Motivational factors influencing readiness to use youth friendly services among secondary school students in East Belesa district, using the Theory of Planned Behavior, 2022

Abstract

Background: Youth refers to people aged between 15 and 24 years. The reproductive health of youth has become a major public health concern. The utilization of youth friendly services is low among Ethiopian school youths. Intention is the best predictor of behavior. However, there is no study done on the area which assesses the intention of the school youths to use youth friendly services. Therefore, this study is aimed to assess intention to use youth friendly services and associated factors among secondary school students in East Belesa.

Objectives: This study was aimed to estimate the average intention to use youth friendly services and its factors among secondary school students in East Belesa district, using the Theory of Planned Behavior, 2022.

Methods: An institution based cross-sectional study was conducted from May 23 to June 12, 2022 in East Belesa district. Stratified random sampling technique was used. Data was entered using EpiData version4.6 and analyzed using STATA version 14. Standardized β and R² values were used to interpret effects and variability with intention to use youth friendly services respectively. Simple and Multiple linear regression analysis were performed. Statistical significance was declared at a p-value of <0.05 with 95% confidence interval.

Results: A total of 511 respondents participated in the study giving a response rate of 99.8%. Around half of the participants were males (52.8%). The mean score of intention to use youth friendly services was 3.39±1.14. Direct perceived behavioral control (β = 0.25, 95%CI: 0.05, 0.45), subjective norm (β = 0.28: 95%CI: 0.09, 0.47), attitude (β = 0.20; CI: 0.03, 0.36), educated mothers (β = 1.65, 95%CI: 0.21, 3.09) and female sex (β = -1.77; 95% CI: -3.10, -0.44) were significant predictors of intention to use youth friendly services.

Conclusion: the magnitude of intention to use youth friendly services was low. Perceived behavioral control, attitude, subjective norm, educated mothers and sex were the predictors of intention to use youth friendly services. The study informed that the theory of planned behavior could be applied to predict intention of youths to use youth friendly services.

Introduction

Youths are people aged between the age groups of 15 and 24 years (1). In 2019, the youth population accounted 1.2 billion (16%) of the global population, 211 million (18.3%) of the youths were living in sub-Saharan Africa (2). In Ethiopia the youth accounts for one third of the Ethiopian population (3). Youth Friendly Reproductive Health Services (YFRHS) are those services that are accessible, acceptable and appropriate for the youth including general counseling services about sexuality, voluntary counseling and testing (VCT), treatment and diagnosis of sexually transmitted infections, contraception, condom, perinatal care services, abortion and post abortion care services  (4,5). Globally,  there were 37.7 million people living with Human Immune Virus Acquired Immune Deficiency Syndrome ( HIV/AIDS), and 90% occur among youths (5). Most youth pregnancies in sub-Saharan Africa ends up with abortion   (6). In Ethiopia, the Sexual and Reproductive Health (SRH ) of youth has become a major public health concern (7). To reduce the sexual and reproductive health problem of the youth the Federal Ministry of Health (FMOH) Youth Friendly Reproductive Health Services (YFRHS) in 2015 (8). Different studies found that sex, past behavioral experience, attitude, subjective norm, and perceived behavioral control were factors associated with intention to use YFRHS (9–11) . In spite of strategic efforts made to promote reproductive health service uptake of youths in Ethiopia, the level of  utilization remains very low (12). According to the Theory of Planned Behaviour (TPB), intention is the best predictor of behavior. To the best of my knowledge there is no study conducted on intention to use YFRHS and associated factors among school youth using behavioral models. Therefore, this study is aimed to assess intention to use YFRHS and its associated factors among secondary school youths in East Belesa district using the TPB.

Methods

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 (9-12^th=4001), Zuy-Hamusit secondary school (9-12^th =2846), Timen secondary school (9-10^th =693) and Mukatera secondary school (9-10^th =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. 

Results

Socio-demographic characteristics of participants

A total of 511 students participated in the study with a response rate of 99.8%. More than half of them (52.8%) were males. The mean age of participants was 19.13 years (±2.37) which was ranged from 15 to 24 years. Regarding religion, majority (90.6%) of the participants were Orthodox Christian and more than half (59.9%) were come from the rural area (Table1).

Table 1፡ Socio-demographic characteristics of secondary school students in East Belesa district, North West Ethiopia, 2022 (n = 511) 

Knowledge about YFRHS and past YFRHS utilization

The mean knowledge score was 7.11±2.21. From all youth who had ever heard about YFSRHS (297) only 108 (36.4%) of them have used at least one of the youth friendly reproductive services within the last twelve months.

Magnitude of intention to use YFRHS 

In this study, the mean intention score to use youth friendly reproductive health services was 3.39±1.14. The actual minimum and maximum scores were 7 and 35 respectively. More than half of the respondents 287 (55.6%; 95% CI: 51.2–59.8) scored above the mean score.

Summary of TPB variables

The table below presents the number of items used to measure each constructs of the TPB model and it ranges from 4 to 8 items. The mean and standard deviations for the components of the cognitive variables applied for 511 respondents. The participants had an overall mean score for intention (M = 23.7, SD = 8.0), attitude (M = 14.8, SD = 4.7), subjective norm (M = 13.3, SD = 4.3), perceived behavioral control (M = 12.2, SD = 3.8) (Table 2).

Table 2: Descriptive statistics for the Theory of Planned Behavior variables among secondary school students in East Belesa district, 2022 (n=511)

Pearson Correlation Analysis of Direct and Indirect variables of TPB

Correlations among the constructs of the TPB for intended YFRHS use, and Cronbach’s alpha coefficients for the theoretical constructs were reported. The Pearson’s correlation coefficient showed that the there was a positive strong correlation among the direct and indirect constructs of TPB (Table 3). 

Table 3: Correlations (Pearson’s r) among direct and indirect measures of Theory of Planned Behavior variables among secondary school students in East Belesa district, 2022 (n=511)

Regression analysis 

Multiple linear regression analysis

Prior to analysis the assumptions of linear regression were checked as mention above in method part. Then Simple linear regression was performed to assess the association of each independent variable with intention to use youth friendly reproductive health services at 95% confidence interval. Variables with a p-value of less than 0.2 in simple linear regressions were entered to multiple linear regressions for further statistical significance. The variance in intention to use YFRHS explained by all predictors was 40%. In multiple linear regression variables which found statistically significant at 5% level of significance were sex, maternal educational level, direct attitude, direct subjective norm and direct perceived behavioral control. Being female decreases intention to use YFRHS by a standard deviation of 1.77 as compared with males keeping other variables constant. Having mothers attending primary education increases intention to use YFRHS by a standard deviation of 1.65 keeping other variables constant. For an increase of one standard deviation in subjective norm, intention to use YFRHS increased by a standard deviation of 0.28 provided that other variables are kept constant. Keeping other variables constant, for an increase of one standard deviation in perceived behavioral control intention to use YFRHS increased by a standard deviation of 0.25. An increase of one standard deviation in attitude could result in an increase of intention to use YFRHS by a standard deviation 0.20 provided that other variables kept constant (Table 4). 

Table 4: Multiple linear regression of intention to use YFRHS and its predictors among secondary school students in East Belesa district, 2022 (n= 511)

Note: (*) statistically significant at p-value <0.05, (ref) reference category.

Discussions

In the current study, the intention to use youth friendly reproductive health services and its associated factors among secondary school students in East Belesa district was assessed using the theory of planned behavior. In this study, the mean intention to use YFRHS in the next six months was 3.39 ± 1.14. The findings of this study is comparable with the studies done in Mizan-Aman town, South West Ethiopia (2.89), Bench Maji Zone, south west Ethiopia (3.54), and Butajira, southern Ethiopia (4.03) (10, 17, 18). However this finding is higher than the study done in Uganda (1.49) (19). This inconsistency could be due to socio-demographic variations, differences in age and maturation (14). The variance in intention to use YFRHS explained by all predictors was 40%. This is lower than the findings reported in Kentucky (64%), Sub-Saharan Africa (77%) and Bench Maji zone, South West Ethiopia (81%) (17, 20, 21). However, this finding is higher than the study done in Jimma (32.7%) (9). The difference might be due to cultural variations, study population and the context in which the study is conducted.

The results of the current study showed that sex was significantly associated with intention to use YFRHS utilization. Females have lower intention to use YFRHS than their counter parts. This is in line with the studies conducted in Sub-Saharan Africa and East Gojjam Zone, Amhara Region, Ethiopia (20, 22). The possible explanation might be that females may shy to seek or access reproductive health services due to fear of stigmatization, parental control and lack of adequate privacy (23). The findings of the current study also revealed that maternal educational level was significantly associated with intention to use YFRHS. Those students having mothers attending primary education were more likely to use YFRHS as compared with those mothers not having education. Educated women might get different health information from different sources including media as compared with their counterparts, which might in turn educate their children about different health aspects including sexual and reproductive health issues, discuss openly about SRH with their children (24).

The result of our study revealed that attitude was a significant positive predictor of intention to use YFRHS. This is in line with the findings reported in Bahir Dar, Bench Maji Zone, Sub-Saharan Africa (11, 17, 20). This implies that health education interventions should be targeted on creating favorable attitude towards YFRHS utilization.

The current study also reported that subjective norm was the significant positive predictors of intention to use YFRHS in the next six months which indicates that significant others have a great role to play in an individual’s intention to use YFRHS services. This finding is consistent with the studies done in Bahir Dar, Addis Ababa, and Mizan-Aman town, Ethiopia (10, 11, 25).. Thus, interventions to improve YFRHS utilization should also target those important others (families, friends, relatives, teachers, neighbors and health professionals) as a whole rather than focusing only on the individual who are eligible to use YFRHS. This finding is in contrast with the studies done in Tanzania and Ghana in which subjective norm was not significant predictor of intention (26, 27). This discrepancy might be due to the difference in cultural setting, study population, social make up, study design and the tool used.

This study prevailed that perceived behavioral control was the significant predictors of intention to use YFRHS in the next six months. This finding is supported with the studies done in French, Bahir Dar city North West Ethiopia, and Bench Maji Zone, South West Ethiopia (11, 17, 28). This suggests that those individuals who were able to control the fear of being positive, lack of confidence, lack of knowledge, lack of money, fear of being seen by others whom they know, unavailability of services, and unethical health professionals so that they may lead to increased intention to use YFRHS. However, the study done in Jimma revealed that perceived behavioral control was not significant predictor of intention (9). The difference could be attributed to the difference in study population, behavior, and the context in which the behavior is occurring.

Limitations

It is difficult to establish temporal association between intention and its predictors. The study used a self-reporting instrument that has a potential of introducing social desirability bias. Another limitation of the current study is the actual measures of attitude, subjective norms, perceived behavioral control and behavioral intention is not feasible there for longitudinal studies should be done. This study might be subjected to recall bias since respondents were requested to answer their past experiences.

Conclusion

The results of this study conclude that the students were undecided on the intention to use YFRHS within the next six months. This implies that magnitude of intention to use YFRHS was low. This study revealed that sex, maternal educational level, direct attitude, direct subjective norm, and direct perceived behavioral control predict the intention to use YFRHS in the next six months. This study prevailed that social pressure has high influence on the intention of youths to use YFRHS therefore, policy makers should design health interventions programs to develop youth’s ability to resist norms that oppose the use of YFRHS and to change community-held norms against the service use and it help youth’s develop a positive attitude toward the services.

Abbreviations

AIDS, Acquired Immune Deficiency Virus; AOR, Adjusted Odds Ratio; CI, Confidence Interval ; HIV, Human Immunodeficiency Virus ; PBC, Perceived Behavioral Control ;SN, Subjective Norm; SRH, Sexual and Reproductive Health; STIs, Sexually Transmitted Infections; TPB, Theory of Planned Behavior; TRA, Theory of Reasoned Action; VCT, Voluntary Counseling and Testing; WHO, World Health Organization , and YFRHS, Youth Friendly Reproductive Health Services

Declarations

Data sharing statement 

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethical consideration

Ethical clearance was obtained from of University of Gondar, College of Medicine and Health Sciences, Institute of Public Health, Institutional Review committee. Permission letter was obtained from district health office and oral permission was taken from each school principals. After the purpose and objective of the study was informed, written informed consent was obtained from each study participants aged 18 and above. For participants with the age of less than 18, the school director gave parental consent since they were at school and assent was also obtained. All participants were informed that participation was on a voluntary basis and they could withdraw from the study at any time if they were not comfortable with the questionnaire. To maintain confidentiality data were collected and analyzed anonymously.

Consent for publication 

Not applicable.

Acknowledgements

We would like to thank the University of Gondar, Institute of Public Health for giving me the chance for preparing this thesis. We are also pleased to thank East Belesa communication office for facilating and providing student profiles of the district and East Belesa health office for writing permission letter. We would like to thank East Belesa secondary school teachers, directors and Mr. Melkamu (East Belesa PHEM officer) for their facilitation. Lastly but not the least, we are glad to thank study participants, data collectors and supervisors for their time and contribution to this work.

Author Contributions

 All authors made substantial contributions to the conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work

Funding

 The study was funded for academic purpose by grants from Ambo University, College of Medicine and Health Sciences, department of public Health. The funders had no impact on design, collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Conflict of interest 

The authors declare that they had no any conflict of interest.

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