Sexual and reproductive health issues and associated factors among female night school students in Amhara Region, Ethiopia: an institution-based cross-sectional study

Abstract

Objective

This study aimed to assess the prevalence of sexual and reproductive health (SRH) issues and associated factors among female night school students in the Amhara Region, Ethiopia.

Design

Institution-based cross-sectional study.

Setting

16 night schools were selected from 4 zones in the Amhara Region. The data were collected between 1 January and 28 February 2019.

Participants

1428 female night school students aged 15–24 years.

Outcomes

Prevalence of SRH issues, defined as those who had experienced at least one SRH issue during their lifetime (including sexual violence, sexually transmitted diseases, teenage pregnancy, unwanted pregnancy, early marriage and abortion). Bivariable and multivariable logistic regression models were used in the analysis.

Results

The prevalence of SRH issues was 32.7% (95% CI 29.5% to 35.9%). Having secondary education (adjusted (OR) AOR = 1.49, 95% CI 1.19 to 1.86), being single in marital status (AOR = 1.33, 95% CI 1.01 to 1.74), not discussing SRH issues with their families (AOR = 2.69, 95% CI 2.13 to 3.40) and poor knowledge of SRH services (AOR = 2.63, 95% CI 2.08 to 3.32) were significantly associated with SRH issues.

Conclusion

The lifetime prevalence of SRH issues among female night school students was high. Being single, having a secondary education, not discussing SRH issues with family, and having a poor understanding of SRH services were associated with SRH issues. Qualitative studies should be conducted to explore students’ feelings and intentions about SRH issues.

Strengths and limitations of this study.

• The study generated primary data and had a relatively large sample size, appropriate sampling procedures, and a high response rate.

• Due to the sensitivity of the issues, there might be social desirability bias affecting the results.

• Recall bias may also be an issue among respondents.

Introduction

Reproductive health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes.¹ Youth is one of the most fascinating and complex periods of life and is accompanied by unique needs for reproductive health (RH).² Healthy young people have incredible potential to contribute to their families, societies, and the country as a whole and are vital assets and resources for social, political and economic growth.³

Every year, a significant number of adolescents and youths aged 10–24 years experience sexual and reproductive health (SRH) issues worldwide due to limited access to services and information.^{3 4} Young people in developing countries, including Ethiopia, are at risk of SRH issues like teenage pregnancy, unsafe abortion, sexual violence, early marriage, unwanted pregnancies, sexually transmitted infections (STIs) and other pregnancy-related complications.^{5 6} Furthermore, youth and adolescents are frequently hesitant to seek health services for their SRH needs because of obstacles like judgemental health workers, a lack of private workspaces, embarrassment, and a lack of training in and understanding of youth RH needs.^{7 8}

There are increasing concerns about SRH issues nowadays due to their adverse effect on the productive population of developing countries. Globally, adolescent girls account for 3.9 million unsafe abortions, 10 million unintended pregnancies and 357 million curable STIs each year.⁹ Around 10%–20% of young people in sub-Saharan African countries, aged 15–24 years, have their first sexual experience before the age of 15 years.¹⁰ Sexually transmitted diseases continue to be a major global health concern, particularly among young people.¹¹ Although Ethiopian law sets the legal minimum age of marriage at 18 years, the evidence showed that 40% of women married before the age of 18 years, 6% of girls married before the age of 15–19 years and 20% married before the age of 15 years.¹²

Globally, one in three women have experienced physical and/or sexual violence in their lifetime, and nearly one in four women experience intimate partner violence, while one in three adolescent girls report their first sexual experience as being forced.^{13 14} Sexual violence is a major public health issue. Almost one in every five women has been raped or attempted to be raped at some point in her life. One in every three female rape victims was raped for the first time between the ages of 11 years and 17 years. One in every eight female rape victims claims to have been raped before the age of 10 years. During their lifetime, about 1 in every 38 males has been raped or attempted to be raped.¹⁵

The WHO promotes youth-friendly reproductive health services to enhance the SRH of the younger generation. The first adolescent and youth reproductive health strategy in Ethiopia was developed in 2006 to provide multisectoral support to every young person with education and information that will lead to the adoption of a healthy lifestyle physically, psychologically and socially.⁷ Currently, the country is implementing the second new adolescent and youth health strategy from 2016 through 2020 by incorporating the recommendations on policies and programmes that respond to the priority health needs of the adolescent and youth through effective coordination with the public, private, NGO, local and international partners. The strategy goes far and beyond SRH, HIV and STIs to provide broad strategic directions to promote, prevent, and protect the health and well-being of Ethiopian adolescents and youth.¹⁶

Despite efforts made to improve access to youth RH services, young populations, particularly adolescent school girls, have faced different SRH issues.¹⁷ Night school female students are the most vulnerable group for SRH issues due to greater opportunities and circumstances for engaging in risky behaviours related to RH. In our context, most of the female night school students are housemaids and daily labourers. Furthermore, the Federal Democratic Republic of the Ethiopia Ministry of Health’s National Adolescent and Youth Health Strategy 2016–2020 revealed that the young population in Ethiopia has limited information and access to SRH services.¹⁶

However, as far as our knowledge is concerned, there has been no study conducted on RH issues and associated factors among female night school students in the Amhara Region of Ethiopia. Therefore, this study aimed to assess SRH issues and associated factors among female night school students in the Amhara Region of Ethiopia.

Methods

Study design and setting

An institution-based cross-sectional study was conducted from 1 January 2019 to 28 February 2019, in the Amhara Region, Ethiopia. Amhara is one of the largest regions (states) in Ethiopia; it has 12 zones and 180 districts (139 rural and 41 urban). The region has a projected population of 21.5 million people, of whom 80% are rural farmers. There are 80 hospitals (5 referrals, 2 general and 73 primary), 847 health centres and 3342 health posts within the region. There are 78 schools providing night education for elementary and secondary school students in the Amhara Region.

Study population

The study population includes female night school students attending elementary and secondary school in the Amhara Region within the age range of 15–24 years.

Sample size determination

The sample size was calculated using the single population proportion formula by taking the assumption of a 20% prevalence of teenage pregnancy in Ethiopia,¹⁸ 95% CI, a 3% margin of error, a design effect of 2 and a 10% non-response rate.

$${\displaystyle \mathrm{n}=\frac{\mathrm{Z}\mathrm{a}/2\mathrm{P}(1-\mathrm{P})}{\mathrm{W}2}}$$

$${\displaystyle \mathrm{n}=\frac{(1.96{)}^2\times 0.2\times 0.8}{(0.03{)}^2}=683}$$

Where: z=CI (with 95% level of certainty)

W=margin of error (3%)

P=20% proportion with SRH issues

n=total sample size

Finally, using design effect 2 and 10% of non-response, 1502 participants were included in the study.

Sampling procedure

A multistage sampling technique was used to select the study participants. The first 4 zones (North Gondar, South Wollo, West Gojam and North Shewa) out of 12 were selected within the region using a simple random sampling technique. Within the selected zones, the schools were stratified into 29 primary and 13 secondary schools. Then 16 night schools (9 primary, 7 secondary schools) were randomly selected after proportional allocation. Finally, study participants were selected by lottery from the existing sample frame (figure 1).

Figure 1.

Sampling procedures.

Operational definitions

Awareness of SRH issues

We measured SRH awareness by giving a score of one (1) for each correct response and a score of zero (0) for each incorrect response. The respondents were characterised as having 'good awareness' if the summary index equals or is greater than the mean of the total score and 'poor awareness' if the summary index is less than the mean of the total score.

SRH issues

Those respondents who have ever faced at least one of the following SRH issues: unwanted pregnancy, abortion, teenage pregnancy, early marriage, sexual violence, and/or sexually transmitted disease during their lifetime. If there is at least one issue, it is nominated as 1, otherwise it is nominated as 0.

Data collection instruments

Data were collected by interviewer-administered questionnaires adapted from previous literature.^1–16 The questionnaire was first prepared in English, then translated to Amharic (local language), and then re-translated back to English by language experts. The questionnaire includes sociodemographic characteristics, the sexual history of the respondents, awareness of SRH issues and RH issues of the participants (online supplemental file 1).

Data collection procedures and data quality assurance

The data were collected by 10 community health extension workers and supervised by 5 MSc degree-holder midwives. Female data collectors within the age group below 30 years were used to minimise the humiliation and embarrassment of adolescent girls. Training was given to data collectors and supervisors for 2 days about the objective of the study, how to approach the students, how to maintain confidentiality and how to collect the information.

The questionnaire was pretested on 72 (5% of the sample size) female night students in the South Gondar zone (which was not included in the actual study) for clarity and to ascertain internal consistency. On the awareness question, internal consistency was tested using reliability tests (Cronbach’s alpha), and value of Cronbach’s alpha was 0.842. After analysing the pretest result, necessary modifications were made accordingly before using it for actual data collection. The investigators of this study supervised the entire process.

Data processing and analysis

The collected data were entered, coded, cleaned and checked by using Epi-Data statistical software to maintain logical errors and skipping patterns, and then exported to the statistical package for social sciences (SPSS) V.20 for analysis. By calculating proportions and summary statistics, a descriptive analysis was carried out. The study population characteristics were described using tables, graphs and narratives. Bivariable and multivariable logistic regression analyses were used to assess the association between the predictor and outcome variables. Hosmer-Lemeshow and Omnibus goodness tests were used. Variables with a value of p<0.2 in the bivariate analysis were involved in the final model of multivariable analysis to control all possible confounders. An adjusted OR (AOR) with 95% CI was assessed to identify factors associated with RH issues, and a value of p<0.05 was considered statistically significant.

Ethics approval and consent procedures

After explaining the purpose and objective of the study, written informed consent was obtained from participants aged 18 years. For students below the age of 18 years, we obtained assent from the students and written consent from their teachers and families. The interview took place in a convenient place to maintain privacy and assure confidentiality.

Patient and public involvement

None.

Results

Of the 1502 participants, 1428 responded correctly to the questionnaires, for a response rate of 95.1%. The mean age of respondents was 20±2.6 SD years. About 60% of them were within the age group of 20–24 years. Regarding their educational status, more than half, 759 (53.1%) of the participants, were attending elementary school. More than two-thirds of the participants were Orthodox Christians. Of the total respondents, 462 (32.4%) were daily labourers (table 1).

Table 1.

Sociodemographic characteristics of female night school students in the Amhara Region, Ethiopia, 2019

Variables (n=1428)	Frequency	Percentage
Age, years
15–19	571	40
20–24	857	60
Educational status
Elementary school (grades 1–8)	759	53.1
Secondary school (grade 9–10)	669	46.9
Religion
Orthodox Christian	1072	75.1
Muslim	280	19.6
Others*	76	5.3
Marital status
Married	309	21.6
Single	1119	78.4
Occupation
Housemaid	354	24.8
Daily labourer	462	32
Housewife	309	21.6
Merchant	303	21.4

*Protestant and Catholic.

Sexual history of the respondents

Four hundred and ninety-five (34.6%) of the students had ever had discussions regarding SRH issues with their families. About 542 (38.0%) students had sexual intercourse at some point in their lives; among those, 121 (22.4%) experienced sex before the age of 18 years. Rape was the reason behind the exposure to sexual contact for 30 (6.8%) of the respondents (table 2).

Table 2.

Sexual and reproductive history of female night school students in the Amhara Region, Ethiopia, 2019

Variables (n=1428)	Responses	Frequency	Percentage
Have you ever discussed RH issues?	Yes No	495 933	34.6 65.6
Peer influence on sexual issues	Yes No	571 857	39.9 60.1
Ever had sexual intercourse	Yes No	542 886	38.0 62.0
Age at first sex (n=542)	< 18 years >18 years	121 421	22.4 77.6
Educational level during the first sexual intercourse (n=542)	Before joining school Elementary school Secondary school	79 306 157	14.6 56.6 28.8
Reason for the first sexual practice (n=542)	Marriage Love To get money Forced sex (rape)	309 152 44 37	57 28.2 8.2 6.8

RH, reproductive health.

Awareness of respondents about SRH issues

In this study, the majority of (1119, 78.4%) of the participants had heard about SRH. Of the total respondents, about 1014 (71.0%) said that a girl could start getting pregnant during puberty. The majority (80%) of the respondents knew that a girl could get pregnant with a single sexual encounter. Eight hundred and sixty-seven (60.7%) participants responded that unprotected sexual intercourse can cause sexually transmitted diseases. More than two-thirds (68.6%) of the respondents had good awareness of SRH issues (table 3).

Table 3.

Awareness of sexual and reproductive health services among female night school students in the Amhara Region, Ethiopia, 2019

Variables (n=1428)	Frequency	Percentage
Have you ever heard about SRH issues?
Yes	1119	78.4
No	309	21.6
Age at which a girl could start pregnancy
Before puberty	96	6.7
During puberty	1014	71
After 25 years	231	16.2
I don’t know	87	6.1
The most probable period for the occurrence of pregnancy
At the beginning of a menstrual cycle	354	24.8
In the middle of the menstrual cycle	846	59.2
At the end of the menstrual cycle	228	16
A girl gets pregnant with a single sexual intercourse
Yes	1141	80.
No	287	20
Aware of the methods for preventing unintended pregnancy.
Yes	1162	81.4
No	266	18.6
Unmarried women can use contraceptive
Yes	955	66.9
No	473	23.1
Age at which a girl could get married
At the time of puberty	952	66.7
After 18 years	295	20.7
After 25 years	181	12.6
HIV/AIDS can be acquired with first sexual contact
Yes	1211	84.8
No	217	15.2
Sexual intercourse can cause sexually transmitted diseases
Yes	867	60.7
No	561	39.3
Could we prevent HIV/AIDS
Yes	1098	76.9
No	330	23.1
Awareness of SRH issues
Good	980	68.6
Poor	448	31.4

SRH, sexual and reproductive health.

SRH issues

The participants faced different SRH issues. In this study, about a third, or 32.7% (467/1428), of the students encountered RH issues during their lifetime. Of these, 14.1% (201/1428) ever had a teenage pregnancy, and 215 (15.1%) ever faced an unwanted pregnancy (figure 2).

Figure 2.

Prevalence and associated factors of sexual and reproductive health issues among female night school students in the Amhara Region, Ethiopia, 2019 (n=1428). STI, sexually transmitted infection.

Factors associated with RH issues

In the bivariate analysis, peer influence on sexual issues, ever-discussed SRH issues, marital status, awareness of SRH services, and educational status of the students were found to be associated with SRH issues. After multivariable logistic regression, students who discussed SRH issues, marital status, awareness of SRH services and educational status were found to be significantly associated with SRH issues.

Single students compared with married students were 1.33 times more likely to have SRH issues (AOR=1.33, 95% CI 1.01 to 1.74). Students attending secondary education were 1.49 times more likely to develop YRH issues than those who were attending primary education (AOR=1.49, 95% CI 1.19 to 1.86). Students who did not discuss SRH issues were 2.69 times more likely to face SRH issues than those who did (AOR=2.69, 95% CI 2.13 to 3.40). Students who had poor awareness of YRH issues were 2.63 times more likely to face YRH issues than those who had good awareness (AOR=2.63; 95% CI 2.08 to 3.32) (table 4).

Table 4.

Multivariable logistic regressions on factors associated with SRH issues among female night school students, Amhara Region, Ethiopia, 2019

Variables (n=1428)	SRH issue		COR (95% CI)	Adjusted OR (95%CI)	P value
	Yes	No
Educational status
Elementary school (grade1–8)	394	365	1	1
Secondary school (grade 9–10)	395	274	1.34 (1.08 to 1.65)	1.49 (1.19 to 1.86)*	0.0001
Marital status
Married	148	161	1	1
Single	641	478	1.46 (1.13 to 1.88)	1.33 (1.02 to 1.74)*	0.038
Discussion on SRH issues with families
Yes	191	304	1	1
No	598	335	2.81 (2.27 to 3.56)	2.69 (2.13 to 3.40)*	0.0001
Peer influence on SRH issues
Yes	492	365	1.24 (1.01 to 1.54)	1.21 (0.97 to 1.52)	0.160
No	297	274	1	1
Awareness of YRH services
Good	408	479	1	1
Poor	381	160	2.79 (2.23 to 3.51)	2.63 (2.08 to 3.32)*	0.001

*Variables significantly associated with SRH issues.

COR, crude odd ratio; SRH, sexual and reproductive health.

Discussion

Youth is a period of transition from childhood to adulthood characterised by significant physiological, psychological and social changes that place their lives at high risk.¹⁹ To address the reproductive and sexual health needs of the youth, Ethiopia established youth RH services. However, youths frequently lack basic RH information, knowledge, and access to affordable and confidential RH services,^{20 21} especially youth at night school students. Worldwide, adolescents are disproportionately affected by early marriage, unwanted pregnancies, unsafe abortions, STIs, including HIV/AIDS, and sexual and gender-based violence.

In this study, a third (32.7%) of the female youth night school students encountered at least one SRH issues during their lifetime. SRH issues included sexual violence, unwanted pregnancy, teenage pregnancy, STIs, early marriage and abortion (see figure 2). The educational status of the participants, marital status, SRH communication with their families and awareness of SRH were associated with SRH issues.

The values in the findings of this study were higher than in the study conducted in Lay Gayint district, Ethiopia.²² The difference might be due to the difference in the target population. The source population of this study was female students who attend their education during the night-time, while the source population of the study conducted in the Lay Gayint district was female students who attend their education during the daytime. Therefore, female students who attend their education during the night are more likely to be prone to different RH issues like physical and sexual violence.

In their lifetime, 17.3% of participants were found experiencing sexual violence of any kind, including sexual harassment and forced sex. Female students who attend classes at night frequently experienced sexual violence. The lifetime results of this study were lower than those of prior research in Butajira, 35%,²³ and Mekele, 45.4%.²⁴ The discrepancy might be due to the study population and sample size.

Unwanted pregnancy has occurred when no children or no more children were desired for at least one of the couples.²⁵ The prevalence of unwanted pregnancy among night school female students was 15.10%. This was lower than the study conducted in Iran, 30.6%,²⁶ Nigeria, 28%,²⁷ Gondar, 20.6%,²⁸ and Wolkaite, 26%.²⁹ This inconsistency might be due to the difference in the study population. In other studies, the study population was pregnant women, whereas this study includes both pregnant and non-pregnant women. Moreover, most of the above studies were based on small sample sizes.

Teenage pregnancy is a global problem and is considered a high-risk group. The proportion of teenage pregnancies among female night school students in the Amhara Region was 14.1%. This was in line with the national report, Ethiopian Demography and Health Survey (2016), at 13%.³⁰ This finding was higher than in another study, at 10%,³¹ but lower than in studies conducted in the Wogedi district, 28.6%,³² Eastern Ethiopia, 30.2%,³³ Nigeria, 31.6%,³⁴ Sudan, 31%,³⁵ Kenya, 31%,³⁶ Jordan, 25%,³⁷ and Turkey, 29%.³⁸ The variation might be due to socioeconomic differences, study participants or the study period.

Early marriage is defined as the marriage of a girl less than 18 years of age and is a common phenomenon.³⁹ Childbearing before the age of 18 years is associated with a higher risk of death, eclampsia, postpartum haemorrhage, HIV infection, malaria, obstructed labour, lower levels of schooling for girls, higher intimate partner violence, and poor maternal and child nutrition status.^{40 41} Early marriage in this study was 9.5%. This prevalence is lower than in studies conducted in Injibara, Ethiopia 44.8%, and sub-Saharan Africa, at 55%.^{42 43}

In the context of Ethiopia, abortion is defined as a pregnancy that ends before 28 weeks of gestation and is classified as either spontaneous or induced.⁴⁴ Although legalising abortion and fulfilling unmet contraceptive needs can reduce abortion and maternal mortality rates, abortion remains one of the top five causes of maternal mortality. The prevalence of induced abortion among night-school students in this study was 7.3%. This prevalence of induced abortion is lower than in the study conducted in Harari, 42.7%,⁴⁵ Gurage Zone, 12.3%,⁴⁶ Wolayita Sodo, 6.5%,⁴⁷ and Nigeria, 10%.⁴⁸ The difference might be due to the fulfilment of SRH services, including the lowering of unmet contraceptive needs and the availability, accessibility and quality of safe abortion services.

STIs are a group of clinical syndromes caused by microorganisms that are acquired and spread mainly via sexual contact⁴⁹ and a major public health problem that causes acute illness, long-term complications, infertility, medical as well as psychological consequences, and death.⁵⁰ Most STIs have no symptoms. The prevalence of STIs was 5.7%. Because the finding was symptomatic and self-reported, the magnitude might be greater.

The marital status of the students was significantly associated with RH issues. Students who were single in marital status were 1.33 times more likely to have SRH issues than their married counterparts. This might be due to societal and cultural influences in a society in which unmarried or single girls are less empowered to go to health facilities for RH services. In the Ethiopian context, the utilisation of SRH by unmarried girls is considered a taboo subject, and this attitude of society hinders them from seeking health services, which leads to SRH issues including unwanted pregnancy, teenage pregnancy, unsafe abortion and developing STIs.

Students who were attending secondary school were 1.49 times more likely to have SRH issues than those who were attending elementary school. This finding might explain why students attending secondary education are older than those attending elementary education. As their age increases, they will have more exposure to sex, increasing their chance of encountering SRH issues.^51–53

Students who did not discuss SRH issues with their families were 2.69 times more likely to face SRH issues than those who did. This finding is in line with the study conducted in Lay Gaynt, Debre Tabor and South East Ethiopia.^{22 54 55} The possible reason might be that those female students who failed to discuss SRH issues with their families refrain from exchanging information and experiences, building comprehensive knowledge about SRH issues, and helping expose them to different SRH service issues. This also leads to fewer opportunities to use SRH services.

Students who had poor awareness of YRH issues were 2.63 times more likely to face youth reproductive health (YRH) issues than those who had good awareness. This might be because female students with poor awareness and understanding of SRH issues might have lesser decision-making skills for preventing SRH issues.^{56 57}

Strengths of the study include the use of a primary source of data, the relatively large sample size, appropriate sampling methods and high response rate. However, due to the sensitivity of the issues discussed in the study, social desirability bias might have impacted the study findings. In addition, since these SRH issues were measured over a lifetime and the results were self-reported, recall bias might also have impacted the results. The study also lacked a qualitative component.

Conclusion

The prevalence of SRH issues was relatively high among female night-school students. Being single, having a secondary education, not discussing SRH issues with family, and having a poor understanding of SRH services were associated with the presence of SRH issues. Qualitative studies should be conducted to explore students’ feelings and intentions about SRH issues. Although causality cannot be established from our observational data, strengthening awareness on SRH issues and encouraging young women to discuss SRH services with their families could be useful approaches to attempt to reduce the prevalence of SRH issues.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was approved by the ethical review committee of the college of health sciences at Debre Tabor University (Ref. 2019-DTU/RE/2095). A supporting letter was obtained from the Amhara Regional Education Bureau. Participants gave informed consent to participate in the study before taking part.