Utilization of Family Planning and Volunteer Counseling and Testing Service and Associated Factors among Preparatory School Students in Arba Minch Town, Southern Ethiopia: A Cross-Sectional Study

Background: The utilization of reproductive health service plays signi�cant role in preventing youths from different reproductive related health problems. Adolescents in Ethiopia have inadequate access to information and services. Objective: To assess utilization of family planning and volunteer counseling and testing service and associated factors among preparatory school students in Arba Minch Town. Method: Institutional based cross sectional study was conducted among randomly selected 522 regular preparatory students in Arba Minch Town from December 01-30/2019. Data was entered and clean into Epidata-4.6 templates then transferred to SPSS-25 statistical software for analysis. A bi-variable and multivariable logistic regression model was used to identify statistically signi�cant variables of the independent variable. Variables with P-value < 0.05 in the �nal model were considered signi�cant determinant variables.


Background
Reproductive health (RH) is de ned as "A state of physical, emotional, and social well-being, not merely the absence of illness or in rmity, in all matters relating to the reproductive system and its functions and processes.It includes human sexual activity and reproductive processes and implies that people can have a "responsible, satisfying, and safe sex life, as well as the ability to reproduce and the freedom to choose whether, when and how often they reproduce² (1).Reproductive health is universal concern, but it is special importance for female during reproductive period.However male also demands speci c reproductive health needs and have power in some reproductive health matters (2).
Adolescence is can be described as those youths age found between 10 up to 19 years (3).It is transition period from youthful to maturity (4).It is demarcated by signi cant change in physical, mental, emotional and behavior.Adolescence is the time of assignation of an extensive variety of activities that put their life at high risk (5).And it can also characterized as a period of high risk taking because adolescents are susceptible to behavioral problems (6, 7).Among these behavioral problem during puberty are; physical health problem consequences such as abortion, school dropout, out of marriage vows as well as pushing prone to sexually transmitted diseases such as HIV (8).All these problems can be prevented through sexual and reproductive health service uptake (3).The bene ts of practicing family planning method is encompassing economic growth, prevents pregnancy-related health risks for women, particularly for adolescent girl, educational advances, and women's empowerment (9).Contraceptive use has multiple bene ts.It prevents unplanned pregnancies, decreases the number of abortion, and reduces the incidence of death and disability interrelated to complication pregnancy, and childbirths.The bene ts of it for longrange of time is increased education for women, and better family health to better family income and robust national economic growth.Increased contraceptive use and reduced unmet need for contraception are essential to improve maternal and adolescent health, and combating HIV (10).
The decisions made during this period of life affect not only the individual welfare of adolescences, but also the wellbeing of whole people.The proportion of unmet need among married & unmarried female adolescence in Central and West Africa is 29.3& 41.7%, respectively.In general, married adolescents aged 15-19 experience greater unmet need than all married women.Generally, the rate of family planning practice is low in all regions in SSA among 15-19-year old married female adolescent.In Ethiopia there are various cultural and social barriers for gender equality, resulting in poor reproductive indices and high prevalence of harmful traditional practices (11).
Ethiopia is a country which unsafe abortion is a prominent cause of maternal mortality and injury (15).
However as many research ndings disclosure that the RHS utilization among adolescents are lower than other age categories (18).
Adolescents in Ethiopia have limited access to SRH information (19).Despite of the high rate of SRH problems; the access of acceptable SRH services to adolescents is very low (20)(21)(22).This poses a major public health problem such as maternal deaths and other complications resulting from early marriage, unplanned pregnancy, and unsafe abortion in the country.From the overall burden of disease due to complicated child birth; Adolescent women accounts for 23% of among women of all ages (23,24).
Worldwide the estimated number of 3.2 million unsafe abortions occur each year among youth girls aged 15-19 years (17).According to the 2016 Ethiopian Demographic and Health Survey report, among sexually active adolescents aged 15-19 years, adults who were tested for HIV test were only 22% and 18% respectively (15).Adolescents' RHS uptake is low particularly in the Southern Ethiopia in which study area is found (23).The objective of this study was to assess reproductive health services utilization of adolescents in preparatory schools in Arba Minch Ethiopia.Determining the prevalence of reproductive health service utilization in Arba Minch will contribute to pave the identi ed gaps and solve the problems related to the service utilization.

Methods
Study Design and Period: School based cross-sectional study was conducted to assess utilization of family planning and volunteer counseling and testing service and associated factors among preparatory school students in December 2019.
Study Area: The study was conducted in Arba Minch town which is found in Gamo zone, the Southern Nations Nationalities and Peoples Region (SNNPR).It is located in Southern 505km far from Addis Ababa (capital city of Ethiopia) and 275km southwest of Hawassa (capital town of the regional state).It is structured or divided in to 4 sub city and 11 kebeles in order to facilitate socio-economic development of the town residents.Arba Minch is home to14 governmental health facilities, 34 private clinics, 13 drug store and 2 community pharmacy providing health care services for the community and also 23 primary schools [8 Governmental, and 15 private (4 of them are 1-4 grade)], 9 high schools (5 Governmental and 4 privates) and 6 preparatory schools (3 Governmental and 3 private schools).All students in randomly selected preparatory schools in Arba Minch town were the study population.
All regular students between age of 15-19 years old enrolled in to preparatory school in 2019 and regular preparatory school students drop out from school, and severely sick during the data collection period were exclude.

Sample Size Determination
A single population proportion formula was used to calculate the required sample size by assuming estimated proportion of RH among preparatory adolescents (p) = 67.3% in Goba town (28), con dence level of 95%, and 5% of margin of error.Because of multistage sampling method was used; sample size was multiplied by design effect 1.5 and the nal sample sizes became 541.Sample size was calculated for second outcome variable; but lower than the sample size calculated from the rst outcome variable and we took the larger one.

Sampling Technique
After calculating sample size, two stage sampling technique was used to select the study participant.
Firstly, students were strati ed in to eleventh and twelve's grade stream.The sample size was distributed to each grade proportional to their size.The samples were selected by using simple random sampling (SRS) technique from each grade.Generally, the required numbers of students were selected by computer generated numbers from each grades and sex (Figure 1).

Data Collection Technique and Quality Control
Data was collected using semi-structured and pre-tested questionnaire by self-administered method.The questionnaire was adopted by reviewing different literature (20,28) and some of the variables were adopted from the EDHS questionnaire.Data collection period was from Dec. 10-13/2019.School instructors were used as a data collection facilitator.The purpose of the study was explained to study participants in order to identify the clarity of questionnaires and their sensitiveness.
To assure the quality of the data, training was given for data collectors and supervisors.The questionnaires was prepared originally in English and translated to Amharic then back to English.Pretesting of the questionnaire was performed on 5% of the sample in similar setting students in Birbir preparatory which is found near to Arba Minch town) before the actual data collection to ensure its clarity, ordering, and consistency.Based on the input from the pretest some questions were rewritten, and the nal questionnaire was prepared.The trained school instructors were facilitate the data collection process and check the completeness of the questionnaires.To assure privacy of the information, each participant was assigned to a single sparsely placed seat.Each questionnaire was checked for completeness of the information jointly by the supervisors, and incomplete and inconsistency lled questionnaires were returned to the respondents so that they ll it in full at the data collection site.

Operational De nitions of the Study Variables
Reproductive health services: particularly considered in this study are FP and VCT services.
FP service utilization: Is de ned as ever use of any modern contraceptives in the last one year.
VCT service utilization: It is measured by requesting study participants getting HIV testing service voluntary in the last 12 months (20).

Data Management and Analysis
Data was entered in to Epi-Data version 4.6 and export to SPSS Version 25 software package for analysis.Descriptive statistics of variables were performed by frequency distribution tables and gures.
Bivariable logistic regression was used to identify the association between the dependent and independent variable.The variables whose signi cance level less than P<0.25 were considered as candidate for the multivariable logistic regression analysis.Before multivariable analysis, independent variables were checked for multi-colinearity effect using correlation matrix.Hosmer-Lemshow test was used to test goodness-of-t to assess whether the necessary assumptions for application of multivariable logistic regression.Finally to determine the independent factors associated with F/P and VCT utilization, multivariable logistic regression was done.The strength of association was interpreted using the adjusted odds ratio and 95% CI.Variables with P-value <0.05 in the nal model was considered statistically signi cant.

Socio Demographic Characteristic of the Study Participants
From the total of 541 students, 522 responded to the questionnaires yielding a response rate of 96.48%.Majority of the students 296(56.7%)were males.The mean age of the study participant was 17.8 with (SD±0.8)years.Among the respondents, 216(41.4%)and 306(58.6%)were attending grade 11 th and grade 12 th respectively.Two hundred fty two (48.3%)respondents were Orthodox religion follower followed by protestant 247(47.3%)and Muslim 22(4.2%).Gamo 380(72.8%)and Gofa 44(8.4%)constitute the major ethnic group.The majority of the respondents 499(95.6%)were unmarried.
Regarding to participants family educational status 160(30.7%) of fathers and 72(13.8%) of mothers were above secondary education (Table 1).

Sexual History of the Participants
Out of 522 participants 307(58.8%)have boy/girlfriend and among these 141(45.9%) of them had two and above two sexual partners.From a total participants 159(30.5%)have had sexual intercourse with their friends in the past 12 months (Table 2).

Awareness and Source of Information
About 468(89.7%) of study participants were heard information about reproductive health services, among these 324(62.1%)and 297(56.9%) of the participants had information (awareness) about family planning and VCT services respectively.The most common source of information for respondents were mass media and health care provider followed by teachers.316(60.5%)study participants were discussed about reproductive health service, 174(33.3%)and 195(37.4%) of the study subjects were discussed about family planning and VCT services respectively.One hundred ninety seven (37.7%) were discussed with their friends or peer groups followed by parents or guardian 94(18%) (Table 3).

Family Planning Service Utilization
Among sexual intercourse experienced study participants 125(78.6%)utilized FP service.Male condoms were most commonly used 79(63.2%)followed by 45(36%) pills and the least used modern contraceptive was female condom only four (3.2%) during their sexual intercourse.The major reason for not using family planning service for 162(31%) of the study participant was have no money for the service followed by one hundred thirty six (26.1) felt ashamed from their friends (Table 4).

Voluntary Counseling and Testing Service Utilization
Among 522 students participated in this study, 153(29.3%) of them had voluntary counseling and testing service.The reason for not using VCT service were felt ashamed from friends 171(32.8%)followed by eighty six (16.5%) of non-convenient behavior of health care providers (Table 5).

Associated Factors for Family Planning Service Utilization
In the bi-variable logistic regression analysis at p 0.25 in 95% CI factors such as sex, marital status, coresidence, mother's educational level, father occupation, discussing about RH and F/P, discussing on RH with parents and health care providers and having sexual intercourse experience were associated with family planning service utilization.But in multivariable analysis at p-value 0.25 at the level of 95% CI, marital status, ever had boy or girl friend ever had sexual intercourse with in the past 12 months and discussing on RH with parents were found to be signi cantly associated with family planning service utilization.Based on this study the odds of family planning service utilization among adolescents those experienced sexual intercourse were 8.24 times (AOR=8.24,95% CI: 6.1-15.76)more likely to utilize F/P service than abstainers.Adolescents who had discussion on RH with their parents were about 2.766 times (AOR= 2.766, CI: 1.25-6.12)more likely to use the service those who do not have discussion with their parents (Table 6).

Associated factors for Voluntary Counseling and Testing Service Utilization
Based on bivariable analysis at p 0.25 factors such as co-residence, mother educational status, discussing about VCT, discussing on RH, discussing on RH with friends and health care providers were found to be associated with VCT service utilization.
Out of the variables which entered to multivariable logistic regression model, at p 0.05 factors such as co-residence with both parents, mother educational status, discussing about VCT and discussing on RH with health care providers were statistical signi cant determinants of VCT service use.The study participants living with their both parents were about 1.63 times (AOR=1.631,CI: 1.07-2.49)more likely to use VCT service compared to those who living with others or alone.The children of formal educated mothers were about 1.88 times more likely to utilize VCT service than those whose mothers had no formal education (AOR=1.888,CI: 1.06-3.36).In this study adolescents who discussing about VCT service and discussing about Rh with health care providers were about 2.077 and 2.53 times more likely to utilize VCT service when compared to their counterparts (AOR=2.077,CI: 1.207-3.573and AOR=2.532,CI: 1.143-4.609)respectively (Table 7).

Discussion
One of the most important aspects of the health extension program is the adolescent reproductive health which is designed to focus on the production of healthy adolescents that will effectively succeed the present generation (1).This school-based study assessed the patterns of family planning and VCT service utilization and associated factors is important to evaluate the progress towards addressing reproductive health problems of adolescents.VCT is an essential element of RH service in the ght against HIV/AIDS.Family planning service utilization is critical in preventing adolescents from different health and health related problems that have a negative impact on the overall aspects of adolescents' health status.In this study, the overall utilization of family planning service among sexual intercourse experienced adolescents was 78.6%.This nding was nearly in agreement with the studies conducted in Nigeria 81.6%, Gondar 79% and Goba 72.4% (20,23,28).However, this nding was higher than the study conducted in Hadyia zone 64.5%, North Shewa 27.9% and Kachabirra 17.6% (25,31,35).This difference might be due to different characteristics of individuals between the study areas and design, whereas this study was conducted in urban and have higher educational level; so adolescents might have good knowledge and attitude towards family planning service utilization.
This study revealed that VCT service utilization was 29.3% from total study participant and 31.6% from sexually active study subjects.This study outcome is similar with the nding of the study conducted in Kachabira 38.2%Southern Ethiopia (25).And also, lower than the research ndings done in Nekemt 59.2%, Ancha 45.8% and Karamoja region, Uganda 82% (24,32,35).This variation could be due to the recent nationwide noticeable emphasis decrement no the ght against HIV/AIDS related health promotion and preventive activities.Other reason could be as the study nding feeling ashamed from friends and unfriendly handling and non-convenient behavior of health care providers.
This study revealed married adolescents were 4.24 times more likely utilized F/P service than their counterparts.This could be due to increased open discussion on sexual and reproductive health issues or family planning between couples.This nding is consistent with a study done in Kenya and Harar, Ethiopia (21,36).
In this study discussing on RH with parents were found to be signi cantly associated with family planning use than their counterparts.Discussion on the service with different people has an effect on F/P service utilization.Adolescents who discussed about RH service with their parents were utilized family planning more than those who do not discussed.This is consistent with the studies conducted in Gondar and Anchar (20,32).This variation might be because of discussion allows adolescents to create opportunity exchange information that increases further understanding about RH service and its bene t.
The practice of family planning service utilization among adolescences who have had sexual intercourse in last one year was higher than abstainers.This nding is consistent with the study done in Goba and Nekemet (24,28).The possible reason sexually experienced individuals might have more time to discuss with their partner about family planning to avoid the risk and consequences of sexual vulnerability and they may also care each other.
VCT service utilization among adolescents co-residence with both parents were high when compared with those who live others or alone.This is similar with the study conducted in East Gojjam (27).This difference could be because of information and experience exchange among parents.In this study maternal educational status affects VCT service utilization.In this study adolescents of formal educated mothers were utilize VCT service more than that of the children of illiterate mothers.This nding supported by the study conducted in Goba (28).The possible justi cation could be educated mothers may have better information and awareness about HIV/AIDS and VCT they may encourage their children to utilize the service.In this study adolescents who discussion on VCT service with health care providers utilize more than not discussed with health care providers.This is also observed in the study conducted in Medawolabu University, Gondar and Goba (20,28).This could be justi ed as discussion about VCT with health care providers allows adolescents to exchange better information that facilitate further understanding and avoid misunderstanding on the service.Also discussing with health worker may not need referral to other health professional for the service.

Strength and Limitation
This study addressed previously unscathed and currently which is area of public health concern.Gender balance is considered during sampling technique by proportionally allocating for both sexes each grade.
Data was collected through self-administered questionnaire which may decrease social desirability bias.

Limitation
This study share the limitations of cross sectional studies.It is impossible to decide causal relationship among dependent and independent variables.This study was conducted in two randomly selected governmental preparatory schools, which means the result, may not generalize to adolescents from private preparatory schools and for rural adolescents.

Conclusions
In general majority of sexual intercourse experienced adolescents were used family planning service whereas VCT service utilization was low.This study shows that marital status, Discussed on with parents, having boy or girlfriend and ever had sexual intercourse were the factors affecting F/P service utilization, whereas co-residence both parents, mother educational status, discussed with Health care providers and discussed about VCT were the signi cantly determinant factors for VCT service utilization.The reason for not utilizing F/P service was having no money for the service followed by felt ashamed from friends, but felt ashamed from friends followed by harsh and unfriendly approach of health care providers during service provision were the two major reasons for not utilizing VCT service. Based Therefore it is important to further investigate what other factors affect the utilization and what are these factors in the context of Arba Minch and to gain a better understanding of the reasons for low utilization of the service as a rst step towards the reduction of teenage pregnancy, unsafe abortion and other reproductive health problems.

Table 1 :
on the study nding, we can recommend that to health initiation and health care providers: Socio demographic characteristics of study subjects preparatory school, in Arba Minch southern

Table 5 :
Reason for not utilizing VCT service among preparatory school students in Arba Minch town, Southern Ethiopia.

Table 6 :
Bi-variable and multivariable logistic regression analysis of associated factors for F/P service utilization among preparatory school adolescents, in Arba Minch town, Southern Ethiopia, Dec.