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R E S E A R C H A R T I C L E Open Access
Sexual and reproductive health services
(SRHS) for adolescents in Enugu state,
Nigeria: a mixed methods approach
Amelia Ngozi ODO
1*
, Efiong Sunday SAMUEL
1
, Evelyn N. NWAGU
1
, Petra Obioma NNAMANI
2
and Chiemezie S. ATAMA
3
Abstract
Background: Availability and accessibility of sexual and reproductive health services for adolescents are very crucial
for prevention and control of sexual and reproductive health problems. These services also play vital roles in the
promotion of adolescents’sexual and reproductive health generally. The main purpose of the study was to
determine the availability and accessibility (geographical and financial) of sexual and reproductive health services
(SRHS) among adolescents in Enugu State, Nigeria.
Methods: A mixed methods approach was adopted for the study. 192 health facilities were reached to check
availability of SRH services. Randomly sampled 1447 adolescents (12–22 years) completed the questionnaire
correctly. Twenty-seven interviews and 18 group discussions were conducted. Instruments for data collection
consisted of a checklist, a questionnaire, a focus group discussion guide and an in-depth interview guide. All
instruments were pre-tested. Quantitative data were analyzed using descriptive statistics and Chi-square tests.
NVivo 11 Pro software was used to code and thematically analyze the qualitative data.
Results: A total of 1447 adolescents (between 12 and 22 years) completed the questionnaire correctly. Among
these adolescents, males constituted 42.9% while females were 57.1%. The majority (86.7%) of the adolescents
reported availability of safe motherhood services, and 67.5% reported availability of services for prevention and
management of STIs and HIV and AIDS. The majority reported that these services were geographically accessible
but few were financially accessible to adolescents. However, qualitative data revealed that available services were
not specifically provided for adolescents but for general use. Age (p=≤.05), education (p=≤.05) and income
(p=≤.05) were found to be significantly associated with access to SRHS.
Conclusion: SRHS were generally physically available but not financially accessible to adolescents. Adolescents’
clinics were not available and this could affect the access of SRHS by adolescents. Education and income were
significantly associated with access to SRHS.
Keywords: Availability, Accessibility, Sexual and reproductive health services, Adolescents, Mixed method
* Correspondence: ngozi.odo@unn.edu.ng;zikaodo@yahoo.com
1
Department of Human Kinetics and Health Education, University of Nigeria,
Nsukka, Enugu 410001, Nigeria
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
ODO et al. BMC Health Services Research (2018) 18:92
DOI 10.1186/s12913-017-2779-x
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
The sexual and reproductive health needs of adolescents
are often underserved in many societies [1], yet adoles-
cents constitute large proportion of the population. They
represent 25% of the world population [2] and are charac-
terized by series of physiological, psychological and social
changes that expose them to unhealthy sexual behaviour
such as early sex experimentation, unsafe sex and multiple
sexual partners [3]. These put them at high risk of sexual
and reproductive health (SRH) problems [1]. Such prob-
lems include early marriage, teenage pregnancies, unsafe
abortion, sexually transmitted infections (STIs), HIV and
AIDS, and other life threatening SRH problems [4].
The high increase in the rate of these SRH problems
among young people in sub-Saharan Africa is alarming
[5]. This suggests the need for adequate attention
towards adolescents’sexual and reproductive health.
Adolescents’SRH needs and problems are yet to receive
adequate attention especially in the developing countries
like Nigeria, despite the recognition of youth-friendly
reproductive health services as a way of improving their
access and utilization of SRH services [6] in order to
achieve quality SRH.
Efforts to attain quality sexual and reproductive health
are constrained by inadequate access to and inequitable
distribution of quality SRH services especially in sub-
Sahara African countries. These contribute to poor
utilization of SRHS among young people in sub-Saharan
African countries [7], resulting to high prevalence of
sexual and reproductive health problems especially
among the adolescents [8]. An estimate of 333 million
new cases of curable STIs occur mostly in developing
countries with the highest rate among 20–24 years old,
followed by those within the ages of 15 and 19 years [9].
It was also estimated that 1.3 million adolescent girls
and 780,000 adolescent boys were living with HIV
worldwide, and 79% of new HIV infection among
adolescents were in Sub-Saharan Africa [6].
Nigeria has an estimated population of 191, 835, 936
[10] with 22.3% adolescents [11]. One in 20 of these ad-
olescents contracts a sexually transmitted infections
each year, and half of all cases of HIV infection take
place among people under the age of 25 years [12].
About 40% of new HIV infection occurs among young
people in Nigeria [13]. This could result from early
sexual debut and early marriage which increase adoles-
cents’HIV vulnerability. The median age at first sexual
intercourse is 17.6 and 21.1 years for women and men
respectively, while the median age at first marriage is
18.1 and 27.2 years for women and men respectively
[14]. Teenage and unwanted pregnancies are also prob-
lems of adolescents especially the unmarried. Although,
the abortion law and policy in Nigeria prohibits legal ac-
cess to legal abortion services, about 1.25 million
commit induced abortion yearly by unskilled providers
and many have serious complications without obtaining
the post abortion care needed [15]. These indicate that
the utilization of SRH services by the adolescents in
Nigeria is low, arising from disparities in both provision
and accessibility of the services and also lack of priority
to adolescents’SRH [16]. Availability and accessibility of
quality and affordable SRHS ensure adolescents’sexual
and reproductive health wellbeing [17].
Despite the global promotion of availability of SRH
services, most rural areas still lack these services [18].
Moreover, both geographical and financial accessibility
to SRH services by the adolescents in low and medium
income countries are influenced by different socio-
demographic factors [19, 20]. Age and educational status
of adolescents were found to affect their use of repro-
ductive health services [21]. This study therefore,
assessed the availability and accessibility of SRHS and
association between access to SRHS and age, gender,
level of education, location and income among adoles-
cents in Enugu State, Nigeria.
Methods
Study area and period
This study was conducted in Enugu State, Southeast
Nigeria between January 2015 and July 2016. The state
comprised 17 Local Government Areas (LGAs) with an
estimated total population of 3,267,837 [22]. Of this
population, 734,297 (22%) were people of age group 12–
22 years; 343,037 (47%) were males and 388,260 (53%)
were females. Some of these LGAs have commercial
areas like big markets and hotels that attract visitors
who come for one business or the other. Adolescents in
these areas unlike those in non-commercial areas,
engage in a lot of business such as hawking and even
commercial sex working. Their males also engage in
commercial motor-cycle riding (okada) which exposes
them to rough or unhealthy lifestyles. Such activities ex-
pose them to unsafe sex and early marriage predisposing
them to sexual and reproductive health problems like
STIs, and HIV and AIDS, teenage pregnancy, abortion
and their consequences. These unhealthy life styles and
SRH problems may arise because the young people in
this area do not utilize SRH services due to some social
and demographic factors. The availability and accessibil-
ity of these services to this group of people remained
uncertain and therefore, necessitated the present study.
Design and sampling techniques
A mixed method (quantitative and qualitative) approach
was employed. The cross-sectional design was adopted
to assess the availability and accessibility of SRH services
to adolescents in Enugu State, Nigeria. The sample was
1620 adolescents; 756 (47%) males and 864 (53%)
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females, and 217 public health facilities. The sample size
was determined using Cohen, Manion and Morrison’s
sample size chart [23] which suggests that when a popu-
lation size is five hundred thousand (500,000) and above
at (95%) confidence level and (5%) interval level, the
sample size should be three hundred and eighty-four
(384) and above and when a population size is five hun-
dred (500) and above at (95%) confidence level and (5%)
interval level, the sample size should be two hundred
and seventeen (217) and above.
Part one: sampling of questionnaire respondents to as-
sess accessibility of SRHS.
Sampling occurred in three stages. First stage sampling
involved stratifying the LGAs in each senatorial zone
into urban and rural LGAs (2 senatorial zones have six
LGAs each, while one senatorial zone has 5 LGAs). The
second stage involved selecting one urban and two rural
LGAs each from the three senatorial zones using simple
random sampling technique of balloting without re-
placement. This is because each senatorial zone is made
up of at least one urban LGA. Two senatorial zones had
only one urban LGA each; therefore, the urban LGA in
the zone was purposively picked. This sampling gave a
total of nine (3 urban and 6 rural) LGAs out of the
seventeen LGAs. In each LGA selected, the target sam-
ple of adolescents was 84 males and 96 females, which
gave a total of 252 males and 288 females from each sen-
atorial zone. The third stage involved selecting six polit-
ical wards (a geographical area made up of few
communities) from each LGA using systematic sampling
technique so as to spread the sample selection to a rea-
sonable representation of the LGA. This gave a total of
fifty-four (54) wards. The target sample at this stage was
14 males and 16 females from each of the six wards
using convenience sampling technique based on accessi-
bility and willingness of the adolescents to participate.
This gave the grand total of 1620 (756 males and 864 fe-
males) being the sample size used for the study.
Part two: sampling of health facilities to assess avail-
ability of SRHS.
In Enugu State, public health facilities are distributed
in LGAs by wards. Every ward therefore, has at least one
public health facility. Public health facilities (which were
used to check the availability of SRHS) were purposively
selected for the study since they attract both government
and non-governmental support for reproductive health
services more than the private facilities. From the 508
public facilities, 217 were selected using proportionate
sampling technique thus ensuring that at least one
health facility was selected from each ward.
Part three: selection of interview and focus group
participants.
Convenience sampling technique was used to select
6–10 male and 6–10 female adolescents from the
questionnaire respondents in each of the nine LGAs se-
lected for focus group discussion. This gave 2 groups (1
male group and 1 female group) from each LGA, giving
a total of 18 focus groups. Convenience sampling
technique was also used to select 3 (1 male and 2
female) interviewees from each LGA for In-Depth
Interview (IDI). This gave a total of 27 interviewees.
Data collection procedure
Checklist, questionnaire, focus group discussion guide
and in-depth interview guide were used to collect data
from the respondents on both personal and group con-
tacts. The checklist was adapted from WHO’s service
availability and readiness assessment core instrument
[24]; and was used to collect data and measure availabil-
ity of SRHS for adolescents in the health facilities. Only
the sections that elicit information on availability of the
SRHS studied were adapted. The health officers-in-
charge of the health facilities sampled were interviewed
with the Checklist.
Structured questionnaire was prepared through review
of related literature. The questionnaire which contained
two parts was used to measure accessibility of SRHS.
Accessibility in our study was measured based on prox-
imity of health facilities (can walk to the health facility
within 30 min or not; or less than 1 mile) and affordabil-
ity of the services to adolescents. First part contained
the socio-demographic characteristics of the respondents
while the second part contained both geographical and
financial accessibility of related components of adoles-
cents’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). Validity of the in-
struments was established by five experts. The reliability
of the questionnaire was established by pre-testing the
questionnaire on 20 adolescents in Anambra State (out-
side the study area but with the same characteristics
with the respondents under study). Kudder-Richardson’s
formula 21 (K-R 21) was used to determine the reli-
ability. A reliability coefficient index of .86 was
obtained and the instrument was judged reliable for
the study. Researchers and nine trained research as-
sistants administered the questionnaire. The research
assistants used were below 25 years of age. This was
to avoid much age disparity between the research
assistants and the respondents in order for the re-
spondents to communicate freely.
Focus Group Discussion (FGD) and In-Depth
Interview (IDI) were conducted using already prepared
FGD Guide and IDI guide. The FGD and IDI provided
detailed information on accessibility of SRHS and
addressed issues not covered by the questionnaire. The
discussions and interviews were recorded with digital
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tape recorders. In addition, non-verbal cues from partici-
pants were recorded through note taking.
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
and 217 checklists used for data collection, only 1447
copies of questionnaire and 192 checklists 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 availability and acces-
sibility of SRHS to adolescents, while Chi-square statistic
was used to test association between the variables at .05
level of significance. Data from the checklist on availability
were presented in Table 2, while data from the question-
naire on accessibility were presented in Tables 3 and 4.
Accessibility in our study was measured both geo-
graphically and financially. Adolescents who lived not
more than one mile from or could walk to any public
health facility where SRHS were provided within 30 min
were regarded as having geographical access to SRHS.
Affordability (which was reported by the respondents)
of travelling cost and costs of services as perceived by
the respondents were used to determine the financial
accessibility.
The responses from focus group discussion and IDI
were transcribed in English language while maintain-
ing 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 findings.
Results
Table 1 shows the socio-demographic data of the study
sample that responded to the questionnaire. Among par-
ticipants (n= 1447), males constituted 42.9% while fe-
males constituted 57.1%. Their age ranged from 12 to
22 years with a mean age of 16.9 years. Most of the par-
ticipants had secondary education (54.0%) and most
were Christians (96.3%). Greater proportions of the par-
ticipants were living with their parents (62.3%) and were
single (86.8%). Majority had a monthly income less than
₦5000.00 (1 USD = 199.3 NGN).
Table 2 presents data from the health facilities on
availability of SRHS. The table shows that 55.8% of the
health facilities had sexuality education services, 57.1%
had family planning information and services, 86.7% had
safe motherhood services, and 67.5% had services for
prevention and management of STIs and HIV and AIDS.
Tables 3 and 4 present data on accessibility of SRHS.
Table 3 shows that overall geographical and financial ac-
cessibility of SRHS was 58.4 and 50.5% respectively.
More participants viewed sexuality education to be geo-
graphically (66.7%) and financially (58.7%) accessible.
Family planning was viewed to be only geographically
accessible (51.9%). Safe motherhood services were con-
sidered by majority to be accessible geographically
(70.6%) and financially (61.7%). Post abortion care ser-
vices were viewed by 51.0% to be geographically access-
ible and prevention and management of STIs and HIV
and AIDS services were considered geographical access-
ible by 51.6% of the respondents.
Table 4 shows that there is significant association be-
tween both geographical and financial access to sexuality
education, family planning, and safe motherhood ser-
vices and age (p≤.05), level of education (p≤.05), and
income (p≤.05). Older adolescents (17–22 years) had
more access to the services than the younger adoles-
cents. There is also significant association between both
geographical and financial access to post-abortion
care and age (p≤.05), level of education (p≤.05) and
income (p≤.05). There are variations in the levels of
education and income of the respondents and their
access to the services.
Qualitative data
Availability of SRHS for adolescents
In-depth interview reveals that adolescents interviewed
agreed that some of the SRHS were available but not
particularly for adolescents. The available services for
adolescents reported were: sexuality education which is
provided in the secondary schools through other health-
related subjects, and services for prevention and man-
agement of STIs and HIV and AIDS, which are mainly
provided by churches and schools during youth week. In
the words of some interviewees:
“I get sexuality education services and services for pre-
vention and management of STIs and HIV and AIDS in
the school and church during youth’s week but for others,
I don’t know about them”(Udenu 002). On the issue of
family planning and safe motherhood services, partici-
pants were of the view that the services were only avail-
able for married women. One of the interviewee said “I
have not received such (family planning services), and I
don’t think it is made for adolescents. It is only for mar-
ried couples”(Enugu-North 003). Another interviewee
said “safe motherhood services are for married mothers
not for us but I know that the services are available in
the health centers for all pregnant women”(Isi-Uzo 001).
Interviewees reported non-availability of post-abortion
care. An interviewee said “I have not heard of post abor-
tion care services and I know there is nothing like that in
the health centers”(Igbo-Eze South 001).
Similarly, focus group discussion revealed that partici-
pants in the 18 groups (male and female) reported that
the available SRHS for adolescents are sexuality
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education and services for prevention and manage-
ment of STIs and HIV and AIDS which they receive
in schools and churches. One participant said “Yes
sexuality education services and screening services for
STIs and HIV/AIDS are being provided for us in
school and church during youth week”(Ezeagu Male
FGD-P1). The participants had not heard of post--
abortion care (PAC). A participant said “Am hearing
the PAC services for the first time”(Nsukka Female-
FGD-P4) and another male participant from FGD said
“No o! There is nowhere these services are provided
for the adolescents. I have not seen”(Nsukka Male
FGD-P1).
Accessibility of SRHS to adolescents
In-depth interview show that interviewees have geo-
graphical access to public health facilities that provide
general SHRS, as they indicated that they can walk to
the health facility within 30 min. One interviewee said,
“Yes for me I can trek within 30 minutes because I stay
near the hospital”(Enugu-North 001). However, partici-
pants revealed that not all the SRHS were available in
the health facilities and the accessible SRHS were not for
adolescents alone. On financial accessibility, few inter-
viewees indicated that they could afford the cost of the
SRHS. An interviewee said “…these services are not fully
accessible to me because I can’t afford the cost of the ser-
vices”(Isi-Uzo 003).
FGD participants indicated that available SRHS were
geographically accessible except in rural areas where
some accessible health facilities do not provide some
of the SRHS but no affordable. In their words, “Some
are cheap while some are not like services for preven-
tion and management of STIs and HIV and AIDS”
(Nsukka Male FGD-P5). “……but the ones I have
accessed are not cheap to me, may be because I am a
student”(Isi-Uzo Female FGD-P1).
Discussion
For adolescents to use SRHS and lead a healthy sexual
and reproductive live, SRHS have to be available and ad-
equately accessible. Addressing the problem of availability
Table 1 Socio-Demographic Characteristics of Adolescents that
Responded to the Questionnaire on Accessibility of SRHS (n= 1447)
S/N Characteristics %
1 Gender
Male 42.9
Female 57.1
Total 100.0
2 Age
12–16 48.2
17–22 51.8
Total 100.0
3 Education
Primary 2.2
Secondary 54.0
Tertiary 42.0
None 1.8
Total 100.0
4 Religion
Christianity 96.3
Islam 1.5
African Traditional Religion 2.1
Total 100.0
5 Location
Urban 43.3
Rural 56.7
Total 100.0
6 Living Status
With parents 62.3
Alone 20.4
With friends/husband 3.2
In school 14.1
Total 100.0
7 Marital Status
Married 12.4
Single 86.8
Divorced .4
Separated .3
Total 100.0
8 Parity (females only)
None 81.5
1–3 13.8
4–6 3.0
7 and above 1.7
Total 100.0
9 Monthly Income
Below 1000.00 k 46.8
Table 1 Socio-Demographic Characteristics of Adolescents that
Responded to the Questionnaire on Accessibility of SRHS (n= 1447)
(Continued)
1000.00 k- 4000.00 k 19.8
5000.00 k- 10,000.00 k 16.0
11,000.00 k- 20,000.00 k 8.8
Above 20,000.00 k 8.6
Total 100.0
Note: 1 USD = 199.3 NGN; for parity, N=826
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Table 2 Percentage of sampled facilities that report availability of SRHS in Enugu State (n= 192)
S/N Items
%
Sexuality Education Services
1 Trained sexuality education provider 60.9
2 Education on human biology 51.0
3 Education on puberty and menstrual hygiene practices for youth 73.4
4 Education on skills to overcome sexual desires for youth 42.7
5 Education on healthy Associations for youth 42.7
6 Education on dangers of premarital and unsafe sex for youth 72.9
7 Information on reproductive rights and policy for youth 34.4
8 Information on harmful cultural practices like female circumcision 65.6
9 Information on prevention of non-infectious conditions of reproductive health such as fistula and cancers 58.9
Cluster % Total 55.8
Family Planning Information and Services
10 Trained family planning provider 59.9
11 Family planning information 80.7
12 Oral pills 61.5
13 Injectable contraceptives 52.6
14 Male condoms 81.8
15 Female condoms 70.8
16 Intrauterine contraceptive device (IUCD) 27.1
17 Emergency contraceptives 22.4
Cluster % Total 57.1
Safe Motherhood Services
18 Trained midwife 62.5
19 Antenatal services for pregnant youth 92.7
20 Safe delivery services for youth 92.7
21 Postnatal services for youth 87.5
22 Immunization services 92.7
23 Growth monitoring services 93.2
24 Information on infant feeding practices 85.9
Cluster % Total 86.7
Post Abortion Care (PAC) Services
25 Trained PAC provider 19.3
26 Emergency health care, in cases of bleeding and shock 69.8
27 Manual vacuum aspiration (evacuation) of retained product of conception 30.7
28 Information on prevention and management of STIs and HIV and AIDS for youth 71.4
Cluster % Total 47.8
Prevention and Management of STIs and HIV and AIDS Services
28 Trained HIV and AIDS services provider 63.0
29 Information on prevention and management of STIs, HIV and AIDS for youth 89.6
30 Voluntary counseling and testing for youth 83.3
31 Antiretroviral therapy for youth 35.4
32 Services for the prevention of mother-to-child transmission of HIV and other STIs 64.1
33 Condoms for sexually active youth 69.3
Cluster % Total 67.5
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and accessibility of SRHS for adolescents is essential to in-
creasing adolescents’utilization of SRHS. Most peer
reviewed literature used quantitative data only. Quantita-
tive data only seem not to get adequate SRH information
from adolescents especially in developing countries like
Nigeria, where culture and tradition still affect adoles-
cents’SRH. This study was therefore, aimed at assessing
SRHS available and accessible to adolescents in Enugu
State, using mixed method (quantitative and qualitative).
The secrecy accorded to sexual issues in the study area
was a challenge to this study and might be the reason
for some differences in qualitative and quantitative data.
The study was delimited to adolescents in Enugu State,
and therefore, may not be used to generalize to all
adolescents in a multi-ethnic country like Nigeria.
The available SRHS were sexuality education, family
planning, safe motherhood, and prevention and manage-
ment of STIs, and HIV and AIDS, most of which are
Table 3 Percentage of Sampled Adolescents that Reported Accessibility of SRHS in Enugu State (n= 1447)
S/N Items Geographical Access % Financial Access %
Sexuality Education Services such as education on
1 human biology 70.0 60.8
2 Puberty 72.3 62.4
3 menstrual hygiene 70.4 63.2
4 skills to overcome sexual desires 61.2 56.4
5 healthy Associations 61.2 52.8
6 dangers of premarital and unsafe sex 65.2 56.5
Cluster % Total 66.7 58.7
Family Planning Information and Services such as
7 Condoms 72.8 65.9
8 Oral pills 52.6 44.9
9 Injectable contraceptives 45.0 35.0
10 Intrauterine contraceptive device (IUCD) 37.2 29.2
Cluster % Total 51.9 43.8
Safe Motherhood Services such as
11 Antenatal 75.5 63.9
12 Safe delivery 69.8 60.5
13 Postnatal 66.3 57.1
14 Immunization 77.2 69.5
15 Infant feeding information 64.2 57.7
Cluster % Total 70.6 61.7
Post Abortion Care (PAC) Services such as
16 Emergency care during bleeding 50.5 41.2
17 Manual removal of retained product of conception 35.9 30.2
18 Information on the prevention of unwanted pregnancy 59.0 52.1
19 Information on prevention of abortion 58.7 51.8
Cluster % Total 51.0 43.8
Prevention and Management of STIs and HIV and AIDS Services such as
20 Voluntary counseling and testing 67.0 56.3
21 Provision of antiretroviral therapy (ART) 36.0 32.9
22 Treatment of STIs 49.1 41.1
23 Supply of condoms 54.0 47.3
24 prevention of mother-to-child transmission of HIV and other STIs 52.0 45.5
Cluster % Total
Overall % Total
51.6
58.4
44.6
50.5
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Table 4 Association between Socio-Demographic Factors and Access to SRHS among Adolescents in Enugu State (n = 1447). Socio-Demographical Factors Associated with SRHS
Factors Sexuality Education Family Planning Safe Motherhood
Geographical Access Financial Access Geographical Access Financial Access Geographical Access Financial Access
%χ
2
P%χ
2
p%χ
2
P%χ
2
P%χ
2
p%χ
2
p
AC AF AC AF AC AF
Gender
Male 72.6 7.477 .006* 69.6 .921 .337** 61.7 .587 .443** 53.9 5.748 .017* 71.8 1.144 .285** 62.0 .176 .675**
Female 78.8 67.2 59.7 47.6 74.3 63.1
Age
12–16 72.9 7.937 .005* 65.6 4.333 .037* 52.7 34.996 .000* 41.6 40.753 .000* 66.1 34.741 .000* 55.8 26.576 .000*
17–22 78.8 70.7 67.9 58.4 79.9 68.9
Level of education
Primary 53.1 26.417 .000* 46.9 22.245 .000* 56.2 45.767 .000* 37.5 47.201 .000* 65.6 29.136 .000* 50.0 26.711 .000*
Secondary 73.0 64.8 53.1 43.0 68.5 57.4
Tertiary 81.9 74.2 70.7 60.9 80.4 70.2
None 65.4 57.7 50.0 38.5 57.7 57.7
Location
Urban 77.4 .870 .351** 64.0 9.237 .002* 61.9 .835 .361** 50.2 .002 .962** 71.6 1.527 .217** 54.4 31.985 .000*
Rural 75.2 71.5 59.5 50.4 74.5 68.9
Income(₦)
<1000 72.4 11.193 .024* 65.7 9.765 .045* 54.1 42.677 .000* 45.2 32.052 .000* 65.6 38.675 .000* 57.0 19.113 .001*
1000–4000 78.7 71.7 59.1 47.6 80.4 70.3
5000–10,000 79.7 66.8 62.9 51.3 78.4 67.7
11,000–20,000 78.1 78.1 78.1 65.6 80.5 64.8
>200,000 76.6 66.1 76.6 66.1 81.5 63.7
ODO et al. BMC Health Services Research (2018) 18:92 Page 8 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 4 Association between Socio-Demographic Factors and Access to SRHS among Adolescents in Enugu State (n = 1447). Socio-Demographical Factors Associated with SRHS
(Continued)
Factors Post Abortion Care Prevention and Management of STIs, HIV and AIDS
Geographical Access Financial Access Geographical Access Financial Access
%χ
2
P%χ
2
P%χ
2
P%χ
2
p
AC AF AC AF
Gender
Male 63.4 .145 .704** 57.5 .831 .362** 55.1 2.122 .145** 50.9 11.561 .001*
Female 62.9 55.1 51.2 41.9
Age
12–16 59.8 5.398 .020* 51.1 13.871 .000* 51.2 1.467 .226** 42.0 7.468 .006*
17–22 65.7 60.8 54.4 49.2
Level of education
Primary 46.9 16.076 .001* 43.8 26.103 .000* 37.5 4.405 .221** 34.4 4.764 .190**
Secondary 59.8 51.0 52.0 44.3
Tertiary 68.3 63.8 54.9 48.5
None 50.0 46.2 50.0 38.5
Location
Urban 65.7 3.773 .052** 55.3 .269 .604** 58.1 11.943 .001* 44.5 .699 .403**
Rural 60.7 56.7 48.9 46.7
Income(₦)
<1000 57.3 19.573 .001* 53.2 10.363 .035* 54.8 7.277 .122** 47.9 10.349 .035*
1000–4000 66.4 57.0 49.7 44.4
5000–10,000 65.5 54.7 48.3 38.4
11,000–20,000 73.4 67.2 50.8 43.0
>200,000 69.4 61.3 60.5 54.0
AC Accessible, AF Affordable, χ
2
= Chi-square, p = p-value, *significant, **Not significant, at .05 level of significance, 1USD = 199.3NGN
AC Accessible, AF Affordable, χ
2
Chi-square, pp-value, *significant, **Not significant at .05 level of significance
ODO et al. BMC Health Services Research (2018) 18:92 Page 9 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
provided in schools and churches. Previous studies also
reported schools and churches as most important com-
munity sources of sex education [25, 26]. Moreover,
family planning and safe motherhood services were pro-
vided in almost all the primary health centers in the
state. However, these services were general services and
not specifically for adolescents as revealed by qualitative
data and absence of youth clinic or unit in all the health
facilities visited. The finding was at variance with previ-
ous studies that reported lack of SRHS [27, 28]. Qualita-
tive data revealed that the most available SRHS for
adolescents were sexuality education services and ser-
vices for prevention and management of STIs, HIV and
AIDS provided in schools and churches during youth
weeks and not in the health facilities [29]. This finding
could be due to the fact that adolescent/youth clinics or
units were lacking in the political wards and health facil-
ities visited. The qualitative data were therefore, in sup-
port of the findings of similar studies which stated that
only few health facilities provided the essential SRH ser-
vices for young people [7, 27].
All the available SRHS were geographically accessible
while only two (sexuality education and safe motherhood
services) were financially accessible. Every political ward
we visited had at least one primary health facility. Sexu-
ality education was financially accessible because it was
provided mainly in the churches and schools and no fur-
ther payments apart from school fees were required. Safe
motherhood services were also financially accessible be-
cause government provided these services at a much re-
duced price and sometimes free. The finding was
consistent with the assertion that young people should
have universal access to SRHS [30, 31]. The finding was,
however, at variance with the finding of low accessibility
of SRHS to adolescents reported by previous studies that
utilized quantitative data [18, 32].
Our qualitative findings from IDI revealed that more
than half (55.6%) of the interviewees had geographical
access to SHRS as they indicated that they could walk to
the health facility within 30 min. However, most of the
interviewees revealed that not all the SRHS were avail-
able in the health facilities [33] and some of the access-
ible SRHS were not for adolescents alone, but rather for
everybody. On financial accessibility, slightly more than
one third (37.0%) of the interviewees indicated that they
could afford the cost of the SRHS. Data collected
through FGD revealed that majority of both male and fe-
male participants indicated that available SRHS were geo-
graphically accessible except in rural areas where some
accessible health facilities do not provide some of the
SRHS. This finding opposes previous assertion that costs of
services were barriers to adolescents’access to SRHS [34].
Though, these services according to the participants are
affordable, they are provided free to only pregnant women.
Statistically significant associations exist between
both geographical and financial access to sexuality
education, family planning, safe motherhood services
and post-abortion care and age, level of education
and income. This implies that age, education and in-
come can influence adolescents’access to sexuality
education, family planning, safe motherhood and post
abortion care. Older adolescents accessed the services
more than the younger ones. Older adolescents are
more independent than the younger ones and so
could decide to access or not to access SRHS. The
finding is consistent with previous assertion that level
of access of health services is lower in younger ado-
lescents [35]. It was also observed during in-depth
interview and focus group discussion that younger
participants were silent and of little knowledge of majority
of issues discussed [36]. The finding could also be related
to poor sexuality education at home and even in
schools. Some parents may not give their children age
appropriate sex education which should begin at home.
It has also been observed by that some schools do not
teach sex education as a separate subject but subsumed
under other subjects.
Our study found that respondents with secondary
education accessed SRHS more than those with other
levels of education, even tertiary. This was at variance
with the assertion that more educated people are
more likely to access health care and understand with
self-confidence to act on them [37]. Similar study
opined that education can lead to higher ability to
process health-related information and also influence
an individual’s preference for future, which in turn
improves his or her health behaviour and health
outcomes [38–40].
Furthermore, the significant association between
income and access (financial) to SRHS in this study is
uncommon. Respondents with income between ₦5000
and ₦10,000 had more financial access to SRHS than
those with income above ₦10,000. Previous studies show
higher access with higher income levels [41, 42]. How-
ever, lower income negatively influenced adolescents’
access to the services [43]. Our qualitative data revealed
that sexuality education and prevention and manage-
ment of STIs and HIV and AIDS were provided mostly
in schools and churches for both male and female ado-
lescents. However, some male participants in the FGD
were of the opinion that SRH services were meant for
girls only. Boys perceived SRHS as designated for girls
[44]. This finding is however, similar to the findings of
studies conducted in Nigeria [45] and Ethiopia [21] that
reported association between gender and access and
utilization of health services. The finding is not consist-
ent with a study that reported no difference between
gender and access to SRHS [18].
ODO et al. BMC Health Services Research (2018) 18:92 Page 10 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Conclusions
We found that the majority of the SRH services were
available and geographically accessible, but very few were
financially accessible to adolescents. These services were
not specifically for the adolescents and therefore, may hin-
der their access as well as utilization. Socio-demographic
factors associated with adolescents’access (geographical
and financial) to SRH services were age, education and in-
come. We therefore, suggest that adolescents-friendly
SRH services should be made available and accessible.
Abbreviations
FGD: Focus Group Discussion; HIV and AIDS: Human Immunodeficiency Virus
and Acquired Immune Deficiency Syndrome; IDI: In-depth Interview;
LGA: Local Government Area; SPSS: Statistical Package for the Social Sciences;
SRH: Sexual and Reproductive Health; SRHS: Sexual and Reproductive Health
Services; STIs: Sexually Transmitted Infections
Acknowledgements
We wish to acknowledge all our research assistants for their cooperation and
hard work.
Funding
No financial support was received for this study.
Availability of data and materials
The data that support the findings of this study are from different datasets
(e.g. Doaj, Google, Google Scholar) and from our Institution’s Library (Journal
Section), and are included in the list of references.
Authors’contributions
AN and ES designed the research work, AN, EN, PO, and CS carried out the data
collection. AN, EN, and E.S contributed to data analysis and drafting of the
manuscript. All authors read and approved the final manuscript.
Authors’information
Authors are members of the Youth-Friendly Reproductive Health Research
Group at the University of Nigeria, Nsukka. This research group is concerned
with the adolescents/youth’s sexual and reproductive health.
Ethics approval and consent to participate
Both oral and written consent were obtained from the participants. The
parents or guardian of participants below the age of 18 years provided both
oral and written consent on their behalf. Participation was total voluntary.
The Local Institutional Review Board (Postgraduate Studies Review Board),
University of Nigeria, Nsukka approved the study procedure.
Consent for publication
Consent form for participation and publication of responses was signed by
participants and parent or guardian of participants below the age of 18 years.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Human Kinetics and Health Education, University of Nigeria,
Nsukka, Enugu 410001, Nigeria.
2
Department of Pharmaceutics, University of
Nigeria, Nsukka, Nigeria.
3
Department of Sociology/Anthropology, University
of Nigeria, Nsukka, Nigeria.
Received: 22 April 2017 Accepted: 6 December 2017
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