Study design and setting
An institution based cross-sectional study was conducted from May 23 to June 12, 2022. The study was conducted in East Belesa district. East Belesa is one of the districts in central Gondar zone, North West Ethiopia, Amhara regional state. It is bordered in the south by South Gondar zone, on the North by Jan Amora, on the West by West Belesa, on the North West by Wegera, and on the East by Wag-Hemra Zone. The district has 22 kebeles. The district found at 720 km far from Addis Ababa (the capital city of Ethiopia). In East Belesa there are four secondary schools those are Gohala secondary school (9-12th=4001), Zuy-Hamusit secondary school (9-12th =2846), Timen secondary school (9-10th =693) and Mukatera secondary school (9-10th =298). There were a total of 7,838 secondary school students attending their education in East Belesa district in those four secondary schools. There is only one youth friendly service clinic in the district.
Source and study population
All secondary school students in East Belesa district were the source population and all secondary school students who were attending their education in East Belesa district and who were available during data collection were the study population for this study.
Inclusion and exclusion criteria
All secondary school students who were attending their education in East Belesa district and available during data collection were included in the study. However, Secondary school students who were seriously ill (to the extent of unable to read and write) during data collection period were excluded from the study.
Sample size determination and sampling procedure
The sample size (n) was calculated by using single population mean formula: 2. Assumptions: standard deviation (11.0) which was obtained from Pilot study, 95% confidence level and a margin of error (d=1%). The total sample size was: n = (1.96)2 (11)2 /12 = 465. By considering non response rate 10% which is 47, the final sample size was 512. Stratified random sampling technique was used. The total sample was allocated to each grade (9–12) in proportion to their student size. The study participants were selected randomly by using computer-generated random numbers based on a sampling frame prepared by using their identification number (ID) obtained from their respective schools.
Study Variables
Dependent Variable
Intention to use youth friendly reproductive health services
Independent Variables
Theory of planned behavior constructs: (attitude, subjective norm, and perceived behavioral control), Socio-demographic variables (age ,sex, marital status, residence, religion, education level, living arrangement , monthly pocket money , parental occupation and parental education), knowledge, Past YFRHS utilization and past sexual history
Measurements and scoring
Youth Friendly Reproductive Health Service : incorporates general counseling services, Family planning service, VCT, using condom, Treatment of sexually transmitted Infections, and perinatal care (ANC, delivery and postnatal care), abortion and post abortion care services (11).
Past Sexual history: was assessed by asking the participants “whether they ever had sexual intercourse or not” (yes/no) (13).
Knowledge of YFRHS: Four composite score of knowledge items were used to measure the level of knowledge of the respondents regarding youth friendly reproductive health services. For each knowledge, item scores were summed up to get over all knowledge scores, individuals correctly answered the item given a value of “1” and for those answered incorrectly valued ”0”, and then mean and standard deviation were calculated. The mean knowledge score was 7.11±2.21 (α=0.75) (12,14).
Past YFRHS utilization: Utilization of at least one of the following sexual and reproductive health services within the last one year: voluntary counseling and testing (VCT), STI screening and treatment, family planning, general counseling services about sexual and reproductive health, condom use, abortion and post abortion care services, and perinatal services(antenatal care, delivery and post natal care) (4,14).
Intention to use YFRHS: Intention (readiness of the youth to use or not to use YFRHS in the next six months) was measured by using seven items with five point likert scales. The intention composite score was ranged from 7 to 35 and the higher sum score indicated higher intention to use YFRHS (α=0.93) (11).
Attitude towards YFRHS utilization: attitude (overall evaluation of YFRHS utilization as favorable or unfavorable) was assessed using four items with five point Likert scales. The sum score ranged from 4 to 20 and the higher score indicates favorable attitude towards using YFRHS (α=0.91) (4,11).
Subjective norm towards YFRHS utilization: subjective norm (perception of the social pressure to use or not to use YFRHS) was measured by using four items with five point Likert scales. The sum score ranges from 4 to 20, the higher summed score indicates the higher social pressure in favor of using YFRHS (α=0.82) (11).
Perceived behavioral control towards YFRHS utilization: perceived behavioral control (the perceived ability of an individual to control factors which influences YFRHS utilization) was measured using four items with five point Likert scales and the composite score ranged from 4 to 20. High composite scores showed strong perceived ability or less difficulty in using YFRHS services within the specified period (α=0.70) (11).
Indirect measures of attitude: Measured by sixteen items with five point likert scales, eight items from behavioral belief and eight items from outcome evaluation. Behavioral belief (one’s belief about the likely outcome of using YFRHS) was measured by using eight salient beliefs about the outcomes of using YFRHS. Outcome evaluation (one’s judgmental evaluation of the outcome of using YFRHS) was measured by asking participants to evaluate the eight salient beliefs about the consequences of YFRHS utilization. Each behavioral belief was multiplied by the outcome evaluation to produce a new variable an indirect attitude. A composite score of an indirect attitude was obtained by summing up all the eight products of behavioral belief and outcome evaluation (α=0.88) (11,15).
Indirect measures of subjective norm: Measured by twelve items with five point Likert scales. Six items were used to assess normative beliefs (one’s belief about what significant others think that he/she should or should not use YFRHS) and the response ranged from 1 (strongly disagree) to 5 (strongly agree). Each normative belief statement converted into six corresponding motivations to comply (one’s readiness to perform the behavior on the way of what significant others want him/her to do) items. Each normative belief was multiplied by the motivation to comply to produce indirect subjective norm. A composite score of the indirect subjective norm was obtained by summing up all the six products of normative belief and motivation to comply. The actual minimum and maximum score was 6 and 30 respectively. The internal consistency of indirect subjective norm was (α=0.90) (11,15).
Indirect measures of perceived behavioral control: Measured by sixteen items with five point Likert scales. Eight items were used to measure control beliefs (belief about the facilitators/barriers to use YFRHS) with responses ranged from 1 (strongly disagree) to 5 (strongly agree). Each control belief statement was converted into eight corresponding power of control (power of the controls to inhibit or facilitate YFRHS utilization) items. Each control belief was multiplied by the power of control to produce an indirect perceived behavioral control. A composite score of indirect perceived behavioral control was obtained by summing up all the eight products of control belief and power of control (α=0.89) (11,15). .
Data collection and analysis
Data was collected through a pretested and structured questionnaire after reviewing different relevant literatures (9,11,16,17) and elicitation study. Four diploma nurses as data collectors and two B.sc health officers as supervisors were trained for two days. The data was collected by interviewing the study participants by using the local language (Amharic) and translated back to English. Data was entered to EpiData version 4.6 and exported to STATA version 14 for its analysis. The results of the descriptive statistics were summarized by using mean, standard deviation, percentage, frequency tables and graphs. The assumptions of multiple linear regression was checked. Both simple and multiple linear regression analysis were conducted. Those variables which have a p-value of <0.2 in simple linear regression analysis were candidate variables for multiple linear regression analysis. Moreover, Standardized β coefficients and R2 values were used to interpret effects and variability with intention to use youth friendly reproductive health services respectively. In multivariable linear regression analysis variables having a p-value <0.05 with 95% confidence interval were considered as statistically significant.