Knowledge, Attitude, and Practice toward Youth-Friendly Reproductive Health Services among Mizan-Tepi University Students, South-Western Ethiopia

Background Youth-friendly reproductive health services are designed to meet the unique needs of young individuals. Nevertheless, in developing countries such as Ethiopia, knowledge, attitude, and utilization of these services are very limited. This study was designed to assess the knowledge, attitude, and utilization of youth-friendly health services and associated factors among students. Method A public university-based cross-sectional study was conducted between October and January 2019. Participants were chosen from the target group using a simple random selection procedure. To find the factors linked to youth-friendly health services, researchers used descriptive analysis, the chi-square test, and a logistic regression model. Result This study revealed that 237 (55.4%), 256 (59.8%), and 262 (61.2%) students had no knowledge, negative attitude, and not practiced youth-friendly reproductive health services, respectively. The binary logistic regression results revealed that male students were more likely to have knowledge and practice (AOR = 1.847; 95% CI: 1.124, 3.034; p=0.015) and (AOR = 1.821; 95% CI: 1.114, 2.975; p=0.017) respectively; however, they had less likely positive attitudes (AOR = 0.519; 95% CI: 0.315, 0.856; p value = 0.010) compared to female students. Students from primary and above educated families were more likely to have knowledge, attitude, and practice compared to students from uneducated families. Conclusion Overall, students' knowledge, attitudes, and utilization of youth-friendly reproductive health services were poor. As a result, additional efforts, such as the availability of service providers and the improvement of facilities, as well as education linked to the service for young people and the allocation of appropriate service time, are required.


Background
Youth is a period of transition from childhood to adulthood, and adolescence (from ages 10 to 19 years) is the process of attaining sexual and reproductive maturity [1,2]. Typical youth behaviors such as experimentation and risk-taking make youths more vulnerable to pregnancy and STDs. erefore, provision of youth-friendly sexual and reproductive health services is a first step to ensure the psychological and biomedical needs of young individuals [3].
In 2002, the World Health Organization (WHO) created the adolescent-friendly health services model, which was later expanded to accommodate all young people's health requirements [4,5]. Youth-friendly service (YFS) is one of the reproductive health services offered to young people in order to satisfy their needs. It includes sexual and reproductive health counseling, sexually transmitted infections (STIs), and voluntary counseling and testing (VCT) services [4,6,7], and these services should be able to effectively attract and meet the needs of young people in a comfortable and responsive manner, as well as successfully retain these young clients for long-term care [1,8,9].
Seventy-eight percent of youths live in developing countries, and 60% of them are from sub-Saharan Africa, where the prevalence of HIV, other sexually transmitted infections (STIs), and unwanted pregnancy among young people is found to be high [1,8,10]. In Ethiopia, young people and adolescents in the age group of 10 to 24 years constitute 22% of the total population, most of them live in rural areas and lack access and awareness to the reproductive health services [7,11].
e Ethiopian Ministry of Health (EMOH) has developed a 10-year National Adolescent and Youth Reproductive Health Strategy (NAYRHS) in 2015, utilization of the services among youths of the country is still low and remains facing several challenges associated with traits related to adolescents' sexuality and their perception towards the YFS delivery centers.
According to research evidence from various sections of Ethiopia, many adolescents still lack access to health care and young people are at risk of reproductive health issues. YFRHS provision is limited in a few government (public) health institutions in metropolitan centers, according to recent studies from rural areas, and many youth are less aware, experienced, and comfortable in obtaining health care in their locations. Moreover, majority of the youth often lack basic YFRHS information and knowledge about the available services, and access to affordable and confidential services [11][12][13][14][15]. As a result, the majority of teenagers are at an increased risk of unintended pregnancy and pregnancyrelated problems [16].
Moreover, reproductive tract infections (RTIs) including HIV/AIDS are other major health threats of young people of the country [7,11,12]. However, studies on the level of YFRHS utilization, knowledge and perceptions of youths towards YFRHS, and associated factors are very limited in Ethiopia. us, this study was carried out with the objective of assessing YFRHS and associated factors among the students of Mizan-Tepi University, Tepi campus, southwestern Ethiopia.

Study Setting.
e study was conducted at Mizan-Tepi university Tepi campus which is situated in Tepi-611 kms away from the capital of Ethiopia. Tepi campus is located in Yeki-Woreda at a mean elevation of 1,097 meters above the sea level and at a latitude of 7°12'N and longitude of 35°27'E. Tepi is the largest settlement in Yeki Woreda, and its climatic condition is characterized by higher temperature, higher moisture content, and lower wind speed. e annual rain fall is 1547 with 22.4°C average temperature, and its altitude is 1400 m above the sea level. Tepi

Study Variables.
e dependent variables in this study were knowledge, attitude, and practice of students toward YFRHS, while the explanatory variables were sex, age, region, religion, mother's education, father's education availability of YFRHS in local area, and source of information.

Study Design and Population.
A public university-based cross-sectional analysis was performed to assess the knowledge, attitude, and practices of MTU-Tepi campus students towards youth-friendly services between October and January 2019. All students of MTU-Tepi campus under two colleges (College of Natural and Computational Sciences and College of Engineering and Technology) and one school (School of Computing and Informatics) were considered. All regular students in the Tepi campus selected as target population of this study. ere is homogeneity among the study population, and in addition, the target population was known; therefore, the simple random sampling technique used to select the sample from target population by applying the lottery method.

Inclusion and Exclusion
Criteria. All class attending regular and volunteer students to enroll in the study are included, whereas those seriously ill and not volunteer to participate were excluded from the study.

Sample Size Determination.
e sample size was calculated using a single population proportion formula using the parameters: confidence level 95% (Z α/2 � 1.96), margin of error 5% (d � 0.05), and assuming the prevalence of having knowledge of YFHS 50% (p � 0.5). en, the sample size (n) was determined as follows: By considering 11% of none response rate, the sample size was calculated as 428.
2.6. Data Collection Procedure and Instrument. After acquiring consent and voluntariness from each respondent, basic sociodemographic and socioeconomic data, as well as sexual-related information, were obtained using a pretested, semistructured self-administered questionnaire. e collected data were cleared, coded, and analyzed using SPSS version 20. For statistical analysis, from descriptive statistics: frequency and percentage and from inferential statistics: chi-square and multiple logistic regression with odd ratio (OR) were applied to identify the significant factors. e predictor variables that were significant in the univariable analysis at the 25% (p value <0.25) level of significance were included in the multiple logistic regression analysis. e estimated odds ratios (OR) and 95% confidence intervals with p value less than 5% indicate that the variables are statistically significant in multivariable analysis.

Operational Definition of Terms.
Youth is the period between childhood and adulthood which involves unique physiological, psychological, cognitive, social, and economic changes, describing individuals in the age range of 15 and 24 years. Youth-friendly health services are services that are considered as sociable, ideal, and suitable for providing solutions for the various health concerns of young people. Youth-friendly centers are any health facility that provides friendly services to the youth [4,7,17].

Knowledge, Attitude, and Practice of Respondents.
From the total participants, 237 (55.4%) of the students have no knowledge of the youth-friendly health service (YFHS) ( Table 2) and never heard of any information about YFRHS. e majority (220 (51.4%)) of them reported having no any YFRHS in their surroundings, while 58 (13.6%) do not know whether there is the service or not. For 131 (30.6%) and 151 (35.3%) of students, their friends and school teachers were the major sources of information about YFHS, respectively. e role of media as a source of information about YFHS is limited to about 21% (4.7% from newspaper and 17.8% from different media). Two hundred forty-eight (57.9%) of the respondents answered that family planning and contraception were services provided at YFRHS centers ( Table 2).
About 53% of the respondents believe that provision of contraception for a young person is obligatory and 53.3% argue that every young person should aware of YFRHS. From total students, 72.4% of the respondents disagree that female students are not the only one to use YFRHS ( Table 3). Out of 428 respondents, 57.9%, 59.3%, and 36.4% had never been practiced services related to VCT, family planning and contraception, and treatment of STIs at YFRHS, respectively (Table 4).

Association of Knowledge of Students and Explanatory
Variables. e results of the chi-square test of association revealed that sex of the student, age of the student, mother education status, father education status, availability of service providers in the student's area, and source of information had statistically significant association with knowledge of students toward YFHS, as summarized in Table 5.
e region and religion of students had no any statistically significant relationship.

Knowledge, Attitude, and Practices and Associated Factors of Youth-Friendly Health Services among Respondents.
e results of binary logistic regression analysis using the forward variable selection method of the parameter revealed that sex, age, mother education, father education, availability of YFRS in the area, source of information about YFRHS, and religion had statistically significant effect on the knowledge, attitude, and practices of students toward YFHS. In this regard, male students were more likely to have knowledge and practice (AOR �     e odds ratio for students from fathers of different educational backgrounds had statistically significant effect on knowledge, attitude, and practicing of YFRHS. As summarized in Table 6, students whose fathers were educated primary and above had odds ratio greater than one, and this implies that those students were more likely to have knowledge and positive attitude of YFRHS compared to from uneducated father. Students having YFRHS in their surroundings were more likely to have knowledge and   (Table 6). Students who get information from newspaper and media were 0.119 and 0.288 times less likely to had knowledge (AOR � 0.119; 95% CI: 0.027, 0.529; p � 0.005) and (AOR � 0.288; 95% CI: 0.112, 0.738; p � 0.009) compared to students who get information from their parents. e odds ratio for students who get information from newspaper (AOR � 7.776; 95% CI: 1.764, 34.290; p � 0.007) and media (AOR � 5.177; 95% CI: 1.944, 13.787; p � 0.001), which implies that students who get information from newspaper and media were more likely to have positive attitude of YFHS than students who get information from their parents ( Table 6).

Discussions
Out of the students of Mizan-Tepi University Tepi campus enrolled in the study, 220 (51.4%) reported having no access to any YFRHS in their locality, and this was comparable with previous studies conducted in Jimma, 47.1% [18]. However, it was much higher than a study conducted in Bahir Dar, 13.6% [19]; Adiss Ababa, 40% [20]; and community based study in Jimma 41% [18] and Harar 36% [21]. For 131 (30.6%) and 151 (35.3%) of the respondents, their friends and school teachers were the major sources of information about YFRHS, respectively, and this is quite similar with findings from Mekelle Town and Bahir Dar that reported the media outlets as a source of information are for 35.5% of the students [19]. Whereas, finding of this study is in contrast to studies done in Nigeria [22], Tanazania [23], and Ghana [1] that indicates parents, close friends, and peers of youths are the most common sources of information.
In this study, about 21% of participants got information from different medias, and this was in agreement with a study done in Harar that showed media as source of information for 22.8% participants [24]. However, this finding is less than a study in Bahir Dar and Mekelle (35.5%) [15,19]. e majority (55.4%) of respondents lack basic information and knowledge of YFHRS, and this was similar with a study in Meda Wolabu University students [16]. However, it was found much less than a research from Hadiya Ethiopia (78.5%) [25]. On the other hand, 27.6% of the respondents believed that female students are the only one to use youthfriendly health service, and this agrees with research studies done in Moldova [9].
Of a total of 428 participants, only 49% had utilized YFRHS, which is higher than a study report from Bahir Dar (32%) [19]. Treatment of STI services (63.6%) and VCT (42.1%) were the most utilized services by the study cases. However, family planning and contraception (40.7%) was a less utilized service at YFRHS center. is was in contrast to the finding in Hadiya Zone, Ethiopia [25], that reported VCT 343 (68.9%) and contraception 321 (64.5%) as the most utilized YFRHS. One of the most reported reasons by the students for not utilizing the services was the unavailability of the service in their locality (51.1%) and less availability of services even in some of the areas where the service provider is available, and this was also reported in West Gojjam Zone, Ethiopia [13]. Other study from Bahir Dar indicated inconvenience hours and fear of being seen by parents, colleagues, neighbors, or other people as roadblocks in utilizing reproductive health services [19]. Among the respondents, condom 195 (45.6%) and emergency pills 169 (39.5%) are the most commonly used contraceptive methods.
is finding was supported with other studies conducted in different parts of the Ethiopia [7,13,14] and beyond like South Africa and Tanzania [23,26,27]. In addition, this requires a great attention of both governmental and nongovernmental organizations working in provision of YFRHS across parts of Ethiopia. On chi-square test analysis, the factors that were found to be significantly associated with knowledge of students toward YFRHS were sex, age, mother's education and father's educational status, availability of any YFRH service in the respondents' area, and source of information. is was in agreement with studies conducted in Bale [2] and Wollisso [28].
Male students had more knowledge and practicing experience than female student, and this is in line with studies done in South Gondar [29], Gujarat India [30], and China [31].
is might be lack of awareness given for female students on YFRHS or lack of service giving facility in their surroundings nearby. However, it is opposing to the study done in East Gojjam zone, Ethiopia [32]. Students in age group 21-22 years were 2.732 times and in age group 23-24 years were 4.345 times more likely to have knowledge compared to student in the age group of 18-20 years, respectively, Moreover, students in the age group of 21-22 years were 2.275 times more likely experienced YFHS compared to students in the age group of 18-20 years. is study is in agreement with studies conducted in Bahir Dari [19], Jimma city [18], India [33], and East Gojjam [32]. Following the growth of students' in age, there is a subsequent increase in having knowledge about YFHS, this might be due to information gap about the service on time. However, it contradicts with study done using multicountry data analysis in China [31].
Students whose permanent residence was Tigiray and Oromia regions had less knowledge about YFHS compared to Addis Ababa city administration. is could be due to student from urban who had more YFHS offering facility access than students from rural parts of the country. As Addis Ababa is the capital city of Ethiopia and also there are many governmental and nongovernmental health facilities, mother and father education status had statistically significant effect on the knowledge, attitude, and practice of students toward YFHS. As shown in this finding, when the mother and father education level increased, the knowledge, attitude, and practice of students toward YFRHS also increased. is study is in line with study conducted in Awabel district northwest Ethiopia [34], and it is contradicting with the study done in south Gondar [29].
Students who had YFRHS access in their surroundings were 3.23 times more likely to have knowledge and 2.475 times more likely practicing experience about YFRHS compared to students who had no any service in their 6 e Scientific World Journal surroundings, respectively, this study is consistent with studies done in Hadiya Zone, Ethiopia [25], and Kenya [35]. Having this information, it can be expected as youths becoming more familiar with the service settings as well as types of services offered, and they will freely adopt to what type of service they have to use. Students who get information about YFRHS from their parents are more likely to have knowledge compared to students who get from different media. is finding agreed with study conducted in Awabel district northwest Ethiopia [34]. Students who get information from newspaper were 7.776 times more likely to have positive attitude compared to students who get information from their parents. is study is consistent with study conducted in Jimma city [18]. Participants who get information from media were 5.177 times more likely to have positive attitudes compared to students who get information from parents. According to practicing experience of YFRHS, this study revealed that there is opposite outcomes for practice and attitudes based on the source of information. is might be due to students who had information about the YFRHS, but no any services given for them.

Conclusion
e findings of this study demonstrated that the respondents' knowledge, attitude, and use of youth-friendly reproductive health services were insufficient. Above half of participants 237 (55.4%) had no knowledge, 256 (59.8%) had negative attitude, and 262 (61.2%) were not practiced youth-friendly reproductive health services. Students from secondary and above educated Mothers were more likely to have knowledge and practice YFRH services. Most of respondents had no awareness about the service, and it was a big problem to the student to use the service.
is study revealed that male participants were more likely to have knowledge and practice toward YFRH services compared to female; therefore, it needs more attention to be given for awareness about the services.

Recommendations.
Most of participants had no knowledge, negative attitude, and not practiced the services; therefore, all concerned bodies must put in much more effort in designing and implementing appropriate information provision through the use of media outlets, as well as incorporating into the curriculum education schools and universities, in order to influence youth-friendly service knowledge, attitudes, and utilization. Furthermore, both governmental and nongovernmental groups should work together to improve the quality and accessibility of YFRHS in order to meet the needs of young people.
Data Availability e datasets used in this study are available from the corresponding author on reasonable request.

Ethical Approval
e Institutional Ethical Clearance Committee of Mizan-Tepi University had ethically cleared the study, while permissions were obtained from the Mizan-Tepi University Tepi campus, Chief Directorate, and each College and School.

Consent
Informed written consent was obtained from each study participant, and confidentiality of the data was assured.

Conflicts of Interest
e authors declare that there are no conflicts of Interests.

Authors' Contributions
Samuel Getachew and Abel Mandefro conceived the research idea and collected data. Samuel Getachew and Lema Abate designed methodology, conducted analysis, and drafted the manuscript. Samuel Getachew, Lema Abate, Abel Mandefro, and Abyot Asres reviewed and edited the manuscript. All authors contributed to interpretation and discussion of the study findings and agreed with the findings presented in the paper. All authors have read and approved the final manuscript.