Abstract
Objectives:
The use of youth sexual and reproductive health (YSRH) services is low in poor nations like Ethiopia. This puts individuals at risk for a variety of sexual and reproductive health issues. Thus, the goal of this study is to evaluate how young people in East Wollega, Western Ethiopia, perceive and use YSRH services.
Methods:
A community-based cross-sectional quantitative study mixed with a qualitative inquiry was conducted among 771 participants from February 1 to 28, 2020. Data were collected through face-to-face interviews using pretested structured questionnaires adopted from reviewed works of literature on YSRH services. Data were entered using Epi Info version 7.0 and analyzed by SPSS version 20. The qualitative data was collected using interview guides and checklists. These data were analyzed using a thematic framework approach.
Results:
In this study, 48.2% of teens felt that the YSRH service units’ location within the medical facilities was inconvenient and difficult to access. More than half, 71.3% of participants, concurred that the health providers offer services that are technically sound. The confidentiality of information is disputed by 18% of participants at YSRH service locations. The limited awareness and use of YSRH services was investigated. Because of their fear of embarrassment, lack of privacy, the providers’ attitudes and workload, and the service unit’s awkward location, the adolescents believe they lack the confidence to use YSRH services.
Conclusion:
Due to low awareness, providers’ attitudes, and characteristics specific to health facilities, such as poorly placed service sites inside such facilities, a lack of services offered there, and a terrible work environment, youth had a negative opinion of YSRH services. Therefore, it is advised that families, local authorities, the medical field, the educational field, and the media all collaborate to alter public opinions of juveniles by utilizing youth-friendly strategies. The authors advise health facilities to respect young people’s privacy, alter health workers’ attitudes, let them use the services, remove obstacles to payment, designate enough health workers for both working and non-working hours, and reorganize the services.
Background
One of the 2030 agenda for Sustainable Development Goals is to achieve universal access to sexual and reproductive health services (SRH). 1 It requires that services are of adequate quality and that providers do not discriminate based on sexuality, gender, ethnicity, and age. 2 Young people (10-24 years) require services that support their physiological, cognitive, emotional, and social transition into adulthood.2,3
Poor sexual and reproductive health (SRH) service provision among young people threatens their future. This is particularly true in developing countries where the weak and staggering health system is the only means to address the SRH needs of young people.3,4 To address this issue African countries have been implementing strategies like comprehensive sexuality education, peer education, mass media campaigns, and establishing youth-friendly centers both at community and facility levels.4,5
Investing in the health of young people is essential for the economic and social development of any nation. 6 The government of Ethiopia has been putting tremendous efforts into awareness raising, expansion of sexual and reproductive health services, and developing health policy to promote YSRH services. 7 Youth-friendly centers were established in different parts of Ethiopia.4,5,7 However, studies in Ethiopia (West Gojam, Harar, and Asgede-Tsimbla district) showed that utilization of YSRH services is still very low because of numerous factors affecting7-9 utilization of YSRH services. Youth-provider interactions, poor awareness of YSRH services, fear and shame related to socio-cultural norms, and perception of youths and their families are among the factors negatively affecting the utilization of YSRH services.5,10-12 A study conducted in Northwestern Ethiopia indicated that client-provider interaction and privacy were the most important factors affecting its utilization. 9 Effective involvement of young people in the design, implementation, and evaluation of programs helps to ensure that their needs are addressed. 13 Therefore, this study aimed to address the perception and experience of youth and providers about YSRH services in Western Ethiopia.
Methods
Study area and setting
This study was conducted in the East Wollega zone of Oromia regional state, Western Ethiopia.
East Wollega is located in the west part of the Oromia regional state. Administratively, it is organized into 18 districts, 43 towns, and 287 rural kebeles. According to the Central Statistics Agency 2007 report, the total population was estimated to be 1.5 million. Nekemte, which is 331 km from the capital city of the country, Addis Ababa, is the capital city of East Wollega. The study was conducted from February 1 to 28, 2020.
Study design
A mixed-methods cross-sectional study comprising a community-based cross-sectional study and qualitative study. A qualitative study was included to support the findings of the quantitative study. A qualitative study was also meant to address the perspectives of providers. A qualitative study was conducted using focus group discussions (FGDs), in-depth interviews (IDs), and observations of health facilities that provide youth sexual and reproductive health services.
Study population
Primary participants (beneficiaries) were married and unmarried youths ages 15 to 24 years who were living in the East Wollega zone during the study period. Secondary participants (non-beneficiaries) were service providers working in the East Wollega zone during the study period. We used the qualitative study to explore important findings from this sensitive research topic. Three participant groups including youths who had never used SRH services, youths having experience with SRH services, and SRH service providers were identified. The study participants who participated in the quantitative study did not participate in the qualitative study. In this study, service providers were nurses, midwives, and general practitioners.
Sample size determination
For quantitative data, the single population proportion formula was used to calculate the sample size with the following assumption. The proportion of adolescents who utilized adolescent and youth-friendly services which were 63.8% was taken. 8 The marginal error of 5%, design effect 2, and 95% confidence level. After adding a 10% non-response rate, the final sample size was 781.
For qualitative data, 4 focus group discussions (FGDs) each consisted of 8 to 9 youths aged 15 to 24 years, and 8 in-depth interviews with service providers were undertaken until saturation was reached. Observations of 7 service units in health facilities were conducted using checklists if they were providing the services per the standard.
Study variables
Age, sex, awareness, perception, and experiences of youths, health professionals’ attitude, confidentiality and privacy, location of service unit, staff workload, logistics and supplies, cost, working hours.
Sampling procedures
For quantitative, a multistage sampling technique was used in this research. We listed all the districts in East Wollega. Then, 7 districts were selected by lottery method. After that, the districts were further stratified by rural and urban kebeles to ensure the representativeness of the study population. Kebeles were sub-divided by predetermined zones, from which 1 zone was randomly selected. Then, a list of households in each selected zone was obtained from the kebele. Health extension workers of the kebeles were contacted to identify the households where the target age groups were found. Finally, the required number of participants were interviewed from randomly selected households.
For the qualitative method, the health centers serving the study kebeles were considered. Observation of purposely selected health facilities and in-depth interviews with direct service providers were conducted. In the next step, local youth were purposively selected for FGDs.
Data collection procedure
For the quantitative method, data were collected by 16 data collectors who knew the Afan Oromo language and the situation of local youth. The quantitative data were meant to address the sociodemographic characteristics of study participants and their perception of YSRH services. The quantitative data were collected through interviewer-administered questionnaires adopted from reviewed literature on AYSRH services.7-9,13-19
For qualitative method
Focus group discussions
Four focus group discussions (FGDs) each consisting of 8 to 9 youths aged 15 to 24 years were conducted. The researchers used an open-ended FGD question guide developed by reviewing different works of literature.7-9,13-19 Group members were carefully selected in a way that a member cannot influence another and free discussion is maintained. Each FGD comprises SRH utilizers and non-utilizers and lasted an average of 2 hours including refreshment breaks. Discussions on youth perception, providers’ attitudes, and problems faced by youths on sexual and reproductive health services were conducted in private rooms at the health facilities. The FGD guide consisted of open-ended questions to elicit the broadest responses. Once these responses were obtained, the facilitators used more structured questions to draw out more specific information regarding knowledge, barriers, and perceptions of youths on SRH and its services.
All FGDs were conducted with 2 researchers; a moderator and a note taker. The moderator was responsible for guiding the discussion while the note taker was responsible for taking notes, noting down non-verbal responses, and ensuring that tape-recoding was ongoing.
In-depth interviews
Ten in-depth interviews of health professionals (nurses, midwives, and general practitioners) providing SRH services for youths were conducted using open-ended questions. The interview guide was designed by gynecologists and reproductive health experts (specialists in reproductive health) all of whom worked closely with youth SRH services. The questioning techniques were meticulously done to explore providers’ perceptions, behavior, and practice of YSRH services. IDIs were conducted by a single researcher and took between 30 and 40 minutes. The IDIs were tape-recorded and short notes were taken as the interview progressed.
Observation of SRH service facilities
Direct non-participant observation of 10 health facilities that provide youth sexual and reproductive health services were conducted. A checklist prepared by investigators was used to assess facilities that deliver SRH service to check whether providers were providing the services as per the standard, location of the service unit within the facility, and logistic status.
Definition of terms
Anyone between the age of 15 and 24 years.
Reproductive services that are accessible to, acceptable by, and appropriate for youths.
The area from which a facility’s patients are drawn.
The perception score is calculated by subtracting the percentage of those who rated disagree about sexual reproductive health services from those who rated agree (i.e., % agree − % disagree). Perception scores range from −100 to +100. Those who rate neutral do not move the perception score toward the positive or negative end of the spectrum. Accordingly, negative and positive perceptions are defined when the difference is calculated to be negative and positive respectively. 20
Data analysis
For the quantitative method, the data were checked, entered, and cleaned using Epi Info version 7.0 and then exported to Statistical Package for the Social Sciences (SPSS) software version 20. Then descriptive analysis was done.
For the qualitative method, transcription of the data collected in this study was done by the research assistants under the guidance of the principal investigator. Transcription was done directly into English from Afan Oromo. The transcripts were typed out and each transcript was saved as an individual word document with clear labeling showing the type of interview, and respondents’ age and sex. Once the transcripts were translated to English, they were saved on a password-protected computer only accessible to the research team. An independent researcher conversant in both Afan Oromo and English cross-checked the transcripts for accuracy and language translation consistency. The data was validated through validation meetings with some of the respondents who took part in the study. Data analysis was conducted using the thematic framework approach.
Data quality assurance
Data quality was assured by pre-testing the questionnaire on 40 students in 1 kebele which was later excluded from the actual study. The training was given to data collectors and supervisors. The overall supervision was carried out by the investigators. Research assistants were trained on the objective of the study and how to conduct interviews and FGDs.
Results
Sociodemographic characteristics of study participants
The majority, 468 (60.7%) of the participants were males. More than half, 456 (59.1%), are in the age group of 15 to 19 years. Three hundred eight (49.9%) and 386 (50.1%) participants were from the rural and urban respectively. Most of the study participants were unmarried. Only 7 participants (0.9%) had never attended school (Table 1).
Socio-demographic characteristics of study participants, East Wollega, 2020.
Perception of youth about youth sexual and reproductive health services
Nearly half 373 (48.4%) agree that staff at the YSRH service keep the confidentiality of information. One hundred forty-two (18.4%) of study participants agree that access to youth-friendly services encourages sexual activity. More than half of the participants agreed that providers deliver technically appropriate service 426 (55.3%). This study also depicted that 163 (21.1%) strongly agree and 162 (21%) agree that they will feel ashamed if somebody from family members sees them there. More than a third of the study participants 291 (37.7) disagree that men/boys were not served at YSRH service while only 110 (14.3) agree with it. Two hundred fifteen (28.9%) agree that the youth-friendly service location is not accessible and convenient (Table 2).
Perception of youths on sexual and reproductive health services, East Wollega, 2020.
Youth were asked about confidentiality during service utilization. There was a perception that youth do not feel confident using the service fearing that their confidentiality might not be kept. A 23 male discussant explained this as, “. . . the service is something you secretly obtain. However, there is only one AYSRH provider in the health center. He is a known person whom you must contact to get the services.”
There was a point of discussion that youth always fear obtaining the service by themselves. However, they send children to buy the services for them by giving them a piece of paper (“prescription”) on which the specific service of their need is written. This might be why it was explained that nobody prefers public health facilities because private health facilities provide the services faster and to the point. Besides, youth perceived that they are considered human immunodeficiency virus (HIV) positive if somebody sees them at service units within the health facilities. A 24 female discussant explained this as “. . .people perceive that a young person coming to the facility for such services has HIV. Therefore, youths fear to visit the facilities not to be labeled as HIV positive.”
Experience of youth during utilization of sexual and reproductive health services
In this study, 28.8% of youth who used YSRH services reported that the approach of health care providers was not welcoming. These participants were also asked whether they received the intended service or not. It was found that 72.7% of them received the intended service. Besides, 77.2% of participants were encouraged to make an informed decision. Only 22.7% of participants consistently get the same provider (Figure 1).
Experience of youths during utilization of sexual and reproductive health services, East Wollega, 2020.
Youth were asked whether they are utilizing youth sexual and reproductive health services or not. It was, then, explored that youth sexual and reproductive health service utilization was very low compared to the target population in the catchment area. For example, 1 male key informant (service provider) was asked about the most frequently used services in the facility he was serving. He said, “Both males and females usually come after practicing unprotected sexual practice. Males come for condoms, HIV testing, and counseling. Females come for pregnancy test once missed their menstrual cycle.”
Youth were asked whether someone was teaching them about YSRH or not. They were also asked about the challenges they were facing to use YSRH services. They reported that nobody was visiting the community where they live to talk about SRH and the services. The challenges related to low service utilization were limited awareness about YSRH and the services, providers’ attitudes, sociocultural factors, and health facility-related factors. It was also discussed that youth have no adequate information about SRH and the services. Some mentioned that they don’t know how to visit health facilities for such services. Others who used the service did it secretly. A 23 female discussant stated about this “We are hearing about it now. I know as if health facilities only focus on patients.”
Youth also asked whether they were getting adequate information about the services, counseling, and when they use YSRH services. They perceive that the service providers always don’t give adequate information and counseling for the youth; they always give the specific services that youth seek and leave them without additional information about the availability of other types of services. It was also explored that youth usually tend to utilize the service when they go for other services.
Discussants reported that nobody was concerned about them by exemplifying that when they go to get the services, providers are usually busy dealing with other routine cases. This was understood as if providers have no willingness to expand their services. A 20-year female discussant mentioned that “youth want professionals who friendly address their issues by patience taking enough time with them and who keeps their confidentiality. However, it is difficult to get such providers in all places where providers have multiple duties in different service units.” From health facility observations, it was witnessed that professionals were giving SRH service not as a routine job, but as an additional duty. Because of this clients are appointed on the other day. At 1 facility, there was only 1 provider who was trained on sexual and reproductive health service provision.
A 40-year male nurse professional key informant perceived that youth sexual and reproductive health services should not be limited to health facilities. Youths at schools or in the community need to be reached through outreach programs. However, health professionals fear that the current unstable political situations in the study area might challenge its realization.
Other key informants perceived that less attention was given to youth SRH services compared to other services though young people are the future generation of the country. They mentioned that governmental and non-governmental programs usually focus on maternal health services. A 31-year male key informant explained this as, “. . . Just like Tuberculosis and Antiretroviral clinics, providers should be separately assigned to SRH service units to provide only this service. The government should strongly work towards ensuring that. I am saying this based on the actual needs and what we are experiencing here.”
There was also a finding that some providers were not comfortable providing comprehensive abortion care services though they had received its training. Regarding this, a 29-year key informant explained, “I will never provide comprehensive abortion care (CAC) as it is considered a sin by my religion. The service is not provided here; we just counsel and refer the clients to other facilities.”
Providers were also asked about their motivation to provide SRH services. They reported that they are motivated to provide the services to adolescents and youths but a high workload was rendering them.
Challenges in health facilities providing Youth Sexual and Reproductive Health services
It was explored that some health facilities were incurring costs on some services. Youth were forced to pay 3 USD for a single premarital human immunodeficiency virus (HIV) testing and counseling. This could potentially hinder service utilization. A 34-year female key informant also mentioned “the scarcity of supplies like condoms and test kits in health facilities.”
During observation of facilities, it was identified that the location of adolescent and youth SRH service units was not convenient for them. For example, in 1 health facility, the SRH service unit was located at the back of the facility which might make access difficult. There was also a case where the service unit was closer to the antiretroviral (ART) clinic in which case the youths might fear that other clients might consider them as ART clinic attendants, and on the other hand those ART clinic attendants may also suspect them as if the youths will disclose them to others about their HIV status.
In most of the study facilities, youths can get services only during working hours, not on weekends and nights. Even during the working hours, there would not be service provision for adolescents and youths either when the assigned provider has other duties in the other service units or when the provider is off of working day duty after the night duty.
Discussions
One of the key findings of this study was limited information on the sexual and reproductive health of youths in the community. Information related to the availability and importance of YSRH services, type of services, and counseling was so limited because there were rarely awareness-raising programs on sexual and reproductive health. Besides this, because of work overload, service providers were not in a good position to give appropriate counseling and information on SRH in a way that youth can benefit from the services. 8 This might also be due to the poor engagement of families of the youths to openly discuss SRH. 11
This study identified feeling shy and lack of privacy as some of the barriers to accessing YSRH services. Youths in western Ethiopia feel ashamed if someone from their parents or whom they know sees them in the YSRH service unit because of prevailing negative cultural attitudes toward premarital sex. Therefore, it is very important to avail of YSRH services at sites where youths can easily access them (private health facilities, youth clubs, school-based services, and community volunteers approach). Moreover, it is important to provide clear information on confidentiality. This is consistent with similar studies.6,8,14,15
In this study, the perception of youths, and providers’ attitudes were found to affect the utilization of YSRH services. Similar to studies from other regions,6,10,16 perceived lack of confidentiality, less motivated and busy service providers, and judgmental attitudes of service providers were preventing youth from accessing AYSRH services. Therefore, these factors can be an important target for intervention. Training that addresses the attitudes, communication, and counseling skills of providers can improve provider performance.
In this study, young people prefer private health facilities for sexual and reproductive health services. The main reasons mentioned by them were fast service delivery and better privacy at private health facilities. The inconvenient location of YSRH service units within the health facilities could also explain this. However, in studies conducted in South Africa 17 and 4 African countries (Burkina Faso, Ghana, Malawi, and Uganda), 18 public health facilities were reported to be the most preferred source of contraceptives and HIV testing among young people. The differences could be explained by the inconvenient nature of public health facilities in the study area.
This study revealed that shortage of supplies and test kits, expensive service costs, uncomfortable location of AYSRH service unit within the health facilities, and inconvenient times were health facility-related factors rendering youths in Western Ethiopia to utilize YSRH services. This is consistent with a study conducted in Harar, Ethiopia which showed the poor quality of service, inconvenient service location, inconvenient hours of operation, and unaffordable service costs as the reasons why young people did not utilize SRH services.8,19
Limitation of the study
This study is not without limitations. Since the research was conducted on a sensitive issue, it might result in social desirability bias, which could underestimate or overestimate an outcome of interest. Some reproductive-related questions might be subject to recall bias and thus could compromise the findings of the study. However, careful attention was given to the study in advance by the researchers to maintain the quality of the data.
Conclusion
Due to low awareness, providers’ attitudes, and characteristics specific to health facilities, such as poorly placed service sites inside such facilities, a lack of services offered there, and a terrible work environment, youth had a negative opinion of YSRH services. Therefore, it is advised that families, local authorities, the medical field, the educational field, and the media all collaborate to alter public opinions of juveniles by utilizing youth-friendly strategies. The authors advise health facilities to respect young people’s privacy, alter health workers’ attitudes, let them use the services, remove obstacles to payment, designate enough health workers for both working and non-working hours, and reorganize the services.
Supplemental Material
sj-docx-1-his-10.1177_11786329221134354 – Supplemental material for Perception and Experience of Youth About Youths Sexual and Reproductive Health Services in Western Ethiopia: A Community-Based Cross Sectional Study
Supplemental material, sj-docx-1-his-10.1177_11786329221134354 for Perception and Experience of Youth About Youths Sexual and Reproductive Health Services in Western Ethiopia: A Community-Based Cross Sectional Study by Temesgen Tilahun, Tariku Tesfaye Bekuma, Motuma Getachew, Rut Oljira and Assefa Seme in Health Services Insights
Footnotes
Acknowledgements
We are very grateful to Wollega University for the facilitation of the necessary research processes including the support letter. Our grateful gratitude and respect also go to Marie Stopes International Ethiopia for funding this research work.
Funding:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Marie Stopes International Ethiopia was the funding source.
Declaration Of Conflicting Interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author contributions
TT was involved in conceptualization, data curation, funding acquisition, investigation, methodology, project administration, supervision, writing—original draft, and writing—review & editing. AS was involved in conceptualization, data curation, funding acquisition, methodology, supervision, and writing—review & editing. TTB, MG, and RO were involved in conceptualization, formal analysis, investigation, methodology, resources, software, writing—original draft, and writing—review & editing
Availability of data and materials
The data sets used and analyzed during the current study are available from the corresponding author on formal request.
Ethical approval and consent to participate
Ethical clearance was obtained from the Research Ethics Committee of the Institute of Health Sciences, Wollega University with number /043CHRT/2012 on 02/06/2012 E.C. Then, a support letter was written to the study zones for the necessary support within different districts and facilities in the zone. Written consent was taken from each eligible study participant. Identifying information was not included in the questionnaire to ensure privacy and confidentiality. All methods were performed per the relevant guidelines and regulations.
Informed consent
Written informed consent was obtained from each eligible study participant. This was approved by IRB number/043CHRT/2012 on 02/06/2012 E.C.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
