Introduction: Students in higher institutions of learning are exposed to diverse sexual and reproductive health problems, such as unintended pregnancies, Human Immuno Virus/Aquired Immuno Deficiency Syndrome, sexually transmitted infections, and unsafe abortions. Despite diverse efforts to improve student use of sexual and reproductive health services, there is still limited evidence on the level of university student use of the available sexual and reproductive health services at university set-ups. Therefore, this study aimed to assess sexual and reproductive health service utilization and associated factors among undergraduate university students in northwest Ethiopia.
Methods: An institution based cross-sectional study was conducted on undergraduate students at the University of Gondar in 2014.Data were collected using a pretested, structured, and self-administered questionnaire on 874 students selected by the multistage sampling technique. Data were entered and analyzed using SPSS version 20 statistical software, while Bivariable and Multivariable logistic regression models were used to identify factors associated with the outcome variable.
Results: The prevalence of sexual and reproductive health service utilization was 62.3%, at a 95%CI (54.1%, 68.7%). Students who discussed SRH issues with families [AOR=4.5 (CI: 2.42, 10.27)], lived in rural areas [AOR=1.60, 95% (CI: 1.22, 2.16)], had better knowledge of SRH services [AOR=1.38 (95% CI: 1.94, 2.03)], and had high risk perception for HIV infection [(AOR=1.80, 95% CI (1.58, 1.10)] were significantly associated with sexual and reproductive health service utilization.
Conclusion: Sexual and reproductive health service utilization in the study area was found to be moderate. Factors like prior discussions of sexual and reproductive health issues, lived in rural areas, knowledge of sexual and reproductive health, level of risk perception for HIV/AIDS were found to be associated with sexual and reproductive health services utilization. Therefore, interventions focused on such factors are recommended.
Keywords: Sexual Reproductive Health services; Utilization; University students; Ethiopia
Abbrevations: AIDS: Acquired Immune Deficient Syndrome; AOR: Adjusted Odds Ratio; CMHS: College of Medicine and Health Sciences; COR: Crude Odds Ratio; COCs: Combined Oral Contraceptives; ECs: Emergency Contraceptives; HCT: HIV Counseling and Testing, HIV: Human Immune Deficient Virus; IEC: Information Education and Communication; IPH: Institute of Public Health, SD: Standard Deviation; SRH: Sexual and Reproductive Health; STIs: Sexually Transmitted Infections; UoG: University of Gondar; VCT: Voluntary Counseling and Testing; WHO: World Health Organization
The proportion of the youth is increasing tremendously on the globe [1,2]. Young people aged 10-24 years comprise over 27% of the world’s population . The majority of them live in
developing countries , where HIV/AIDS and other sexual and
reproductive health problems are widespread [1,2]. Globally, 15 million adolescents experience unwanted pregnancies each year [4,5]. According to the World Health Organization (WHO)
report, nearly half of the induced abortions took place under
unsafe conditions , and nearly all unsafe abortions (98%)
occur in developing countries . Moreover, half of the new HIV
infections are observed in the 15-24 age groups . Each year,
one in 20 adolescents suffers from STIs other than HIV [8.9].
In Ethiopia, adolescents and young people aged 10 to 24
years comprise about 30% of the population . These people
are disadvantaged in terms of having access to sexual and
reproductive health information and services [10-13]. Gender
inequality, sexual coercion, early sexual debut, unwanted/
unplanned pregnancy, adolescent pregnancy, abortion, sexually
transmitted infections, and HIV/AIDS are the major youth sexual
and reproductive problems in Ethiopia [11,12]. Several factors
operating at individual, peer, family, school, and community
levels fuel the sexual and reproductive health problems of youth
in Ethiopia [9,14].
The majority of Ethiopian university students fall under
the youth age group (15-24 years); thus, they are sexually
active, and engage in mainly risky sexual behaviors . Risky
behaviors among undergraduate students may be aggravated by
factors like decreased parental control, peer pressure, economic
problems, and lack of youth friendly services . Risky
behaviors, particularly the consumption of alcohol, cigarette
smoking, or the use of illicit drugs have been shown to be
associated with increased risks of sexual intercourse, multiple
sexual partners, and low rates of condom use [15,16]. The youth
in universities usually lack access to information and health care
services regarding sexual and reproductive health [15,16]. Also,
are characterized by low sexual and reproductive health service
utilization due to feelings of discomfort or fear of being seen by
others at health care delivery points, and the embarrassment
of seeking reproductive health services [16,17]. As a result,
increasing access and utilization of health care relating to sexual
and reproductive health, especially for the youth are high priority
policy objectives in many countries . Moreover, the provision
of SRH services in universities is thought to be very effective in
the prevention of students from developing various risky sexual
behaviors and health related problems .
A study conducted in Kua Zulu, Natal, showed that even
though the majority of students indicated to have awareness
of VCT as an HIV/AIDS prevention method, only 37.9% utilized
the services, whereas 43.9% utilized free condoms, 4.8%
wellness Programs; 2% Peer Education Programs and 0.6% ART
. Another study conducted on Kenyan university students
demonstrated that 76% somehow used the condom; only 18% of
the males and 14% of the females confirmed to have used it every
time they had sex; 89% had risk perception for HIV infection;
28% tested for HIV .
An Ethiopian study conducted at Medawolabou University
showed that 80.5% of the study participants had used at least one
reproductive health service . Another study in Harar town
of Ethiopia showed 64% of the respondents used at least one
reproductive health service at the time of the survey . A study
at Debre Markos University showed SRH/VCT service utilization
was 58.5% among students . Previous studies showed
that VCT/SRH discussions with health care providers ,
information on health related services [19,21], age, educational
status, and occupation were some of the factors associated with
sexual and reproductive health service utilization among young
Although exposed to any SRH problems, university student
are on transformation to adulthood [15,19,20]. They also are
on the process of building their academic and social carrier. As
such, they are filled with lots of ambition. On top of that, what
makes higher institution students different from the other youth
is that they are confined to separate campuses, usually away
from parents; they don’t know where to go to get the services
they need and have no money as well as time to go out for SRH
services . Although Ethiopia has developed a national youth
policy in 2004, more effort is expected to satisfy the reproductive
health care needs of university students . Moreover, little has
been explored about SRH service utilization and its associated
factors in the context of Ethiopian Universities in general and
the University of Gondar in particular. Therefore, this study was
conducted to assess the SRH service utilization and associated
factors among University of Gondar students.
An institution based cross sectional study was conducted
at the University of Gondar between May and June 2014.The
University of Gondar is one of the 31 public universities in
Ethiopia with more than 60 postgraduate and 30 undergraduate
programs. According to the university registrar, more than twentyfive
thousand students were enrolled by the 2014 academic year.
The university has 5 campuses, namely the College of Medicine
and Health Sciences (CMHS), Maraki, Tewodros, Fasil, and Tseda,
with various colleges. Female students accounted nearly 50 % of
the total University enrollment. The University has five student
clinics located in each of the campuses. In addition, there are
Reproductive Health and Anti–HIV/AIDS clubs that aim at
creating awareness on sexual and reproductive health issues
All regular undergraduates were the source population,
and all undergraduate students available during the study
were the study population. All regular second year and above
undergraduate students were included. Undergraduate students
who were seriously ill and unable to respond to the questions
as well as weekend and post-graduate students were excluded.
The sample size (884) was obtained by using the assumption
that SRH service utilization of university students was 50% at a 95% CI (as there has been no such investigation in the study
setting), margin of error 5%, design effect of 2, and non response
rate 10%. Since the university has campuses, we allocated the
sample to each campus using the multi-stage sampling procedure.
Firstly, out of the 7 colleges and faculties in the university, 4
faculties were selected by the lottery method. Then, the simple
random sampling technique was used to select 3-4 departments
from each faculty. Then, proportional samples were allocated
to each faculty considering the student population. Finally, all
students in the selected departments were invited to participate.
A structured and pre-tested questionnaire prepared in
English and translated to the local language (Amharic) and
then back to English was used for data collection. Three
supervisors and ten data collectors participated in the process.
After recruitment of data collectors and supervisors, a one-day
intensive training was provided on the aim of the study, how to
collect data, and clarification of the questionnaire before the
The filled questionnaire was checked for completeness,
cleaned manually, coded, and entered into EPI info version 3.5.3
statistical software and exported to SPSS windows version 20
for further analysis. Frequencies, proportions and summary
statistics were used to describe the study population in relation
to relevant variables and presented using tables and figures.
The Bivariate analysis was employed primarily to check which
variables had associations with the dependent variable. Then
variables found to have p-values of less than 0.05 were entered
the Multiple Logistic regression for controlling the possible
effects of confounders. Finally, variables which had significant
associations are identified on the basis of the Adjusted Odds
Ratio (AOR) with a 95%CI and at aP-value of 0.05.
Data quality was assured by pre-testing the questionnaire on
42(5%) students in one department which was later excluded
from the actual study. Training was given to data collectors and
supervisors before the actual data collection day. The overall
supervision was carried out by the chief investigators. The
questions were reviewed and checked for completeness and
consistency by supervisors and the principal investigator every
day and necessary feedback was offered to data collectors in the
Ethical clearance was obtained from the Institutional Review
Board of the University of Gondar after describing the purpose
and objective of the study, and verbal & written consent was
obtained from each study participant. Participants were also
informed that participation would be voluntary and that they
could withdraw at any time they were not comfortable with
the questionnaire. In order to maintain confidentiality, the
information was gathered throughout with the exclusion of
names as identifications by interviewing them separately.
The response rate of this study was 98.9% (874/884). More
than half (56.1%) of the participants were female. The mean age
of the respondents was 21year (SD=1.98), and 476 (54.5%) of
them were below or equal to 20 years of age. With regard to their
religion and ethnicity, 636 (72.8%) were Orthodox Christians,
and 489 (55.9%) Amhara by ethnicity. The majority (97.5%) of
the students lived on the university campuses, (Table1).
All of the respondents were asked whether they had ever
visited the university clinic or not, and more than half, 544(62.3%)
95%CI (54.1%, 68.7%), said they visited the clinic for different
reasons in the past one year. The main reasons for visiting the
clinics were getting condoms, VCT service, contraception, STIs
management, and Information Education and Communication
(IEC) services from 220(40.4%), 119(21.8%), 91(16.7%),
88(16.1%), and 26(4.9%), respectively (Figure1).
Out of the total participants, 774 (90.4%) had heard about
SRH issues. The major sources of SRH information were the radio
for 567 (37.9%), followed by television for 515(34.4%), posters
for 256(17.1%), and magazines for 160(10.6%). The majority,
777(88.9%), of the participants reported they had already heard
about STIs, and 671(37.0%), 572(31.6%), and 569(31.4%)
mentioned dysurea, genital ulcer, and genital discharge as the
major symptoms for their visits, respectively. Regarding the
methods they preferred for the prevention of HIV/AIDS, more
than three-fourths, 759(36.0%), pointed out abstinence, while
696(33.0%) and 653(31.0%) chose faithfulness and condom
use, respectively (Table2).
Regarding their previous sexual practice, 219(25.1%) had
sexual intercourse, of whom 214(97.7%) started before they
joined the university, and 44(20.4%) used the condom. More
than half of them, 141(64.4%), started sex with their boy/
girlfriends, and the mean age at first sex was 18 years (SD+2.2).
Only 35 (16.0%) and 30(14.0%) of the sexually active students
had HIV counseling and testing (HCT) and STI screening and
treatment services in that order. One hundred-sixty five (18.9%)
were sexually active during the last 12 months, of whom
81(49.1%) had more than one sexual partners, and 95(57.6%)
used condoms during sex. Of all the respondents, 376(43.0%)
had high risk perception for HIV infection (Table 2).
Bivariable and Multivariable Logistic regression models
were employed to determine factors associated with sexual
and reproductive health service utilization (variables with
p-value of <0.05). Students who had prior discussions on sexual
and reproductive health issues had 4.5 times higher odds of
utilization of sexual and reproductive health services [AOR=4.5
(CI: 2.42, 10.27)] than those who had not. In addition, students
from rural areas were about 1.6 times [AOR = 1.6, 95% (CI: 1.22,
2.16)] more likely to utilize reproductive health services than
those from urban areas. Those who had good knowledge of SRH
[AOR= 1.38 (CI: 1.94, 2.03)] and high risk perception for HIV
infection [(AOR=1.80, CI (1.58,1.10)] were also found to have
significant associations with sexual and reproductive health
service utilization (Table 3).
This study showed the prevalence and factors associated
with sexual and reproductive health service utilization among
university students. The level of SRH service utilization was
found to be 62.3%, with 95%CI (54.1%,68.7%). The result is
similar with that of a study conducted in Harrar (64.0%) .
The level of SRH service utilization in this study was higher
than those of studies conducted in Nepal (9.2 %) , Bahir Dar
(32.0%) , and Jimma (34.7%) . The possible justification
for the different findings could be the presence of discrepancies
in the study setups. For instance, if we compare the current study
with those of Nepal and Bahir Dar, the study conducted in Nepal
was on secondary school students and the Bahir Darstudy was on
high school students, while this study was on university students.
University students may have better knowledge regarding SRH
issues and the places they get the services are likely to be more
accessible compared to secondary and high school students. Since
the study in Jimma took place in 2004 and ours in 2014, there is
a time gap of ten years between the two works which might have
brought about differences not only in participant awareness but
also in the availability and accessibility of services, resulting in
variations in the two findings.
Our finding is lower than that of a study conducted in
Medawolabo uuniversity (80.5%) . The possible justification
could be the difference in the proportion of sexually active
participants in the two studies. In the Medawolabou study,
40.3% of the study participants were sexually active during
the time of the study compared to 18.9% in this study. Sexually
active students use SRH services more frequently because they
need condoms, family planning services, and STIs diagnosis and
Students from rural areas were about 1.6 times [AOR=1.6,
95% (CI: 1.22, 2.16)] more likely to utilize reproductive health
services than those from urban areas. The possible justification
might be that most students from rural areas may practice sex
for the first time on the campuses, and need help about SRH
issues from campus clinics, whereas students from urban areas
may practice sex earlier (had history of previous SRH service
use) and they might not seek help from the student clinics that
is, they may go to other SRH clinics out of university campus.
Students who had discussions on sexual and reproductive
health issues were 4.5 times more likely to utilize sexual and
reproductive health services [AOR = 4.5 (CI: 2.42, 10.27)]
compared to those who had not. This is in agreement with
studies conducted in Jimma  and Medawolaboue . The
possible reason might be that having discussions on SRH issues
may build student confidence and help them to expose their SRH
health concerns, get information from where they get services
and are thus more likely to use services.
Participants who had enough knowledge on SRH services
were more likely to utilize the services compared to those
who had poor knowledge. This finding is in line with those of
studies conducted in Debre Markos , Harrar , and Jimma
. Enough knowledge about SRH services could increase
SRH service utilization may be the possible explanation for the
Students who had a high level of risk perception for HIV/
AIDS were found to have significant associations with sexual and
reproductive health service utilization. This finding is supported
by those of studies conducted in Debre Markos , Harrar ,
andJimma . The possible explanation may be that having a
high level of risk perception for HIV/AIDS might push students
to know their HIV status and seek VCT services which increases
their SRH service utilization.
Sexual and reproductive health service utilization in
the study area was found to be moderate. Factors like prior
discussions on sexual and reproductive health issues, rural life,
knowledge of SRH, and level of risk perception for HIV/AIDS
were associated with sexual and reproductive health service
utilization. Therefore, concerned bodies are called upon to work
on the factors identified. Causality could not be ascertained due
to the cross-sectional nature of the study. In addition, the result
can only be generalizable to university students. Therefore, we
highly recommend further studies on out of school and in school
youth, including university students.
Ethical clearance was obtained from the institutional
review board (IRB) of Institute of Public Health, University of
Gondar. Permission was obtained from each college Authorities.
Informed consent was obtained from each study subjects.
Respondents were also informed about their right to refuse or
discontinue participation at any time. Information was recorded
anonymously to maintain respondent’s confidentiality and
AA, AK, GAT, KE, TB, YAH and TA were involved in study
conception, design, coordination, data collection, data analysis,
interpretation, and write up. YAH was involved in data analysis,
write up and prepared the manuscript. All authors read and
approved the final manuscript.
The authors would like to acknowledge all the study
participants, the data collectors, and supervisors, for
participation in the study. We also acknowledge authorities of
UoG, IPH for ethical approval.
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