuity of discussion, communication, and information to bring behavioral change. These contradictory findings call for a further investigation to the effect of discussion on SRH issues with a family or peers on the subsequent SRH service uptake.
Policy recommendations
There is a need for more efforts in order to scale up SRH services in YFS non implemented areas among the stakeholders at different hierarchies. In addition, it is better to promote open discussion with adolescents at the family level, and emphasis should be given for women education in the broad sense. Furthermore, wide-range awareness creation strategies should be used to address poor knowledge and negative attitude.
Power of the study
Based on findings from the study, power was calculated using STATA software Version 13 with a significance level of 0.05, sample size (N)= 458, P1= proportion of youths from YFS not implemented areas and who utilized SRH services=9.9%=0.099, P2= proportion of youths from YFS implemented areas and who utilized SRH services=33.8%=0.338, and allocation ratio=1. Based on this assumptions and values, the power was estimated to be 1.
Strength and limitations of the study
This study is the first of its kind in comparing SRH service utilization among adolescents in the YFS implemented and non-implemented areas. Moreover, the power estimated after conducting the study was high which refers to the inclusion of adequate samples to see the difference in the two groups.
However, the study has some limitations to consider. As this study was cross-sectional, the factors do not establish temporal relationship; therefore, inference of causation is not possible. Had it not been for resource limitations, the study would have been better if it were a longitudinal study which compares SRH service among adolescents in YFS implemented and non-implemented areas. However, this cross-sectional comparison would provide useful information as an input to future studies of longitudinal nature. Recall bias may also affect responses related to SRH service use over the last one year and this might have resulted in either over or under reporting for the presence of both undesirable and desirable sexual and reproductive health practices and events as responses in the questions [29]. The recall bias might be more of a concern among YFS-non implemented areas as these areas had a lessor chance of getting peer education which would help as a cue for memory. There could also be a social desirability bias particularly among adolescents from YFS implemented areas for such adolescents might expect that SRH service use is appropriate to their family and society at large. Moreover, the quantitative study did not allow for probing into certain variables like cultural issues and perception. This implies a need for further qualitative study to complement the findings of this study.