Youth Reproductive Health Service Utilization and Associated Factors among Amhara Region Female Night Students, Ethiopia

Introduction Youth is a decisive age to shape the direction of their life and that of their family. However, due to the host of biological, social, and economic factors, adolescent females can be at high risk of adverse sexual and reproductive health outcomes. Therefore, assessing youth reproductive service utilization and associated factors among female night students is very crucial for timely intervention to their gaps. Method An institutional-based cross-sectional study design was conducted in Amhara region among 2,050 female night students from September 15 to November 15, 2018. A self-administered pretested questionnaire was used to collect the data. Bivariate and multivariable logistic regression models were used. Odds ratio with 95% confidence interval was computed to determine the strength of association between predictor and outcome variables. P value less than or equal to 0.05 is considered as the level of significance. Results Out of the total respondents, about 54.6%(CI: 52.5%-56.8%) of them utilized reproductive health services. Respondents who were attending secondary education (AOR = 2.55, 95%CI = 1.97‐5.62), attitude towards youth reproductive health services (AOR = 2.74, 95%CI = 2.07‐5.30), those who had a habit of communicating on sexual and reproductive health issues with their family (AOR = 3.66, 95%CI = 3.59‐7.41), discussion on sexual and reproductive health issue with peers/friends (AOR = 1.43, 95%CI = 1.01‐2.02), respondents with good knowledge on youth reproductive health services (AOR = 2.03, 95%CI = 1.49‐2.75), and those who had faced reproductive health problems (AOR = 2.03, 95%CI = 1.49‐2.75) were significantly associated with youth reproductive health service utilization. Conclusion Youth reproductive health service utilization among female night students was not satisfactory. Therefore, special focus should be given to female night students by providing accessible, acceptable, confidential, flexible, and friendly reproductive health service utilization. Finally, community health promotion and education are mandatory to promote the practice of discussing youth reproductive health issues with their children.


Introduction
Youth is a period of transition from childhood to adulthood characterized by significant physiological, psychological, and social changes that place their life at high risk [1]. According to the World Health Organization (WHO), youth is defined as a young person between the age group of 15 and 24 years [2]. More than a quarter of the world's population is between the ages of 10 and 24, with 86% living in less developed countries [3]. More than 1/3 of the Ethiopian population is found between 10 and 24 years in which they are the most vulnerable to a range of sexual and reproductive health problems [4].
Young people can be labeled as the vulnerable group, because this segment of population is subjected to curiosity, sexual maturity, and natural inclination towards experimentation, and peer pressure leads to risky behavior [5]. Many girls in developing countries are vulnerable to leaving school, child marriage, early pregnancy, human immunodeficiency virus (HIV), sexual exploitation, coercion and violence, unwanted pregnancy, and unsafe abortion and its complications [6].
The need to have a healthy youth is of great value to the nation's socioeconomic development. The reproductive and sexual health decisions they make today will affect the health and wellbeing of their communities and of their countries for the future. After the 1994 international conference on population and development in Cairo, many countries have started giving an emphasis to the problems of youth and adolescents [7].
To solve the problems of youth, our country Ethiopia establishes youth reproductive health services (YRHS) for addressing the reproductive and sexual health needs of youth. In Ethiopia, the YSRH services are provided in the already existing health facilities by specially trained health care providers together with peer educators in a separate corner having waiting and consultation spaces. The service packages include counseling and testing for HIV and other sexually transmitted infections, pregnancy test, counseling for contraceptives and offering full range of contraceptives, antenatal care, postnatal care, postabortion care, referral service for antiretroviral therapy, delivery and prevention of mother-to-child transmission of HIV, and promotion of condom. However, youths often lack basic reproductive health information, knowledge, and access to affordable and confidential health services for reproductive health [8,9].
Many of them do not feel comfortable discussing reproductive health (RH) issues with their parent. Likewise, parents, health care workers, and educators frequently are unwilling or unable to provide complete, accurate, age-appropriate RH information to young people. This is often due to parents' discomfort about the subject or the false belief that providing the information will encourage sexual activity [9].
Night school students in Ethiopia are students who are unable to continue their day time education due to resource limitations, absence of supporters, and working conditions. In our context, most of the female night school students are housemaids and daily laborers. Therefore, they are supposed to have limited awareness about sexual and reproductive health services which may affect their utilization [10].
Even though few research works have been done on daytime students, there is no study conducted concerning youth reproductive health service utilization focusing on adolescent girls attending night school in Ethiopia generally and in Amhara region particularly. Therefore, assessing youth reproductive health service utilization among female night students and identifying factors affecting their utilization are very vital in designing, implementing, and monitoring effective youth reproductive health intervention programs for these particular groups.

Methods and Materials
2.1. Study Design and Setting. A school-based cross-sectional study using a quantitative method of data collection was conducted from September 15, 2018, to November 15, 2018, in Amhara region, northwest Ethiopia. Amhara region is one of the nine regional states in Ethiopia which is found between 11°30 ′ 00 ″ N latitude and 38°30 ′ 00 ″ E longitude on the northwestern part of Ethiopia. Amhara is one of Ethiopia's largest regions; it has 12 zones, three city administrations, and 180 woredas (139 rural and 41 urban). According to the Ethiopian Central Statistics Agency, the region has a projected population of 21.5 million people, about 80 percent of whom are rural farmers. The region has 80 hospitals (5 referral, 2 general, and 73 primaries), 847 health centers, and 3,342 health posts. There are 55 elementary and 23 secondary schools that provide night education.
2.2. Participants. All female night students aged 15-24 years in Amhara region were the source population of the study. All youth female night students attending elementary and secondary school in selected zones of Amhara region during the study period were considered as the study population.
2.3. Sample Size Determination. The sample size was calculated using single population proportion formula by taking proportion of youth reproductive health utilization (32%), 95% confidence interval, 3% margin of error, design effect of 2, and 10% of nonresponse rate. Finally, a total 2,050 participants were included for the study.

Sampling Procedure.
A multistage sampling technique was used to select the study participants. In the first stage, 5 zones were selected by using a simple random sampling technique from a total of 12 zones within the region. In the second stage, 22 night schools were selected by lottery method from 88 night schools in the selected zones and the sample size was proportionally allocated to all selected elementary and secondary schools. Finally, study units were selected by using a simple random sampling technique.

Operational Definitions
(i) Youth: a person with an age group of 15-24-year-old (ii) Knowledge on YRHS: If the respondents mentioned at least five YRHS on their own, they were considered to have good knowledge; otherwise, they were considered to have poor knowledge (iii) Attitude of the respondents on YRHS: we assessed the attitude of the respondents regarding YRHS using a five-point Likert scale. The scoring system used was as follows: strongly disagree = 1, disagree = 2, indifferent = 3, agree = 4, and strongly agree = 5. Then, the responses were calculated and those respondents who scored the mean score and above were considered as having a positive attitude, whereas those respondents who scored below the mean score were categorized as negative attitudes towards YRHS (iv) Youth reproductive health service utilization: those respondents who utilize at least one of the following main RH services in the past one year (pregnancy test, ANC, delivery service, PNC, VCT, FP, STI diagnosis and treatment, abortion and postabortion care, get information, and counselling on sexuality) 2 BioMed Research International (v) Reproductive health problems: those respondents who faced at least one of RH problems (unwanted pregnancy, abortion, sexual violence, teenage pregnancy, and STI)

Data Collection Instruments and Data Collection
Procedure. The data was collected by interviewer-administered, semistructured questionnaires adapted from different literature [11][12][13][14][15]. The data collection tool (questionnaire) was first prepared in English and then translated to a local language (Amharic) and then retranslated back to English language by language experts. The questionnaire comprises socioeconomic and demographic characteristics, individual level, and communication-related factors. About 20 data collectors and 10 supervisors were involved during data collection.

Data Quality Assurance.
To assure the quality of the data, technical training was given for data collectors and supervisors for three days. Pretest was given for 5% of the sample size in out of selected schools. During data collection, supervision was conducted. After data collection, checking of data entry and cleaning were conducted for the completeness of the data. Throughout the course of the data collection, interviewers were supervised at each site, and regular meetings were held between the data collectors, supervisor, and the principal investigator together in which problematic issues arising from interviews were discussed and addressed. The collected data were reviewed and checked for completeness before data entry; the incomplete data was discarded.

Data
Analysis. The data were entered into EPI data statistical software and then sorted, cleaned, and analyzed by using the SPSS version 20 statistical package. Descriptive statistics were done to describe the study population in relation to relevant variables by using text, tables, and graphs. Bivariate and multivariable logistic regression models were used. Odds ratio with 95% confidence interval was computed to determine the strength of association between predictor and outcome variables. P value less than or equal to 0.05 is considered as the level of significance.
2.9. Ethical Approval and Consent to Participate. Ethical clearance for this study was obtained from the ethical review board of Debre Tabor University College of Health Sciences, and a supporting letter was obtained from Amhara Regional Education Bureau. This support letter was sought to each zonal town and forwards to elementary and secondary school on which the study was conducted. Informed consent for ≥18 years old and assent for <18 years from their family were obtained after explaining the purpose and objective of the study. An interview was taken place in a convenient place to maintain privacy and to assure confidentiality.

Results
From a total of 2,050 students included in the study, about 2,044 of them responded to the questions correctly yielding a response rate of 99.7%.

Reproductive Health Problems of the Respondents.
In this study, the reproductive health problems of the students were assessed. Nearly half 1,040 (50.8%) of the students had faced reproductive health problems considering that students faced at least one of reproductive health problems (unwanted pregnancy, abortion, sexual violence, teenage pregnancy, and STI). Out of the 2,044 respondents, 464 (22.7%) had unwanted pregnancy and 986 (42.4%) had faced sexual violence (Table 3).

Preference of Youth Reproductive Health Services among
Respondents. Preference of the students in terms of health institution, time of provision, and service provider regarding youth reproductive health services was assessed. About 864 (42.27%) and 112 (5.5%) of respondents reported that they thought better place for provision of SRH services was at public health institutions and schools, respectively. While assessing the time preference of students for RH services, 892 (43.6%) of respondents preferred service time to be in the absence of other users and 1,126 (55%) preferred service provider to be young and of the same sex (Table 4).

Attitudes of the Respondents towards YRHS.
We assessed the attitude of the respondents regarding YRHS using the   Likert scale. The responses were summed, and the mean score was obtained. Those respondents who scored the mean value and above were considered as having a positive attitude, whereas those respondents who scored below the mean value were categorized as negative attitudes towards YRHS.
In this study, out of the total respondents, 1,138 (55.7%) had a positive attitude towards youth reproductive health utilization.
3.6. Youth Reproductive Health Service Utilization. More than half of the participants 1,117 (54.6%) were utilized at least one youth reproductive health service in the last 12 months. Of whom, 464 (42%) used contraceptives, 313 (28%) got voluntary counseling and testing HIV/AIDS, and 435 (39%) got information, education, and communication about SRH issue (Figure 1).

3.7.
Reasons for Not Utilizing YRH Services. Of the total respondents, 927 (45.4%) of them were not utilized at least one youth reproductive health service. The main reason for not seeking the service was too young to the services (58.6%), afraid of their parent (41.3%), and being embarrassed from cultural against to get the service (39.6%) (Figure 2).

Discussion
Young people have limited access to reproductive health service utilization that focuses on the special needs of adolescents. Inadequate knowledge about adolescent sexual behavior, cultural influences, and the limited capacity of implementers hinders the provision of reproductive health education and services to young people. Hence, this study was aimed at assessing the YRHS utilization and associated factors among Amhara region female night students in Ethiopia. It has tried to include youths aged between 15 and 24 years who were residing in the study area.
In this study, only 54.6% of the students were utilized youth reproductive health services. Educational status of respondents, attitude towards YRHS utilization, ever faced reproductive problems, habit of communicating with family about SRH issue, discussion with peers on sexual and reproductive health issues, and knowledge of respondents on YRHS were significantly associated with utilization of YRH service.
In this study, 54.6% (95%CI = 52:5%-56:8%) of the students were utilized youth reproductive health services within the last one year. This finding is in line with the study done in North Shewa, Amhara region 54.7% [11], but higher than studies conducted in Bahir Dar 32% [12], Woreta town, South Gondar zone 24.6% [13], Nekemte 21.2% [14], and Metekel 33% [15]. This finding is lower than the study done in Mekelle town, northern Ethiopia 69.1% [16] and Harar town, east Ethiopia 63.8% [17]. This difference might be due to the participant's sociodemographic and socioeconomic characteristics, target population difference, definition of YRH service utilization, and availability and accessibility of SRH service.
Students who were attending secondary education were 2.6 times more likely to utilize YRH service than those who were attending elementary education. This finding is supported by a study conducted in Woreta town, South Gondar  BioMed Research International zone [13]. The possible resean might be when students were more educated they might have better understanding on sexual and reproductive health issues which increases their health care-seeking behavior Students who had a positive attitude towards YRHS were 2.7 times more likely to utilize YRH services than those who had a negative attitude. This is due to the fact that students having a favorable attitude would motivate them to use reproductive service utilization.
Respondents who had a habit of communicating with family about SRH issue were 3.66 times more likely to utilize SRH service than those who had not. This is supported by similar findings from Mecha district, Gondar, East Gojjam zone, and Kenya [18][19][20][21]. This might be due to the fact that open discussion about SRH issue between family and their daughter increases awareness and avoids feeling shy and fear of being seen while getting SRH service. Moreover, the discussion creates more opportunities to exchange SRH information and experience of health-related problems and influence utilization of the YRH service.
Respondents who had a habit of communicating with peers about SRH issue were 1.4 times more likely to utilize YRH service than those who had not. This finding was supported by a study conducted at Madawalabu University [22]. This might be explained by students who had free discussion with their friends regarding sexual issues; they would have better knowledge on SRH issues which in turn leads to utilization of the service.
Participants who had good knowledge on YRS were 2 times more likely to utilize YRH services than those who had poor knowledge. This finding is in line with the study done in Mekelle and East Gojjam [15,19]. This might be due to the fact that students with better knowledge and understanding about sexual and reproductive health issues might have better decision-making skills for reproductive health service utilization.
Students who had a history of SRH problems were 7.17 times more likely to utilize YRH services than those who had not. This finding was supported by the study done at Bahir Dar [12]. This might be explained by students who faced reproductive problems like unwanted pregnancy, sexual violence, or abortion; they are more likely to visit health facilities to get youth reproductive health service utilization.

Strength and Limitation of the Study.
Using a large sample size can be taken as the strength of the study. Even though the study has strengths, it has its own limitations: the first limitation would be due to sensitivity of the issues, social desirability bias might be faced. Another limitation would be it might be subjected to recall bias since respondents were requested to answer their past experiences.

Conclusion and Recommendation
Youth reproductive health service utilization in the study area was not satisfactory. Inconvenient location, inconvenient service time, cultural barriers, lack of information on where to get the service, fear of their parent, and perceived as too young to get the services were the main reasons for not utilizing YRS services by female students. Educational status, habit of discussion on sexual and reproductive health issues with family, attitudes towards YRS, knowledge on RH services, ever faced RH problems, and ever had a discussion with peers about sexual and reproductive health issues were factors found to be associated with youth reproductive health service utilization.
Therefore, special focus should be given for female night students by providing accessible, acceptable, confidential, and friendly reproductive health services. Youth reproductive health services shall be given in a convenient place at a time when there are less people around and with a convenient time such as after school, evening, and/or weekend hours. Furthermore, government and other stakeholders should strengthen youth awareness creation strategies and empower them to have positive attitudes towards using YRS services. Finally, community health promotion and education are mandatory to promote the practice of discussing youth reproductive health issues with their children.

CI:
Confidence interval IEC: Information, education, and communication RH: Reproductive health RHS: Reproductive health service SRHS: Sexual and reproductive health service VCT: Voluntary counseling and testing WHO: World Health Organization YRHS: Youth reproductive health service.

Data Availability
All relevant data are available within the manuscript.

Conflicts of Interest
The author declares that there is no competing interest.

Authors' Contributions
TL was the investigator and involved in proposal writing, designing, recruitment and training of supervisors and data collectors, analysis, and writing the manuscript. YG, HB, GM, HT, and AA were involved in proposal development, data analyses, and manuscript writing. All authors have approved the final manuscript.