Utilization of Reproductive Health Services and associated factors among secondary school students in Woldia Town, Northeast Ethiopia, 2020

Background : Despite policy actions and strategic efforts made reproductive health service uptake of youths in Ethiopia, its utilization remains low. Local evidence about the utilization of reproductive health service among adolescents and associated factors are relevant to design age-appropriate intervention strategies. Objective : The main aim of this study was to assess the utilization of reproductive health service and associated factors among adolescents in Woldia town secondary schools, Amhara, Ethiopia, 2019. Methods : Institutional based descriptive cross-sectional study was conducted on 420 secondary school students in Woldia Town from January - June 2019. A self-administered, structured questionnaire was used to collect the data. The samples were distributed proportionally and participants in each school were selected by systematic sampling technique. Bivariate and multivariable logistic regression was carried out to asses’ association between dependent and independent variables. Result : Two hundred seventy (64.3%) respondents utilize reproductive health service. Residence, educational status of the partner, presence of RHS facility in school, good knowledge level on RHS were significantly associated with the reproductive health services utilization. Conclusion and Recommendations : Knowledge of respondents on reproductive health issues in the study area was found to be low. This low service utilization might make students disposed to different reproductive health risks; STI, HIV, and unwanted pregnancy; which in turn can increase the school dropout rate, and have an impact on an individual’s future life. utilization remains low. Therefore, local evidence about the utilization of reproductive health service among adolescents and associated factors are relevant to design age-appropriate intervention strategies. The study was conducted on 420 secondary school students in Woldia Town from January June 2019. Knowledge of respondents on reproductive health issues in the study area was found to be low. This low service utilization might make students disposed to different reproductive health risks; Sexually Transmitted Infections, HIV, and unwanted pregnancy; which in turn can increase the school dropout rate, and have an impact on an individual’s future life. Which shows, a great effort and attention of all the concerned bodies including parents, school staffs, and health care professionals to improve service utilization in schools is highly required.


Introduction
According to World Health Organization (WHO), Reproductive Health (RH) is defined as a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity, in all matters related to the reproductive system and its functions and process (1).
Reproductive health is a universal concern but is a special importance for women particularly during the reproductive year (2). It addresses the human sexuality and reproductive processes at all stages of life and implies that people can have "a responsible, satisfying and safe sex life and that they can reproduce and the freedom to decide if, when and how often to do so. Youth and adolescents are characterized by unique physical, psychological, social, and emotional changes that put their life at high risk (3).
The term Youth Friendly Reproductive Health Service (YFRHS), refers to those services that are accessible, acceptable and appropriate for youths such as counseling, family planning, Voluntary Counseling and Testing (VCT) and treatment of Sexually Transmitted Infections (4). The services are provided in line with the minimum health package and aim to increase the acceptability and use of health services by young people (5). Currently, there is a low level of access to high-quality RH information and services, especially for adolescents (6). In the past few years, the issues of RH have been increasingly perceived as a social problem; they have been emerging as a topic of increasing concern in both developed and developing countries (7).
Adolescence is not quite capable of understanding complex concepts. This makes them vulnerable to sexual exploitation and high-risk sexual behaviors and reproductive health problems (8). Globally, 45 percent of all new HIV infections worldwide are occurring among young people aged 15 to 24 years, 500,000 young people are infected with STI per day, approximately 80 million women have unwanted pregnancies every year (9,10). HIV/AIDS prevalence data shows that 15-24 year-olds have the highest rates of new HIV infection ,with adolescent girls considerably more likely to be infected than adolescent boys (11). This is because many adolescents are less informed, less experienced, and less comfortable accessing health services for RH than do adults (12). Moreover, the magnitude of unsafe abortions in young women aged 15-24, reached 45 percent and the level of comprehensive knowledge of AIDS is being 48% for young women 15-24 aged, and 43% for young men aged 15-24 years (13).
Young people in high schools are highly vulnerable and at-risk to HIV infection due to various reasons such as; unprotected casual sex relationships and multiple sexual partners, lack of comprehensive knowledge about HIV/AIDS, sexual and reproductive health, lack of access to HIV services, sexual experimentation, early sexual debut and peer pressure, and other related factors (14).
In Africa, 430,000 young people are infected with HIV per year; 2.6 million young people are living with HIV; teenage pregnancy rates remain high and maternal mortality is among the leading causes of death for adolescent girls in this region (15). There are also problems related to SRH services which include accessibility, availability, and quality. Moreover, secondary school students indicated that health providers in most of the HEIs are not trained to respond to the needs of young persons (16).
The shortage of youth-friendly health services and counseling poses significant challenges to address SRH issues, including HIV prevention.
In Ethiopia, educational institution-based RH services are often limited by restrictive policies, personnel shortages, lack of private areas for counseling and poor links to resources outside the institutions. Since adolescents have a unique reproductive health risks of unplanned pregnancies, childbearing; sexually transmitted infections (STIs) including HIV and unsafe abortion (17,18) access and utilization of Reproductive Health Services (RHS) is a primary concern for them surrounding the promotion of reproductive health rights (19,20).
In addition to these, the response to deliver RHS for students has been fragmented and Ethiopian schools have limited capacity in delivering health-related services for their students; As a result a significant proportion of students are developing RH related problems (20); and the available literatures in Ethiopia were limited in addressing factors that influence utilization of RHS among secondary school students. Hence, the main aim of the study was to assess utilization and factors affecting RHS among secondary School Students in Woldia Town, Northeast Ethiopia.

Study Setting and period
This study was conducted in Woldia town from January -June 2019 G.C. The town is located in the North-East Ethiopia Amhara regional state under the administration of North Wollo Zone, located at about 521 km from Addis Ababa in the east direction. The town has nine kebeles and four secondary schools. The study was conducted in all secondary schools namely Woldia secondary school, Millennium secondary school, Selam secondary school, and Gubo secondary school.

Study Design
Institutional-based descriptive cross-sectional study was employed

Source Of Population
All secondary school students in Woldia town

Study Population
Selected students of Woldia town secondary schools

Sample Size Determination
The sample size of the study was calculated using single proportion population formula as n= (Z 2 α/2* P (1-P)/ d 2 ); while n = sample size, p = proportion Sexual practice < 18 years (taken as 53.3% according to the study on Reproductive health service utilization in Mizan Tepi university students, Ethiopia 2017 (21),d = maximum allowable error (margin of error) = 0.05, Z = value of standard normal distribution at 95% confidence level (Z = 1.96).
By adding 10% non-response rate the total sample size will be 382*10%=38. Thus the final sample size was n = 420.

Sampling Techniques And Procedure
In the study area, from each school, sections were selected by using simple random sampling method. The samples were distributed proportionally based on probability proportional to size (PPS).
Participants from the selected section were selected by using a systematic sampling technique after calculating sampling interval (K) for each section according to students roll number in the class and the first student was selected by a simple random method.

Eligibility Criteria Inclusion criteria
Woldia town secondary school students who were present during the data collection period Exclusion Criteria Students who weren't available during the data collection period Students who were physically and mentally not capable to be interviewed

Operational Definitions
Good utilization: Those students who answer mean and above the mean score of practice questions were categorized had Good practice while those students answer below the mean score was categorized had poor practice.
Good knowledge: Those students who answer mean and above the mean score of knowledge questions were categorized as knowledgeable while those students answer below the mean score was categorized under poor knowledge.
Good attitude: Those students who answer mean and above the mean score of attitude questions were categorized as had a good attitude while, those students answer below the mean score was categorized as had a poor attitude.

Data Collection Tool And Procedure
Data was collected by using structured interviewer-administered questionnaire and pretest was conducted before starting the actual data collection. The questionnaire was containing written consents, socio demographic data, and reproductive health related questions which were developed by adapting from different peer reviewed literatures. The questionnaire was first developed in English and translated to Amharic language by an expert. It was translated back to English by an independent translator to check for consistency. The interview was conducted in Amharic language by four diploma clinical nurses and supervised by two master's public health students.

Data Quality Control
For Ensuring data quality training was given for data collectors and supervisor. After this Pretest of the questionnaire was conducted on 5% of Dessie town secondary school students a week prior to the actual survey; and necessary modification was done according to the gap identified. Data collectors and the supervisors were trained on the data collection techniques. Besides, the completeness, accuracy, and consistency of the collected data were checked daily during the data collection time.
Supervisors &principal investigators closely follow the data collection process. The data were entered daily and missing data were identified.

Data Analysis And Presentation
Data were entered by using EPI-data Version 4.2.0 and was exported to SPSS Version 24 for analysis.
Frequencies were calculated to describe the study population in relation to relevant variables. Binary logistic regression analysis was conducted to assess the crude association between dependent and independent variables. Finally Variables which shows association in Binary logistic regression analysis and have P-value less than or equal to 0.25 entered in to Multivariate logistic regression model, to adjust the effects of possible confounders. Finally significant factors were identified based on AOR with 95% Confidence level and P-value less than 0.05.

Ethical Consideration
Ethical clearance was obtained from Woldia university research and Technology transfer office.
Permission letter was obtained from Woldia University College of health science research and community service coordinating office and each high school directors. Then, written informed consent was taken from each participant after clearly explaining the purpose of the study. Finally participants were informed to withdraw from the study at any time and/or to refrain from responding to questions if they were not interested to participate by any reason.

Results
All 420 respondents complete the questioner with the response rate of 100%. Among these most of the respondents, 304(72.4) were from urban area. About 204 (48.6%) were females. The majority of the respondents 238 (56.7%) were within the age group of 15-19 years. Most of the respondents were single 384 (91.4%) followed by have boy/girlfriend 231 (18.1%) ( Table 1).  to read and write. Respondents whose neighbors feel ashamed were 76% less likely to utilize RHS compared to those who have no money to get the service. The odds of RHS utilization among participants whose friends encouraged to use RHS (AOR = 1.46, 95%CI (1.87, 6.44) was higher compared to those whose friends didn't encourage to use RHS. Respondents who have good knowledge of RHS were approximately 4 times more likely to utilize reproductive health service (Table 3).

Discussion
The overall utilization of RHS among secondary school youths in Woldia Town was found to be 64.3%; which is in line with a study done in Bahir Dar which showed that (63.8%) (22). However, this finding higher than a study conducted in Nekemet (23), Madawalabu university (24), Mekele (25)and Mechakel, East Gojjam (8); in which (21.2%, 27.7%, 23%, and 21.5%) of participants utilized RHS respectively. The possible reason for this difference might be due to the participants' sociodemographic characteristics, time reference used in the definition of RHS utilization and socioeconomic variation. Furthermore, this discrepancy might be also due to differences in the availability and accessibility of reproductive health facilities and youth centers within the school. The odds of utilization of reproductive health service among respondents from urban residence were higher compared to those respondents from rural residences. This finding was supported by other studies in Ethiopia (20,26). This might be because of the accessibility of RHS in the urban area and the availability of media in urban areas will ease the information transmission regarding the benefit of utilizing RHS. The odds of the utilization of reproductive health service among those who have RHS facility in school was higher compared to those respondents who haven't RHS facility in the school.
This finding was supported by other studies in Ethiopia (20,22,26). This might be due to the fact that those school-based RHS facilities will deliver services like counseling and easily accessing the facility students need timely. Respondents who are grade 10 were 1.15 times more likely to utilize RHS compared to grade 9 respondents.
In this study, the odds of RHS utilization among respondents whose partner's educational status falls under secondary and above was higher compared to those partners educational status is unable to read and write. This finding was supported by other studies (22,27,28). Those families with higher educational status are more likely to expose to RHS related issues. Respondents whose neighbors feel ashamed were 76% less likely to utilize RHS compared to those who those who have no money to get the service. This finding was supported by other studies (28,29). This might be because of the stigma due to the utilization of RHS, will result in isolation from their peers and society as a whole. To prevent this discrimination they prefer not to use RHS. The odds of RHS utilization among respondents whose friends encourage using RHS was higher compared to those whose friends didn't encourage to use RHS. Other studies also support this finding (28,30). This shows the influence of peer pressure weather it is positive or negative on utilization of RHS. Respondents who have good knowledge of RHS were approximately 4 times more likely to utilize reproductive health service. A similar finding has been reported in other studies (8,(31)(32)(33). The possible justification for this might be, those respondents with a good level of knowledge regarding RHS will understand the benefit of using RHS and the consequence of not using RHS.

Conclusions
Knowledge of respondents on reproductive health issues in the study area was found to be low. This low service utilization might make students disposed to different reproductive health risks; STI, HIV, and unwanted pregnancy; which in turn can increase the school dropout rate, and have an impact on an individual's future life. Therefore, it needs a great effort and attention of all the concerned bodies including parents, school staffs, and health care professionals to improve service utilization in schools.

Ethics approval and consent to participate
Ethical approval was obtained from the research ethics review board of the Woldia University College of health science. An official letter of permission was obtained from Woldia University College of health science and was submitted to the respective administrative bodies of the Woldia Town secondary school directors; permission from these administrative bodies was also obtained.
Confidentiality was ensured throughout the research process. The purpose of the study was explained to the participants and data was collected after full informed written consent obtained and confidentiality of the information was also maintained by omitting their names and personal identification. Written informed consent for participation in the study was obtained from their parent or guardian where participants are children (under 16 years old).

Consent for publication
Note applicable.

Availability of data and materials
Data is available and it can be accessed from the corresponding author when asked with the reasonable inquiry.