Predictors of adolescents’ use of sexual and reproductive health services in Nigeria: a mixed-method approach

Background Sexual and Reproductive health Services (SRHS) are essential for prevention and control of SRH problems among adolescents and the achievement of sustainable development goal 3. These services may be available but certain factors interfere with their access and utilization by the adolescents. This study sought to determine factors that predict adolescents’ utilization of SRHS in Enugu State, Nigeria. Methods The study adopted mixed method research employing cross-sectional research design. The population of the study comprised adolescents (12-22 years). Multi-stage sampling procedure was used to select 1,447 adolescents used for the study. Questionnaire, in-depth interview, and focus group discussion were used for data collection. Percentages, Chi-square, and logistic regression were used to analyse quantitative data, while qualitative data were thematically analysed using NVivo software. Results Socio-demographic factors of gender, age, education, income and living status (p = < .05) were signicant predictors of utilization of SRHS. Psycho-cultural and health system factors (p = < .05) were also signicant predictors of utilization of SRHS. Conclusion The study concluded that some socio-demographic factors (of gender, age, level of education, income and living status), psycho-cultural and health system factors can be used to predict adolescents’ utilization of SRHS. These predictors could be addressed through home sex education, regular training of health care providers on youth-friendly services delivery and policy reforms

reproductive health outcomes such as pregnancy and birth, prenatal and neonatal mortality, maternal mortality, Sexually Transmitted Infections (STIs) and HIV and AIDS, and complications of abortion [14]. The World Health Organization stated that nearly 20 per cent of all global maternal deaths happen in Nigeria [15] with the risk higher among adolescent girls [16], suggesting that adolescents' utilization of sexual and reproductive health services is low.
Many factors could determine adolescents' utilization of SRHS in Nigeria, despite efforts to make SRHS available at the primary healthcare facilities. These factors which are referred to as predictors in this study range from social, personal, psychological and health system factors. The level of secrecy accorded to sexuality in Nigeria with its direct and indirect implications, makes it di cult for sexually active adolescents to freely access and use SRHS, exposing a high percent of them to STIs [17]. It is, therefore, important to study the perceived predictors carefully to inform health professionals and policy makers, which would enable them to understand the SRH challenges the young ones are facing and explore possible ways of addressing them. For this study, predictors were studied under the following subcategories: socio-demographic, psycho-cultural, and health system factors, to nd out if they predicted adolescents' utilization of SRHS. Socio-demographic factors include age, gender, level of education, religious a liation, location, living status, marital status, economic status. Research has linked sociodemographic factors and adolescents' utilization of health services [18,19].
Moreover, one's cultural and personal belief may in uence the individual's perception of accessing and using health services. Psycho-cultural refers to the interaction of psychological and cultural factors in the individual's personality or in the characteristics of a group [20]. Psycho-cultural factors in this study refers to those cultural beliefs or values that affect the psychology of the youth in seeking for or using SRHS in Enugu State. Psychocultural factors included: belief that discussing sexual issues is a taboo, fear of stigmatization or embarrassment based on cultural beliefs, fear of meeting their parents or people they know in the clinics, fear of being labeled a prostitute by community members, fear of not getting married later in life, fear of being barren, and other cultural beliefs regarding the use of SRHS by youths. For example, in some societies, most people assume that providing SRHS for the youth, like provision of sexuality education and contraceptives, promote promiscuity. These fears and burdens are capable of limiting adolescent's use of SRHS and could result in stigmatizing youths that are bold enough to access and use available SRHS [21]. Furthermore, health system factors such as availability of quality reliable services, proximity of the facility to users, cost of services, lack of privacy and con dentiality, long waiting time, using services with adults, and the attitude of service providers were assessed as predictors of adolescents' utilization of SRHS. The nearer the facility to the users, the higher their level of access and utilization. Geographical access, therefore, in uences service utilization [22,9] The main objective of the present study was to determine if these factors predict the adolescents' utilization of SRHS in Enugu State. This has become necessary because such prediction studies are lacking in the State, while there are observed low utilization of health services among adolescents in Nigeria. We used adolescents and young ones interchangeably in this study.

Methods
Study area, design, and sampling techniques This study was conducted in Enugu State, Southeast Nigeria between January 2015, and July 2016. The crosssectional design using the mixed method research approach was adopted for this study. Multi-staged sampling procedure was used to randomly select 1,447 young ones within the ages of 12 and 22 who completed the questionnaire correctly. Twenty-seven interviews and 18 group discussions were conducted. The rst phase of this study which is focused on availability and accessibility of SRHS had been published [9]. Details of the study area, design and sampling techniques be found in the study [9].
Data collection procedure Questionnaire, in-depth interview guide and focus group discussion guide were used to collect data from the respondents on both personal and group contacts. Structured questionnaire was prepared through review of related literature. The questionnaire which contained two parts was used to measure utilization of SRHS. First part contained the socio-demographic characteristics of the respondents while the second part contained utilization of sexual and reproductive health services (sexuality education, family planning services, safe motherhood services, post abortion care and prevention and treatment of STIs and HIV and AIDS). Details of the data collection procedure is described elsewhere (9) Data processing and analysis Data collected were cross-checked for completeness. Logical techniques were employed to identify errors during data cleaning. Out of 1620 copies of questionnaire only 1447 copies of questionnaire did not have errors and were used for data analysis. The Statistical Package for the Social Sciences (SPSS) version 20.0 was employed for statistical analysis of quantitative data. Percentages were used to assess the utilization of SRHS to adolescents, while Chi-square statistic and logistic regression were used to test association between the variables at .05 level of signi cance. Data from the questionnaire are presented in Tables. The responses from focus group discussion and IDI were transcribed in English language while maintaining the contexts of the responses. The NVivo 11 Pro software was used to code and analyze the data thematically. The data are presented alongside the quantitative ndings.
Outcome variables (SRHS: sexuality education, family planning, safe motherhood, post abortion care and prevention and management of STIs and HIV/AIDS services) were measured dichotomously. Respondents were asked to indicate "Yes" if they have used or helped another young person use the services, otherwise "No".
Explanatory variables include: Socio-demographic, psycho-cultural and health system factors. The variables were categorically measured. Socio-demographic variables were gender, age, level of education, living status, location and income status. Psycho-cultural variable was measured by the cumulative of responses to questions related to cultural beliefs and fear such as belief that discussing sexual issues is a taboo, fear of stigmatization or embarrassment based on cultural beliefs, fear of meeting their parents or people they know in the clinics, fear of being labeled a prostitute by community members, fear of not getting married later in life, and fear of being barren. While health system variable was measured by the cumulative responses to questions relating health facility and service providers such as availability of quality reliable services, proximity of the facility to users, cost of services, lack of privacy and con dentiality, long waiting time, using services with adults, and the attitude of service providers. Table 1 shows the socio-demographic characteristics of the respondents. One thousand, four hundred and fortyseven (1,447) adolescents within the ages of 12 and 22 years, with a mean age of 16.9 years responded to the questionnaire. More than half (57.1%) of the respondents were females while 42.9% were males. Slightly more than half (54.0%) had secondary education. Majority (56.7%) of the respondents lived in rural area and most of them were living with their parents (62.3%). Majority had a monthly income less than ₦5000.00 (1 USD = 199.3 NGN) [9].    Table 3 shows that age (p ≤.05) and level of education (p ≤ .05) are signi cantly associated with the utilization of sexuality education, safe motherhood, and post-abortion care. Younger adolescents (12-16 years) used sexuality education more than the older adolescents. The table also shows that income (p ≤ .05) is signi cantly associated with the utilization of sexuality education, post-abortion care services and services for the prevention and management of STIs, HIV and AIDS. While level of education (p ≤ .05), location (p ≤ .05) and living status (p ≤ .05) are signi cantly associated with the utilization of family planning services. Respondents that had higher education utilized most of the SRHS more than others with lower education. Those who lived in urban areas utilized SRHS slightly more than their counterparts in rural areas. Furthermore, respondents who were living alone utilized family planning services more than adolescents that were living with their parents. The table further shows that utilization of sexuality education, family planning, safe motherhood, post-abortion care and services for prevention and management of STI, HIV and AIDS are signi cantly associated with psycho-cultural (p ≤ .05) and health system factors (p ≤ .05).   Qualitative data Data generated through in-depth interview reveals that only 9 (33.3%) out of 27 interviewees agreed that they have used other SRHS apart from sexuality education which 26 (96.1%) of them use in the schools, churches and at homes. In the words of some interviewees:

Results
"I have never used any of these services" (Enugu-North 002). "I have only used sex education services" (Nkanu-West 002). "I don't use them because I don't think I need them" (Udi 001). "I did not use any of them………….though last year during youth week in my church, a health provider came and thought us about sex education" (Udenu 002). "Yes I used only sexuality education and services for prevention and management of STIs and HIV and AIDS" (Ezeagu 002). However, many of these interviewees did not want to reveal the particular services being used.
Few participants in the focus group discussions admitted using SRHS apart from sexuality education. Most males were of the view that SRHS are mainly for females except sexuality education and services for prevention and management of STIs and HIV and AIDS. "I have not used any of these services. They are only for females or married people" (Udenu Male FGD-P1). "It is true. P1 is correct" (other Ps chorused). "Yes at times we get some during youth week, seminars and school" (Udenu Female FGD-P7). "I was tested for HIV last year" (Nkanu-West Male FGD-P6). This implies that majority of the participants use sexuality education and services for prevention and management of STIs and HIV and AIDS only.

Discussions
Utilization of sexual and reproductive health services among adolescents is key to reducing in the prevalence of SRH problems in developing countries [23,24], which is posing a challenge to the actualization of the SDG 3.
Determining the factors that make adolescents to use or not to use SRHS is very important in designing interventions to promote adolescents' SRHS utilization. We utilized mixed method research because we have learnt from experience that triangulating multiple methods of data collection is better than using single method especially when collecting sensitive data such as sexuality information. The study aimed at determining predictors of adolescents' utilization of SRHS in Enugu State using quantitative and qualitative methods.
The utilization of SRHS among the adolescents was low. Sexuality education was the only SRHS utilized by slightly more than one-half of the respondents. This nding could be because these services, apart from sexuality education, were normally provided in the general health facilities which are not so comfortable for adolescents. Previous studies in other countries also reported [25,19] low utilization of reproductive health services among adolescents. Similarly, qualitative data generated through in-depth interview revealed that very few of the participants agreed that they had used other SRHS apart from sexuality education, which majority of them used in the schools, churches and at homes. However, many of these interviewees did not want to reveal the services being used, which was not surprising to us because of the secrecy accorded to sexual issues generally and particularly in the study area. Few participants in IDI and FGD admitted using SRHS apart from sexuality education.
The utilization of sexuality education, safe motherhood, and post-abortion care services was associated with socio-demographic factors of age and level of education. Association also exists between income level and sexuality education, post-abortion care, and services for the prevention and management of STIs, HIV and AIDS while utilization of family planning services was associated with location, level of education and living status.
Younger adolescents utilized sexuality education more than the older adolescents. This could be because younger adolescents are still in schools were sexuality education is taught, as majority of the adolescents revealed in qualitative data that they used sexuality education services only in schools. The nding is consistent with [11] who reported that age is signi cantly associated with SRHS but the nding differs from Nisar and White [26], who reported no association between age and antenatal care utilization. Surprisingly, adolescents with no formal education used all the SRHS except sexuality education more than adolescents with any formal education. Although some previous studies reported association between level of education and utilization of SRHS [27,26,28], the common report has been that those with higher level of education utilize the services more than those with no formal education.
All the SRHS were associated with pyscho-cultural factors. Qualitative data revealed that adolescents believed that services under family planning services are taboo for unmarried adolescents. The cultural belief is that family planning services are for married couples only. They also believed that SRHS will make youth become promiscuous and barren later in life. These beliefs make some adolescents feel ashamed and afraid of using SRHS. This nding is consistent with previous research [29] which reported that cultural beliefs and practices affected utilization of maternal health services and the reason adolescents do not use contraceptives include feeling embarrassed or ashamed to use or purchase contraceptives [21]. Similarly, association also exist between all the SRHS and health systems factors. The nding could be because there is lack of youth clinics or units which are expected to have specially trained service providers that provide youth friendly SRHS. Information from the qualitative data revealed that most interviewees and FGD participants said that pattern of service delivery like long waiting hours, lack of privacy, attitude of health providers and not being youth-friendly in services provision were the major health system factors that in uence their use of SRHS. The nding is consistent with Cheptum, et al [29] who reported that lack of facilities, inadequate sta ng and negative staff attitude were associated with access and use of health services. Anusornteerakul, Khamanarong, Khamanarong, and Thinkhamrop [30] reported that health service system is one of the important factors in uencing management of youth reproductive health services.
The nding showed that socio-demographic factors (of age, level of education, income and living status), psycho-cultural, and health system were predictors of adolescents' utilization of SRHS. This implies that an adolescent's personal factor can determine whether he or she would use SRHS. The nding agrees with previous studies that reported some of these demographic factors as predictors of SRHS utilization [26,31]. Previous studies also reported psychological and cultural factors as signi cant predictors of utilization of SRHS [32,29]. The common reason adolescents do not use contraceptives included feeling embarrassed or ashamed to use or purchase condom or any other contraceptives [33]. Additionally, the belief that discussing sexual issue is a taboo prevents parents from rendering age appropriate sex education at home, limiting young ones from getting basic information about sexuality early enough [11]. Health systems factors such as providers' attitude, having good and friendly relationship with the youth, keeping client's information con dential among others, determine youth's access to reproductive health and make youth reproductive health services successful. Proximity of health facility, available services and good reputation of the providers were main predictors for choosing health facilities [34,35].

Conclusion
The study concluded that some socio-demographic (of age, level of education, income and living status), psycho-cultural and health system factors are predictors of adolescents' access to and utilization of SRHS. These predictors could be addressed through home sex education, regular training of health care providers on youth-friendly services delivery and policy reforms.

Limitations
The study utilized the cross-sectional design, therefore, cannot assume cause and effect association. The legal age of consent was a challenge because it was di cult to convince the parents of adolescents below the age of 18 years even when the adolescents were ready to participate. On the other hand, some adolescents declined their participation because their parents were to give the consent. Nigeria is a multi-ethnic country and this study was conducted only in one state, therefore, generalization of the ndings may not be realistic.