Young Females Perception of Sexual and Reproductive Health Services and Factor Affecting Utilization of Services in High Schools of Ambo town Oromia Region, Ethiopia

Background: Encouraging sexual and reproductive health and rights of young people still leftovers as public health challenge. Young people are facing different sexual and reproductive health problems including unwanted pregnancy, which leads them to unsafe abortion, sexually transmitted disease including HIV/AIDS. The aim of this study was to look at perceptions of young females and assess factors associate with utilization of SRH services in Ambo town. Method: Both qualitative and quantitative methods of data collection was applied. The qualitative method was used to explore the perception about the sexual and reproductive health service utilization. Sample size was determined by using single population proportion formula for quantitative method and purposive sampling for qualitative. Multivariable logistic regression model was done using SPSS version 21.0. Thematic analysis was done for qualitative. P-value of less than 0.05 was the cut off point for statistical significances at 95% CI. Result: Only 26.63% of study participants had utilized sexual and reproductive health services in the last twelve months. The three main reasons of not utilizing the service mentioned by participants were 209 (77.41%) fear of parents, 184 (68.15%) feeling ashamed when they get any person they know and 167 (61.85%) lack of confidentiality on health providers. This was supported by qualitative findings. In final model of logistic regression variables which had shown significant association with utilization of SRH service were age of young female, discussion with family, exposure to sexual intercourse and having reproductive health problems. Conclusion: According to this study young females are facing different challenges to use SRH services. Intense commitment of government and stakeholder involvement in sexual and reproductive health education is required to meet the uptake of sexual and reproductive health services and to increase the utilization of service and awareness of young females.


Introduction
Young people age from 10-24 years comprises 26% of the population in the world and majority of this population is living in developing country. In 2010, 70% of Africa's population was under the age of 30, and slightly more than 20% were young people between the ages of 15 to 24 [1]. Ethiopian largest population proportion is constituted by the young people category which is estimated about 30% of country's population. One of the regions in the country is Oromia regional state with 41.2% of youth population residing in urban area of the region [2]. Encouraging sexual and reproductive health and rights of young people still leftovers as public health challenge. Young people are facing different sexual and reproductive health problems including unwanted pregnancy, which leads them to unsafe abortion, sexually transmitted disease including HIV/AIDS [3]. It is clear that investing in the wellbeing of young people is fundamental for any country's socioeconomic improvement [4]. However adolescents' access and utilization of sexual and reproductive services is limited due to different reason like socio-cultural norms and taboos which leads them to feel shame, fear of the attitude of service providers, lack of privacy and confidentiality, lack of costs and knowledge of SRH, and an bad attitude of parents and negative community perceptions towards health seeking behaviors of reproductive service by the young people's [5]. Sub-Saharan African youths are facing the greatest risk of sexually transmitted infections (STI) including HIV/AIDS. According to evidence from different studies females are more at risk than males. For examples more than half of new HIV infection occurs in girls being four times more likely than boys [3].
Even though sexual communication is a main means of conveying sexual values, expectations, beliefs, and knowledge between children and their parents [6], discussions on sex-related issues are a forbidden in Africa [7] and believed that informing adolescents about sex and teaching them how to protect themselves would lead them to sexual activity [8]. In similar way, in Ethiopia parent-youth communication on SRH issues is believed to be culturally shameful [9]. Socio-cultural taboos attached to it and lack of appropriate knowledge puts open discussions about sexual and reproductive health only topics difficult. This difficulty can be explained from study conducted, in Ethiopia, in Ziway, in which 20% of parents reported to ever discussing on SRH with their young people sometimes in the past [10].
In Ethiopia the health seeking behavior of young people especially on issue of their sexual and reproductive health is very low and the available reproductive health (RH) services are formed to address the interest of adults which mean adult-centered; so this makes the accessibility of the service less to young people's [11,12].
Among social differences which can influence young people's RH behaviors, gender difference is an important issue to give attention up on it currently. Evidence has shown that males take more sexual risks than females. Younger age at first sex and premarital sex is more common among males [13,14]. Females have more negative attitudes towards sex, such as guilt and shame, as compared to males and are less likely to take on premarital sex as well as sex with non-regular partners. Females are socioeconomically more vulnerable, especially in poor communities and are more likely to be forced into sexual entrance and early marriage than males [15].
SRH for youths is a culturally sensitive issue in most Ethiopian region [9,10]. Thus this issue is not adequately addressed in Ethiopia. A careful identification of gender specific factors which affects their utilization of SRH services will help to establish culture and gender suitable solutions in improving youth's reproductive health.

Material and Methods
Ambo town was the study area; currently it is divided in to three urban and three per-urban kebeles with approximately 114 km far from Addis Ababa the capital city of Ethiopia. Among high schools the town consists of one school which currently teaching from nine to twelve and two schools having nine and ten grades. The study used mixed method both quantitative and qualitative method of data collection. The source populations were young female aged 15-24 years living in school, in the study area for at least six months at the time of the data collection.

Study design
The study design was institutional based cross-sectional survey conducted among young females in high school students of Ambo town.

Sample size and technique
Sample size was determined using single population proportion formula for quantitative considering the following parameters P=32% taken from study conducted at Bahir Dar [16], 95% CI, 5% margin of error 334 sample and possible nonresponsive rate 10% and totally 368 sample was determined. For qualitative purposive sampling in school young female participating in girls club but who were not included in quantitative interview were selected.

Data collection method
Both quantitative and qualitative methods of data collection were applied by using structured and semi structured questioners. Data collection tools were adapted from various similar studies and modified accordingly. Interview guide were also used for Focus Group Discussion.
Data was collected by self-administer questioners for quantitative by trained health professionals, Focus group discussions (FGD) for qualitative by the investigators and one note taker. The entire discussion was guided by the investigator and note taker was facilitating the tape recorder as well as taking note when it is important. The Questioners were developed by English language and translated to Oromiffa which is the local language of study area to facilitate the data collection process and back translated to English language to keep the consistency of the data.
FGDs were consists of six to eight people and duration of discussion was made between one hour and one and half hour.
To keep data quality training was given for the data collectors and supervisors for two days by the principal investigator on the objective of the study and data collection tools. Before the actual data collection, the quality of the data was assured by translation and back translation of the questionnaire and pre-testing of the questionnaire. The questionnaire was pre-tested in Guder wereda very close to Ambo town which is out of study area on 5% of sample size before the actual data collection. The principal investigator and supervisors was engaged in all the entire process of data collection.
To keep privacy and confidentiality: Participation was voluntary and participants were informed that the information obtained from them was only used for the research purpose and not exposed to any other purpose. They also informed that they can withdraw from the study at any time of the interview if they need without any fear.

Data management
Quantitative data was analyzed using SPSS version 21.0 and multiple logistic regression models were done. Descriptive statistics was used to describe the study population in relation to relevant variables. First Bivariate model was done to see the association between each independent variable with outcome variable at p-value of 0.25 significance level then all variable which had shown significances candidate to multivariable models to assess the presence of association between independent and outcome variables. Crude and adjusted odds ratios were used to find out the strength of associations between the dependent and independent variables. For multivariable model significance level was made at p-value less than 0.05 at 95% CI.
The collected qualitative data was transcribed by the research assistants under the guidance of the principal investigator. The verbatim transcription was done from Oromiffa into English. Initially the tape-recorded interviews transcribed in Oromiffa and then translated into English. Qualitative data was analyzed thematically and triangulated with qualitative findings.
More than half of them, 203 (55.16%) were in the age group of 15-19 years. Nearly one third, 116 (31.52%), of respondents had arrived at grade ninth education and 208 (56.52%) were orthodox in religion. Concerning their ethnicity, 277 (75.270%) were Oromo and most, 353 (95.93%) of them were single in marital status. Majority of them, 270 (73.37%) were living with their both father and mother during data collection time (Table 1).

Utilization and Perception of young females about utilization of SRH service
In the current study, in the past 12 months, 98 (26.63%) of study participants had utilized sexual and reproductive health services. The main sexual and reproductive health services received by young females were 82 (22.28%) contraceptive, 76 (20.65%) VCT service, 48 (13.04%), seeking treated for STD and 18 (4.89%) of them visit for safe abortion purposes. Majority (73.37%) of the study participants were not utilized the service in the last twelve months because of different reasons. The three main reasons of not utilizing the service mentioned by participants were 209 (77.41%) fear of parents, 184 (68.15%) feeling ashamed when they get any person they know and 167 (61.85%) lack of confidentiality on health providers. This result was supported by qualitative findings about their perception towards SRH services.
The perception of young females was discussed using FGD methods.
Majority of the discussants feel that utilization of sexual and reproductive health service for unmarried women is considered as shame or being rude in the community.
"For example when I feel to go for the service immediately I start to fear who knows may be people from around our neighbor will be there and I stop to go there" (age 18 years).
On top of this a 17 years young female add: "Not only fear of community people even doctors or some health professionals working there can be from a person we or our family knows. So in this situation it is difficult to receive services related to sexuality" Age 22: "For female not engaged in marriage it is very not easy to visit health facilities with topic of sexual health, the next day you will start to hear about your arrival of health facility for this purpose and considered as rude female. ' On the discussion point about privacy and confidentiality they believe that information is not private.
Most of the discussants agree that professional working there didn't keep confidentiality.
According to age 21 years discussant: "One day I heard that one health professionals working hospital was talking about female undergo abortion by calling her name, so if I go there he will do the something on me. " Other age 23 years: "You don't know this? For example let's say I went for searching contraceptive, immediately morning I start to hear that some teasing on me like" is she reached for having sex? Yesterday she was asking contraceptive in the hospital, this generation is sexually active and like", "so it is difficult to believe anybody. " Age 20: "Author remembers one day one of my friends wants to buy a method of contraceptive which can be taken after having sexual intercourse sorry I don't remember the name anyways instead of buying herself she sent a small child to pharmacy shop" Adequacy of the services: Most of discussants were not sure about the adequacy of the services.
According to age 24 participant: "Really I can't say it is adequate or not because I'm not sure what is there or not" Additionally age 22: "I heard some people like my mom said that they have adequate things for free".

Factors Associated with Utilization of sexual and Reproductive Health Service among High School Students Ambo Town, 2015
In order to see the effects of different independent variables on dependent variable or utilization of youth reproductive health logistic regression analysis were carried out. Accordingly, Age of young female, discussion with family, exposure to sexual intercourse and having reproductive health problems were significantly associated with utilization of sexual and reproductive health service. Young females who were in the age group of 20-24 years were about 2.55 times more likely to use RH services than whose age ranges from 15-19 years (AOR=2.55, 95% CI (1.21, 3.56)). Exposure to sexual intercourse was assessed in the last 12 months and those exposed to sexual intercourse were 4.36 times more likely utilize this service compared to those didn't exposed to sexual intercourse. (AOR=4.36 (2.29, 8.33)). The probability of reproductive health service utilization for young female who had discussion with their parents about SRH service was 3.64 times more likely than those didn't had discussion (AOR=3.64 (1.15, 7.02)). Young females with reproductive health problems were almost two times more likely to use RH service than those had no RH problems (AOR=1.98, 95%CI (1.08, 6.57)). Below table 2 showed factors associated with RH service utilization (

Discussion
There is still a lot to be done in increasing the utilization of sexual and reproductive services among adolescent in this study area. The utilization of sexual and reproductive health service by young female in this study was about quarter (26.63%). This showed us low utilization status of the SRH service in general and specifically more lower among age group between 15-19 years. This utilization status is low compared to the study conducted in Bahir Dar 32.2%, Addis Ababa 40% and Jimma 41% but higher (21.5%), than study conducted at Machakal district [16][17][18][19].
In this study age of young females identified as important factors which associate with the utilization of sexual and reproductive health services. Accordingly young females those age groups between 20-24 years were two times more utilizing compared to age group between 15-19 years. This finding is similar with the study conducted in Jimma and Bahir Dar were younger age group less utilizes than that of older group. This could be when the age increases females gets more mature and can feel more responsible that leads them to take the available sexual and reproductive services [16,18].
Sexual exposure was also assessed to see the association with utilization of sexual and reproductive health services. The result showed that those who had ever sex in the last 12 months were 4.36 times more utilize the SRH service compared to those not exposed to sexual intercourse. This could be in fact because of the fear of unwanted pregnancy females need to use at least contraceptive. This judgment was supported by a study conducted in Awabe district, were those respondents who ever had sexual intercourse 1.88 times more likely to utilize the service than those who were not sexually active [20].
Young females' sexual and reproductive health services utilization was significantly associated and higher among those who had discussion on SRH issues with their parents compared to those didn't had discussion. This could be due to open talk with their parents, they would have a good understanding and knowledge about SRH services and this can encourage them to use the service. This finding was agreed with other studies done in Mekele town which brought a positive finding sexual and reproductive health communication as a means of contraceptive awareness [20].

Conclusion
According to the result of the present study regardless of more than half (54.89%) of them had exposure to sexual intercourse the utilization of sexual and reproductive health services was about quarter. From this result we can judge that they are at the risk of STD including HIV/AIDS. This low utilization showed a need of appropriate intervention to increase the use of this service by young females. Variables like Age of young female, discussion with family, and exposure to sexual intercourse and having reproductive health problems were significantly associated with utilization of sexual and reproductive health service. Intense commitment of government and stakeholder involvement in sexual and reproductive health education is required to meet the uptake of sexual and reproductive health services and to increase the utilization of service and awareness of young females.

Limitation of the Study
Since the study design is cross-sectional, it cannot establish causal relationship between the outcome and covariate variables. For some variable which asks sexual behavior of young female it could be difficult to get the true response due to the cultural sensitivity nature of the issues.