Reproductive health services utilization and its associated factors among adolescents in Debre Berhan town, Central Ethiopia: a community-based cross-sectional study

Cross-sectional study was conducted from April 5–May 1, 2016 in Debre Berhan town, North Shoa, Ethiopia with an objective to assess the reproductive health service utilization and to find out associated factors among adolescents of age 15–19 years. Debre Berhan town is located at 9°41’N 39°32′E/9.683°N 39.533°E, that is, 130 km North of Addis Ababa, the capital city of Ethiopia. It has 2840 m elevation above sea level and covers 14.71km². The town is founded by Emperor Zara Yakob in 1456 [9], and it has 9 administrative kebeles. According to the information obtained from the District Health Office, in 2015/16 population data, the total population size of the district was 92,887, out of which 50,883 (54.78%) were females. The number of households and adolescents (10–19 years of age) in the district were estimated to be 18,453 and 22,014 respectively. In the town, there were 2 hospitals, 3 health centers, 9 health posts, 6 private clinics, and 17 pharmacies which render health services for the community. Family planning service was also available in most of the above health institutions including health posts.

A multi-stage sampling technique was employed for the selection of the sampling units. In the district, there were 9 kebeles, of which a total of 5 kebeles were selected using lottery method. The sample size for each selected kebeles was determined proportionally to the number of households within each kebele. Then, systematic sampling method was employed to select the households where adolescents reside from each kebele assuming in a household at least one adolescent aged 15–19 will be found. In cases of household with more than one eligible respondent, only one respondent was selected by using a lottery method.

A self-administered, semi-structured questionnaire was used in the study. The questionnaire was developed by combining the John Cleland’s Illustrative questionnaire for interview-survey with young people’s [10], and also several literatures reviewed to achieve the research objectives.

The main points included in the questionnaire were: socio demographic characteristics; adolescents’ individual attribute regarding to sexuality and reproductive health; service accessibility (geographical accessibility); and four main aspects of RH services (sexual and RH information and education, modern contraceptive, voluntary counseling and testing for HIV, STI diagnosis and treatment) (See Additional file 1). The data was collected by 6 trained data collectors for 25 days under close supervision and facilitation by 1 supervisor and the principal investigator as needed.

The questionnaire and consent documents were first developed in English language, and then translated into Amharic language for data collection purpose using the local language. Then finally, the subject matter experts retranslated the data back into English language in collaboration with a translation expert to check its consistency.

Face validity of the questionnaire was assessed. Items interpretability and understandability by the study participants was evaluated by pre-testing the questionnaire on 34 adolescents (5% of the total sample size) living in unselected kebeles, and the necessary correction has been taken accordingly. Six data collectors (3 females and 3 males) who were third year Nursing Department students from Debre Berhan University participated in the data collection process of the study after they were provided with the appropriate orientation and guidance about the overall project plan, and how to approach and communicate with adolescents to elicit reliable data.

The anticipated time duration to complete the questionnaire was not more than 30 min. For respondents who were absent in the first visit, a maximum of two additional schedules were established for revisit. Supervision was also done on the spot by principal investigator and supervisor. The collected data was checked for its completeness and clarity by the principal investigator daily. Data cleaning and cross-checking were also done before analysis.

After checking for its completeness, the data was processed and analyzed by SPSS version 21. Descriptive and analytical statistics including, bivariate and multivariate analysis was employed. Percentage, ratios, frequency distribution, measure of central tendency, and measure of dispersion have been used for describing different variables. Bivariate analysis has been used to examine association between dependent and independent variables. All variables with p < 0.05 in bivariate analysis was fitted in to the multiple variable logistic regression model to identify factors associated with RH service utilization. P value less than 0.05 was considered as a level of significance.

From the total 682 participants, 648 of them responded to the questionnaires yielded a response rate of 95.01%. Out of 648 participants 348 (53.7%) were males. The mean and median age of the respondents were 17.13 (SD + 1.33), and 17.0 respectively. Six hundred four (93.2%) respondents were Orthodox Christian followed by Muslim 27 (4.2%), and protestant 17 (2.6%). Based on their ethnic group, Amhara ethnic constituted 611 (94.3%), and majority of the respondents 624 (96.3%) were single.

Regarding to their school status, 606 (93.5%) participants were currently enrolled at schools. In contrast, only 5 (0.8%) of the respondents were found without any formal education experience. Among the participants who were attending education, 443 (68.4%) of the respondents reported their educational status as secondary education (Grade 9–12) followed by primary education (Grade 1–8), and above secondary education 132 (20.4%) and 68 (10.5%) respectively.

Concerning the Participants’ mother educational status, nearly similar figures were reported that lies between 20th and 30th percentile with slight percentage increment in mothers with no formal education 175 (27.0%). Out of the total respondents, 412 (63.6%) reported about the absence of discussion habit on sexual and reproductive issues in their family. On the other hand, the median perceived monthly family income was 2095.0 Ethiopian Birr. More than three-fourth, 493 (76.1%) of the study participants were living with their mother and father together (Table 1).

To assess their knowledge, the study participants were asked about the components of RHS and service delivery points which have a total score of 15. Accordingly, respondents who had high knowledge (scoring above the mean = 8.6 (SD+ 3.4)) were 356 (54.9%). Out of the total participants, 232 (35.8%) have had boy/girlfriends, and among those who had boy/girlfriend, nearly half of them 114 (49.1%) had one boy/girlfriend (mean = 2.06, SD + 1.44). Moreover, one hundred sixty-two (25.0%) of the respondents have had sexual intercourse in their life.

One hundred eighty (27.8%) of the study participants reported that they have had discussion on at least two of the sexual and reproductive health issues [SRH discussion points; Abstinence, condom use, STI/HIV/AIDS, unwanted pregnancy, contraception] with their peers in the last 12 months prior to the study. Discussion on the same issues was also reported by 88 (13.6%), and 82 (12.7%) of the respondents with their sexual partner and with health workers respectively.

Depending on their risky behavior that leads to being infected with HIV virus, the study participants’ perception towards being infected of HIV virus reveals that 559 (86.3%) respondents perceived themselves as free from HIV infection risks.

Regarding to the participants’ last 12-months experience of alcohol, ‘khat’ or cigarette use: majority of them 568 (87.2%) reported that they didn’t consume any of these addictive substances. The remaining use at least one of those drugs at a different regularity. Majority, 28 (33.7%) of the ‘drug-users’ who used those drugs less frequent than monthly followed by weekly 20 (24.1%), monthly 17 (20.5%), daily 15 (18.1%) and more frequent than daily 3 (3.61%). Considering the operational definition used in this study, 55 (8.5%) of the respondents had use those substances (Table 2).

Regarding to the accessibility of reproductive health service delivery points, Hospitals and Health centers were among the commonly mentioned service delivery points 250 (38.6%) and 239 (36.9%) respectively followed by Clinics (both private and NGOs’) 62 (9.6%). In addition, Pharmacy constitutes 42 (6.5%), Health posts comprise 22 (3.4%), and Youth friendly health service clubs constitutes 17 (2.6%), while Health extension workers comprise 16 (2.5%).

The mean distance from the respondents’ home to the nearest service delivery point was 1.43 km and it was reported to take an average of 19 min to walk. The majority of the participants said that there was RH service delivery center within a 30-min walk (69.4%) and within 1.6 km radius (88.4%) from their home which yields an overall high geographical accessibility of 68.5% and low geographical accessibility of 31.5%. However, there was a slight variation of geographical accessibility between male and female respondents (Table 3).

Nearly, 1 among 3 adolescents, 219 (33.8%) had used at least one of the reproductive health services (see Fig. 1). Accordingly, among these RH service users (n = 219), voluntary counseling and testing service for HIV service accounts 175 (43.6%) followed by SRH information and education service users 95 (23.7%), modern contraceptive users 88 (21.9%), and STI diagnosis and treatment service users 43 (10.7%) (See Fig. 2).

According to the data obtained on contractive methods used with reference to gender, the most frequently used modern contraceptive method by male adolescents was condom (60.2%) followed by female adolescents using oral contraceptive pills (20.4%) (See Fig. 3).

Based on the Bivariate analysis, the factors found to be significantly associated with reproductive health service utilization were adolescents age, marital status, and educational status; mothers’ educational status; poor family communication habit on SRH issues; co-residence with both parents; family monthly income; history of sexual intercourse; poor discussion on SRH matters with sexual partner, pears, and health workers; perception of risk towards HIV/AIDS; exposure towards mass media; addictive substance or drugs use; and geographical accessibility.

With an intention of controlling confounding effect, variables that were statistically significant with reproductive health service utilization on bivariate analysis were interred in to multiple variable logistic regressions. Based on this analysis, adolescents who had discussed sexual and reproductive health issues with their sexual partner and peers were two times more likely to use at least one of the four RH services than their counter parts (AOR = 2.368, 95% CI: 1.168–4.802 and AOR = 2.360, 95% CI: 1.155–4.820 respectively). Adolescents who weren’t co-resided with both their parents were about two times more likely to utilize RH service than those who were living together (AOR = 2.570, 95% CI = 1.155–4.820). Positive perception of oneself towards being infected of HIV/AIDS was a driven force for the adolescents to use RH services twice than those who didn’t perceive themselves as risky (AOR = 2.231, 95% CI: 1.001–4.975) (Table 4).