Variations in utilization of health facilities for information and services on sexual and reproductive health among adolescents in South-East, Nigeria

[EXSCINDED] Abstract Background Adolescents’ sexual and reproductive health have an important inuence on a country’s long-term national growth. There is high level of burden due to poor adolescent sexual and reproductive health (ASRH) in Nigeria, especially Ebonyi state. Evidence shows that in Sub-Saharan Africa region, most adolescents experience poor access to information and other services relating to their sexual and reproductive health. Many cultures in Africa see matters around sex and sexuality as social taboos. This study aimed to access variations in utilization of health facilities for sexual and reproductive health information and services among adolescents in Ebonyi State, Nigeria. This will inform the design of interventions to improve ASRH.Methods A total of 1057 in-school and out-of-school adolescents aged 13 to18 years were selected using cluster sampling of households from the 6 selected LGAs in this cross sectional survey. Structured questionnaires were used to collect data. Descriptive statistics was performed alongside stratication analysis. Tabulation, bivariate and multivariate logistic regression analysis were undertaken. A household wealth index was calculated using the total household consumption calculated divided by the number of people in the households (per capital household consumption). The per capita household consumption was used to categorize households into socio-economic quintiles. The variable was used to differentiate where key variables into socio-economic quintile equity analysis.Results Majority of respondents had never visited any type of health facility to receive either SRH information (90.2%) or services (97.1%). Utilization rate of health facilities for SRH information was 9.8% while for other SRH services was 2.8%. Patent medicine vendor (PMV) was the most visited type of facility for SRH information and other services. Schooling is a strong predictor of health facilities’ utilization for SRH information (P<0.01) and other services (P<0.01).Conclusion Utilization of health facilities for information and services among adolescents in Ebonyi State is very low and favourable towards informal service providers such as PMVs. Establishment and strengthening of the existing youth friendly centres, school clinics and occasional outreach programs designed specically to target adolescents would perhaps improve adolescents’ access to adequate information and health facility utilization for sexual reproductive and health services.


Introduction
Adolescents' sexual and reproductive health have an important influence on a country's longterm national growth 1, 2 . This age bracket has special needs as the period is characterized by rapid growth/advancement and they also tend to have an increased interest on the opposite sex 3 . Adolescents' sexual curiosity and quest for information and experiences lays foundation in forming new relationships, indulging in an unprotected premarital sexual activity and continuous experiment of other unhealthy behaviors that are detrimental to their health 3 .
The onset of adolescence brings new vulnerabilities to human right abuses, especially in the areas of sexuality, marriage and child bearing 4 . For this, adolescents require access to accurate, comprehensive sexual and reproductive health information and other services but barriers exist, as most of them are not able to access these services and care 5,6 . The need to accessing and utilizing the available health services and information is crucial in promoting sexual and reproductive health of adolescents. Poor access to and utilization of available health facility for quality services and adequate information have been identified as contributors of largely preventable SRH problems (like unwanted teenage pregnancies, unsafe abortions) and mortality among adolescents 1 . Roughly every 1 in 5 young women becomes pregnant before the age of 18 years and this unwanted pregnancy among adolescents impacts negatively on their social, economic and psychological well-being 7 .
Evidence shows that in Sub-Saharan Africa region, most adolescents experience poor access to information and other services relating to their sexual and reproductive health 1 . The provision of comprehensive sexual and reproductive health interventions in developing countries has been impeded by ideologically driven restrictions 8 . Available evidence shows that some African countries are ambivalent to reproductive health service provision for adolescents 9 . This in effect, makes the health system in many developing countries unfriendly for adolescents to access SRH information and services 10 . Many cultures in Africa see matters around sex and sexuality as social taboos, for that reason it should not be discussed and this regularly denies unmarried adolescents of their sexual and reproductive health rights 11,12 . Adolescents should be empowered to know and exercise their rights, including the right to delay marriage and the right to refuse unwanted sexual advances, which can be achieved by offering comprehensive sexuality education; services to prevent, diagnose and treat STIs; and counselling on family planning.
In developing countries like Nigeria, most adolescents suffer SRH preventable problems like unwanted teenage pregnancies, unsafe abortions and STIs which might lead to death of the individual 13 . Twenty-two percent of Nigeria's population are between the ages of 10-19 years with a national fertility rate of 122 births per 1,000 young women aged 15-19 years and this fertility rate is higher in north western states of the country 14 . These rises concern on the importance of addressing issues around sexual and reproductive health of adolescents in Page 4/21 Nigeria. One of the key issues in addressing matters around sexual and reproductive health of adolescents in Nigeria is that utilization of health services remains low among this age group 10,14 . Many studies identified limited access to SRH services, poverty, societal stigma, discrimination and restrictions around sexuality as partly what limit adolescents from utilizing the available health facilities for adequate SRH information and quality services 9,14 .
Variations in utilization of health facilities for sexual and reproductive health information and services among adolescents are well documented 15  Ohaozara. An additional criteria for selection included LGAs which were prioritized by the State government for adolescent SRH intervention and also those with the highest unmet contraceptive need proven by high rate of unwanted teenage pregnancies and unsafe abortions.
Households were selected through a random walk from the nearest public facility either a school, church, town hall or primary health centre (PHC) in the main entrance of the community into the villages. The study population consisted of unmarried adolescents aged 13 to 18 years, including both in and out of school adolescents. Those that refused consent to participate were excluded from the study.
A pretested structured interviewer-administered questionnaire was used to collect data from a sample of 1045 adolescents aged 13 to 18 years that were selected using cluster sampling of households in the six selected LGAs. Data was collected on levels of utilization of health facilities for sexual and reproductive health information and services.
The questionnaire was adapted from WHO illustrative questionnaire for interview-surveys with young people 19 . The questionnaire was adapted to our local circumstances and priorities by rephrasing some questions, re-ordering some sections, adding more options to questions, adding new section of questions, and deleting some questions altogether. The adapted instrument was pre-tested among 24 adolescents that were selected purposively to ensure an equal representation of gender (male and female), place of residence (urban and rural), and schooling (in-school and out-of-school) in a non-participating LGA. Data was collected in pairs by 54 trained research assistants over a period of 10 days. Each pair collected data from eligible respondents both manually and electronically using paper-based questionnaire and electronic questionnaire respectively. Electronic copies of the questionnaires were uploaded to android tablets using Survey CTO. Individual matching of information on completed paper-questionnaire with corresponding electronic-questionnaire was done before and after uploading data to the server and data was viewed concurrently.   other services (p= 002), with out-of-school adolescents having higher utilization rates than inschool adolescents. The difference in utilization of health facilities for SRH information among adolescents in different wealth quintiles was not statistically significant (p= 0.28). The difference in their utilization of other SRH services did not vary significantly (p= 0.63).  Table 4 presents logistic regression analysis of demographic correlates of utilization of health facilities for SRH information among adolescents. The odds of utilizing health facilities for SRH information was 3.29 times less among in-school adolescents compared to out-of-school adolescents. This shows that out-of-school adolescents are 3.29 times more likely to utilize health facilities for SRH information (AOR = 3.29, C.I = 0.14, 0.64).    Schooling was found to be a strong predictor of utilization of health facilities for SRH information and other services among adolescents in the State. Out-of-school adolescents were three times more likely to visit health facility for SRH information than in-school adolescents. Likewise, in-school adolescents were found to be 4.4 times less likely to utilize health facilities for other SRH services than out-of-school adolescents. This finding is slightly similar with an investigation carried out in Ethiopia which revealed that adolescents who received SRH information from their school teachers were less likely to utilize SRH services than those adolescents who never received SRH information from school teachers 33 .
Consequently, there is need to understand and identify the nature of SRH information delivered in schools that deters in-school adolescents from utilizing health facilities for SRH services. beneficence through favourable balance of benefits and risks, justice through fair inclusion, and privacy of information by anonymised collection and use of data were duly observed.
Both verbal and written informed consent were obtained from both the household heads and from study participants (adolescents) before administering the questionnaire.

Consent for publications
We declare that permission for publication was obtained for this study.

Availability of supporting data
The dataset used for this study is available and can be obtained from the lead author upon request. As well as any other material needed.

Competing interests
The authors declare they have no conflict of interest nor competing interests.

Funding
Not applicable. No funding was receive for this study.