|Year : 2021 | Volume
| Issue : 11 | Page : 1582-1589
Variations in utilization of health facilities for information and services on sexual and reproductive health among adolescents in South-East, Nigeria
IC Agu1, CO Mbachu2, U Ezenwaka3, C Okeke2, I Eze4, I Arize3, N Ezumah4, O Onwujekwe3
1 Health Policy Research Group; Institute of Public Health, University of Nigeria Nsukka, Nsukka, Nigeria
2 Health Policy Research Group; Institute of Public Health; Department of Community Medicine, University of Nigeria Nsukka, Nsukka, Nigeria
3 Health Policy Research Group; Health Administration and Management, Nsukka, Nigeria
4 Health Policy Research Group, Nsukka, Nigeria
|Date of Submission||26-Jan-2021|
|Date of Acceptance||08-May-2021|
|Date of Web Publication||15-Nov-2021|
Dr. C Okeke
Health Policy Research Group, University of Nigeria Nsukka; Department of Community Medicine, University of Nigeria Nsukka; Institute of Public Health, University of Nigeria Nsukka. P.O. Box, 451, Ogui Road, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Adolescents' sexual and reproductive health has an important influence on a country's long-term national growth. There is a high level of burden due to poor adolescent sexual and reproductive health (ASRH) in Nigeria, especially the Ebonyi State. Evidence shows that in the Sub-Saharan African region, most adolescents experience poor access to information and other services relating to their sexual and reproductive health. Many cultures in Africa see matters around sex and sexuality as social taboos. Aims: This study aimed to access variations in the utilization of health facilities for sexual and reproductive health information and services among adolescents in the Ebonyi State, Nigeria. This will inform the design of interventions to improve ASRH. Patients and Methods: A total of 1,057 in-school and out-of-school adolescents aged 13–18 years were selected using cluster sampling of households from the six selected local government areas (LGAs) in this cross-sectional survey. Structured questionnaires were used to collect data. Descriptive statistics were performed alongside stratification analysis. Tabulation, bivariate and multivariate logistic regression analyses were undertaken. A household wealth index was calculated using the total household consumption calculated divided by the number of people in the household (per capita household consumption). The per capita household consumption was used to categorize the households into socioeconomic quintiles. The variable was used to differentiate key variables into socioeconomic quintile equity analysis. Results: A majority of the respondents had never visited any type of health facility to receive either sexual and reproductive health (SRH) information (90.2%) or services (97.1%). The utilization rate of health facilities for SRH information was 9.8% while for other SRH services was 2.8%. The patent medicine vendor (PMV) was the most visited type of facility for SRH information and other services. Schooling was a strong predictor of health facilities' utilization for SRH information (P < 0.01) and other services (P < 0.01). Conclusion: Utilization of health facilities for information and services among adolescents in the Ebonyi State is very low and favorable toward informal service providers such as PMVs. The establishment and strengthening of the existing youth-friendly centers, school clinics, and occasional outreach programs designed specifically to target adolescents would perhaps improve adolescents' access to adequate information and health facility utilization for sexual, reproductive, and health services.
Keywords: Adolescents, information, services, sexual and reproductive health, utilization
|How to cite this article:|
Agu I C, Mbachu C O, Ezenwaka U, Okeke C, Eze I, Arize I, Ezumah N, Onwujekwe O. Variations in utilization of health facilities for information and services on sexual and reproductive health among adolescents in South-East, Nigeria. Niger J Clin Pract 2021;24:1582-9
|How to cite this URL:|
Agu I C, Mbachu C O, Ezenwaka U, Okeke C, Eze I, Arize I, Ezumah N, Onwujekwe O. Variations in utilization of health facilities for information and services on sexual and reproductive health among adolescents in South-East, Nigeria. Niger J Clin Pract [serial online] 2021 [cited 2022 Aug 17];24:1582-9. Available from: https://www.njcponline.com/text.asp?2021/24/11/1582/330466
| Introduction|| |
Adolescents' sexual and reproductive health has an important influence on a country's long-term national growth., This age bracket has special needs as the period is characterized by rapid growth/advancement and it also tends to have an increased interest in the opposite sex. The adolescents' sexual curiosity and a quest for information and experiences lay the foundation in forming new relationships, indulging in unprotected premarital sexual activity, and continuous experiment of other unhealthy behaviors that are detrimental to their health.
The onset of adolescence brings new vulnerabilities to human rights abuses, especially in the areas of sexuality, marriage, and childbearing. For this, the adolescents require access to accurate and comprehensive sexual and reproductive health information and other services, but barriers exist, as most of them are not able to access these services and care., The need to accessing and utilizing the available health services and information is crucial in promoting the sexual and reproductive health of adolescents. Poor access to and utilization of the available health facility for quality services and adequate information have been identified as contributors to largely preventable SRH problems (like unwanted teenage pregnancies, unsafe abortions) and mortality among the adolescents. Roughly every one in five young women becomes pregnant before the age of 18 years and this unwanted pregnancy among adolescents impacts negatively on their social, economic, and psychological well-being.
Evidence shows that in the Sub-Saharan African region, most adolescents experience poor access to information and other services relating to their sexual and reproductive health. The provision of comprehensive sexual and reproductive health interventions in developing countries has been impeded by ideologically-driven restrictions. The available evidence shows that some African countries are ambivalent to reproductive health service provision for adolescents. This, in effect, makes the health system in many developing countries unfriendly for adolescents to access SRH information and services. Many cultures in Africa see matters around sex and sexuality as social taboos. For this reason, it should not be discussed and this regularly denies unmarried adolescents of their sexual and reproductive health rights., The adolescents should be empowered to know and exercise their rights, including the right to delay marriage and the right to refuse unwanted sexual advances, which can be achieved by offering a comprehensive sex education; services to prevent, diagnose, and treat sexually transmitted infections (STIs); and counseling on family planning.
In developing countries like Nigeria, most adolescents suffer SRH preventable problems like unwanted teenage pregnancies, unsafe abortions, and STIs which might lead to the death of the individual. Twenty-two percent of Nigeria's population is between the ages of 10 and 19 years with a national fertility rate of 122 births per 1,000 young women aged 15–19 years and this fertility rate is higher in the northwestern states of the country. This raises concerns on the importance of addressing issues around the sexual and reproductive health of adolescents in Nigeria. One of the key issues in addressing matters around the sexual and reproductive health of adolescents in Nigeria is that utilization of health services remains low among this age group., Many studies identified limited access to SRH services. Poverty, societal stigma, discrimination, and restrictions around sexuality as partly what limit adolescents from utilizing the available health facilities for adequate SRH information and quality services.,
Variations in the utilization of health facilities for sexual and reproductive health information and services among adolescents are well-documented. The previous studies suggest that demographic variations by schooling (in-school or out-of-school) exist among the adolescents in their utilization of health facilities for sexual and reproductive health information and services. This study aimed to access the variations in the utilization of health facilities for sexual and reproductive health information and services among adolescents in the Ebonyi State, Nigeria.
| Methods|| |
This study was conducted in the urban and rural areas in the Ebonyi State, southeast Nigeria. Based on the 2006 census, with a projected annual growth, the Ebonyi State is estimated to have about 6.3 million inhabitants with over 40% of the state's population under the age of 15 years in 2017., The Ebonyi State's population growth rate is about 2.7% yearly and it is estimated that the state's population will be doubled by the year 2050 if the population growth continues at the same rate. The state has 13 local government areas (LGAs) and three senatorial zones. The health services are provided through public and private health facilities in the Ebonyi State. The formal health facilities in the state include 1 tertiary hospital, 13 secondary hospitals, 431 primary health centers, and private hospitals including missionary hospitals that are engaged in public-private partnership. The residents of the Ebonyi State participate in various occupations such as civil servants, farmers, traders, and artisans. The Ebonyi State has the lowest ASRH service utilization prevalence rate including contraceptive services as compared to other southeastern states in Nigeria.
The Ebonyi State was purposefully selected from the five states in southeast Nigeria due to its poor indices. Six LGAs were purposively selected for this study from the 13 existing LGAs in the Ebonyi State to represent the geographic locations (urban and rural) and the 3 senatorial zones. The LGAs include Abakaliki, Izzi, Ezza South, Ikwo, Afikpo South, and Ohaozara. Additional criteria for selection included LGAs which were prioritized by the state government for adolescent SRH intervention and also those with the highest unmet contraceptive need proven by the high rate of unwanted teenage pregnancies and unsafe abortions.
The households were selected through a random walk from the nearest public facility—either a school, church, town hall, or primary health center (PHC) in the main entrance of the community into the villages. The study population consisted of unmarried adolescents aged 13–18 years, including both in- and out-of-school adolescents. Those who refused consent to participate were excluded from the study.
A pretested structured interviewer-administered questionnaire was used to collect data from a sample of 1,045 adolescents aged 13–18 years who were selected using cluster sampling of households in the six selected LGAs. Data were collected on the levels of utilization of health facilities for sexual and reproductive health information and services. The questionnaire was adapted from the World Health Organization (WHO) illustrative questionnaire for interview surveys with young people. The questionnaire was adapted to our local circumstances and prioritized by rephrasing some questions, re-ordering some sections, adding more options to the questions, adding a new section of questions, and deleting some questions altogether. The adapted instrument was pretested among 24 adolescents who were selected purposively to ensure an equal representation of gender (male and female), place of residence (urban and rural), and schooling (in-school and out-of-school) in a non-participating LGA. Data were collected in pairs by 54 trained research assistants over a period of 10 days. Each pair collected data from eligible respondents both manually and electronically using a paper-based questionnaire and electronic questionnaire, respectively. Electronic copies of the questionnaires were uploaded to Android tablets using Survey CTO. Individual matching of information on the completed paper questionnaire with the corresponding electronic questionnaire was done before and after uploading the data to the server and data were viewed concurrently.
Tabulation, bivariate and multivariate logistic regression analyses were undertaken. A household wealth index was calculated using the total household consumption calculated divided by the number of people in the household (per capita household consumption). The per capita household consumption was used to categorize households into socioeconomic quintiles. This was used to differentiate key variables into socioeconomic quintile for equity analysis.
Ethical consideration was sought and obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital and the Ethics Committee of Ebonyi State Ministry of Health. Written informed consent was obtained from parents/guardians of all eligible adolescents aged 13–17 years whereas adolescents aged 18 years and mature minors aged 15–17 years gave consent for themselves. The participation was voluntary and confidentiality was assured.
| Results|| |
[Table 1] presents the results on demographic and socioeconomic characteristics of surveyed adolescents in the Ebonyi State. From 1,045 usable questionnaires, 50.7% of the adolescents reside in urban areas of the Ebonyi State whereas 49.3% reside in rural areas. The surveyed adolescents comprised 57.2% females and 42.8% males. At the time of the survey, most adolescents (92.4%) were currently in-school, only 7.6% were out-of-school adolescents. With respect to the employment status, out of 502 who reported that they had ever worked for pay, 52.5% were currently employed while 47.5% were not employed.
|Table 1: Demographic and socioeconomic characteristics of the respondents surveyed in the Ebonyi State|
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[Table 2] summarizes the results of adolescents' utilization of health facilities for SRH information and other services in the Ebonyi State. It was revealed that among the 1,045 surveyed adolescents, only 9.8% had ever visited a health facility for SRH information whereas 90.2% never visited a health facility for SRH information. Among those who had ever visited a health facility, the majority (33.5%) visited patent medicine vendor (PMV) shops. Also, among the 1,045 surveyed adolescents, only 2.8% of them reported that they had ever visited a health facility for other SRH services.
|Table 2: Utilization of Health Facility for SRH information and other SRH services among respondents in Ebonyi State|
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The results of the demographic and socio-economic status (SES) correlates of the health facility visit for SRH information and other services are shown in [Table 3]. There are statistically significant associations between schooling and adolescents' utilization of health facilities for SRH information (P = 0.001) and other services (I = 002), with out-of-school adolescents having higher utilization rates than in-school adolescents. The difference in P utilization of health facilities for SRH information among adolescents in different wealth quintiles was not statistically significant (P = 0.28). The difference in their utilization of other SRH services did not vary significantly (P = 0.63).
|Table 3: Demographic and SES correlates of health facility visit for SRH information and other SRH services|
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[Table 4] presents logistic regression analysis of demographic correlates of the utilization of health facilities for SRH information among adolescents. The odds of utilizing health facilities for SRH information were 3.29 times less among in-school adolescents compared to out-of-school adolescents. This shows that out-of-school adolescents are 3.29 times more likely to utilize health facilities for SRH information (adjusted odds ratio [AOR] = 3.29, confidence interval [CI] = 0.14, 0.64).
|Table 4: Logistic regression analysis of demographic correlates of utilization of health facilities for SRH information|
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[Table 5] shows the logistic regression analysis of demographic correlates of the utilization of health facilities for other SRH services. Schooling was found to explain statistically significant P utilization of health facilities for other SRH services. Out-of-school adolescents were 4.41 times more likely to utilize health facilities for other SRH services (AOR = 4.41, CI 0.08, 0.61). However, other demographics were not found to statistically correlate with P utilization of health facilities for other SRH services.
|Table 5: Logistic regression analysis of demographic correlates of utilization of health facilities for other SRH services|
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| Discussion|| |
The utilization of health facilities for SRH information and other services among adolescents in the Ebonyi State is very low. Health facility utilization for SRH information and services was favorable toward informal service providers such as PMVs. Adolescents not utilizing health facilities to access available sexual and reproductive health information and other services increase concerns about the quality of information/service adolescents obtain. This finding is similar to several other findings which revealed poor utilization and postponement of health facility visits by most young people.,, Poor utilization could be attributed to poor knowledge and understanding of the importance of SRH service utilization in addition to self-treatment perceived as the first choice. Most health facilities are visited when the need requires specialized care due to the perceived seriousness of the health need. However, adolescents identified embarrassment and fear of stigmatization as reasons that limit them from accessing and utilizing SRH services. The issue of poor access and utilization of health facilities for SRH information or services has been emphasized as what should be addressed to promote ASRH because it increases the chance of SRH preventable diseases (like STIs, unwanted teenage pregnancy, and unsafe abortion) among adolescents.
Adolescents who had ever visited the health facility for SRH information and other services mostly obtain services from PMVs. On the other hand, there are records of other sources like primary health centers, general hospitals, mission/private hospitals, youth-friendly centers, school clinics, and outreach tents for SRH information and services among adolescents but from a lower proportion. Most government-owned health facilities were not utilized by adolescents and this present finding relates to another study. The study reported a low utilization of formal health facilities for SRH needs among adolescents but they utilized PMV shops more than any other health facility as a result of the availability and proximity of PMVs. However, evidence has shown that some of the services provided in formal health facilities are not tailored to meet the sexual and reproductive health needs of adolescents.
Schooling was found to be statistically associated with the utilization of health facilities for SRH information and other services. This indicates that variations in the utilization of health facilities for SRH information and other services among adolescents exist. The utilization of SRH information and other services was more among out-of-school adolescents, while most adolescents who attend school do not utilize the available health facilities for SRH information or other services. Considering that most adolescents in the study site attend school, increased awareness through innovative programs in schools aiming to enlighten these adolescents on the available SRH services would possibly increase access and utilization of health facilities.,, Provision of adolescent-friendly health facilities significantly promotes the utilization of health facilities for information and other services among adolescents., However, another study observed that higher educational attainment is significantly associated with health facility service utilization for SRH information or other services because of exposure to sexuality education in schools.
On the contrary, other demographics were not significantly associated with the utilization of health facilities for SRH information and other services. The adolescents who utilized health facilities for SRH information and other services were mostly urban dwellers with more males than females accessing health facilities. Young girls were less likely to utilize health facilities for sexual and reproductive health services which is similar to some studies. Unmarried adolescent girls are less likely to seek sexual and reproductive health information or services because of the sacredness attached to sexual acts and fear of condemnation in most cultures and societies.,, However, some other studies reported that female adolescents access health facilities for SRH information when compared to males. It is attributed to the fact that most males perceived that health facilities are tailored to attend to the needs of females.,,
Schooling was found to be a strong predictor of the utilization of health facilities for SRH information and other services among adolescents in the state. Out-of-school adolescents were three times more likely to visit the health facility for SRH information than in-school adolescents. Likewise, in-school adolescents were found to be 4.4 times less likely to utilize health facilities for other SRH services than out-of-school adolescents. This finding is slightly similar to an investigation carried out in Ethiopia which revealed that adolescents who received SRH information from their school teachers were less likely to utilize SRH services than those adolescents who never received SRH information from school teachers. Consequently, there is a need to understand and identify the nature of SRH information delivered in schools that deters in-school adolescents from utilizing health facilities for SRH services.
| Conclusion|| |
Adolescents' sexual and reproductive health is an essential component of health which can influence a country's long-term national growth. Limited access to SRH services relates to the adolescents' susceptibility to sexual health risks which could have been prevented if provided with the right SRH information and other services. In the Ebonyi State, the utilization of health facilities for SRH information and other services among adolescents is very low and favorable toward informal service providers such as PMVs.
This wide gap in the utilization of health facilities for SRH needs among adolescents increases an apprehensive thought around the quality of information the adolescents receive. Most SRH services provided to adolescents have not yet met their SRH unique needs. There is a need to assist this age group in understanding the significance of accessing and utilizing health facilities in order to receive the right SRH information and other services for present and future actions, goals, and healthy achievements. Outreach programs and sensitizations should be designed specifically to target adolescents, providing them with the right information on how and where to access sexual, reproductive, and health services.
Schooling was found to be a strong predictor of health facilities' utilization, SRH information, and other services. The provision of comprehensive and unbiased sex education in schools should be considered to enable adolescents to have access to the right SRH information. There is a need to continuously revise the nature of sexuality education delivered by teachers in schools and make provisions for school clinics for easy access to SRH information and services. Multiple approaches should be considered to spread and meet the diverse unique needs of the different (males/females, age categories, in-/out-of-school, urban/rural) groups of adolescents.
| Declarations|| |
Ethical approval and consent to participate
Ethical approval was obtained from the Ethics and Research Committee of the University of Nigeria Teaching Hospital (UNTH), Enugu, and the Ethics Committee of Ebonyi State Ministry of Health, Abakaliki. During data collection and analysis, the principles of ethical conduct of research involving humans; respect for autonomy through voluntary informed consent, beneficence through a favorable balance of benefits and risks, justice through fair inclusion, and privacy of information by anonymized collection and use of data were duly observed. Both verbal and written informed consent were obtained from both the household heads and from the study participants (adolescents) before administering the questionnaire.
Consent for publications
We confirm that informed written consent was received for the publication of the manuscript and figures. “Written informed consent was obtained from the participant for publication of their individual details and accompanying images in this manuscript. The consent form is held by the authors and is available for review by the Editor-in-Chief.”
Availability of supporting data
The dataset used for this study is available and can be obtained from the lead author upon request as well as any other material needed.
CM, OO and NE conceived the idea of the study. IA, CM, UE, CO, OO, NE, participated in the design of the study and data collection. CM, IA performed the statistical analysis and interpretation of result, IA drafted the first version of the manuscript. All the authors contributed in revising the first draft of the paper and approved the final version.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ngilangwa DP, Rajesh S, Kawala M, Mbeba R, Sambili B, Mkuwa S, et al
. Accessibility to sexual and reproductive health and rights education among marginalized youth in selected districts of Tanzania. Pan Afr Med J 2016;25(Suppl 2):2.
Wombeogo M, Kuuzuing LT. Your advice, my choice: A case study of adolescents' reproductive health choices at Nadowli-Kaleo district of the Upper West region of Ghana. J Nurs Health Sci 2015;4:70-80.
Kothari MT, Wang S, Head SK, Abderrahim N. Trends in Adolescent Reproductive and Sexual Behaviours. DHS Comparative Reports No. 29. Calvertonn, Maryland, USA: ICF International; 2012.
Onyeonoro UU, Oshi DC, Ndimele EC, Chuku NC, Onyemuchara IL, Ezekwere SC, et al
. Sources of sex information and its effects on sexual practices among in-school female adolescents in Osisioma Ngwa LGA, south-east Nigeria. J Pediatr Adolesc Gynecol 2011;24:294-9.
Orji EO, Esimai OA. Introduction of sex education into Nigerian schools: The parents', teachers' and students' perspectives. J Obstet Gynaecol 2003;23:185-8.
Sedgh G, Finer LB, Bankole A, Eilers MA, Singh S. Adolescent pregnancy, birth, and abortion rates across countries: Levels and recent trends. J Adolesc Health 2015;56:223-30.
Hindin MJ, Fatusi AO. Adolescent sexual and reproductive health in developing countries: An overview of trends and interventions. Int Perspect Sex Reprod Health 2009;35:58-62.
Dunor H, Urassa, JK. Access to reproductive health services and factors contributing to teenage pregnancy in Mtwara Region, Developing Country Studies 2017;7:30-41.
Ahanonu EL. Attitudes of Healthcare Providers towards Providing Contraceptives for Unmarried Adolescents in Ibadan, Nigeria. J Family Reprod Health 2014;8:33-40.
Boamah AE. Sexual Behaviours and Contraceptive Use among Adolescents in Kintampo, Ghana. Dissertation, 48th
International Course in Health Development 2012:7.
Okereke C. Assessing the Prevalence and determinants of adolescents' unintended pregnancy and induced abortion in Owerri, Nigeria. J Biosoc Sci 2010;42:619-32.
Odo AN, Samuel ES, Nwagu EN, Nnamani PO, Atama CS. Sexual and reproductive health services (SRHS) for adolescents in Enugu state, Nigeria: A mixed methods approach. BMC Health Serv Res 2018;18:92.
Cortez R, Saadat S, Marinda E, Oluwole O. Adolescent Sexual and Reproductive Health in Nigeria. Health, Nutrition and Population Global Practice Knowledge Brief. Washington, DC. © World Bank: World Bank; 2015. Availablefrom: https://openknowledge.worldbank.org/handle/10986/21626
Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, et al
. Adolescence and the social determinants of health. Lancet 2012;379:1641-52.
Aderibigbe SA, Araoye MO, Akande TM, Musa OI, Monehin JO, Babatunde OA. Teenage pregnancy and prevalence of abortion among in-school adolescents in North Central, Nigeria. Asian Soc Sci 2010;7:122.
Commission NP. Legal Notice on Publication of 2006 Census Final Results. In: Federal Republic of Nigeria Official Gazette. 2009;96:B1-42.
Cleland J. Illustrative questionnaire for interview-surveys with young people. Asking Young People About Sexual and Reproductive Behaviors. Illustrative Core Instruments, Geneva: World Health Organization; 2001.
Sychareun V, Vongxay V, Houaboun S, Thammavongsa V, Phummavongsa P, Chaleunvong K, et al
. Determinants of adolescent pregnancy and access to reproductive and sexual health services for married and unmarried adolescents in rural Lao PDR: A qualitative study. BMC Pregnancy Childbirth 2018;18:219.
Dehne KL, Riedner G. Sexually Transmitted Infections among Adolescents: The Need for Adequate Health Services. Geneva: World Health Organization; 2005.
Abajobir AA, Seme A. Reproductive health knowledge and services utilization among rural adolescents in east Gojjam zone, Ethiopia: A community-based cross-sectional study. BMC Health Serv Res 2014;14. Available from: http://www.biomedcentral.com/1472-696
Sousa BC, Santos RSD, Santana KC, Souzas R, Leite ÁJM, Medeiros DS. Sexual behavior and associated factors in rural adolescents. Rev Saude Publica 2018;52:39.
Baku EA. Influence of knowledge, attitude and Beliefs on adolescent contraceptive use in greater accra Region, Ghana. West Afr J Nurs 2012;23:1-15.
Raj AD, Rabi B, Amudha P, van Teijlingen Edwin R, Glyn C. Factors associated with teenage pregnancy in South Asia: A systematic review. Health Sci J 2010;4:3-14.
Chandra-Mouli V, McCarraher DR, Phillips SJ, Williamson NE, Hainsworth G. Contraception for adolescents in low and middle income countries: Needs, barriers, and access. Reprod Health 2014;11:1-8.
Godia PM, Olenja JM, Hofman JJ, van den Broek N. Young people's perception of sexual and reproductive health services in Kenya. BMC Health Serv Res 2014;14:172.
Godswill J. Adolescents' sexual and reproductive health challenges in Northern Nigeria: Road map to effectiveinterventions. Developing Country Studies 2017;24:2300-697.
Atuyambe LM, Kibira SP, Bukenya J, Muhumuza C, Apolot RR, Mulogo E. Understanding sexual and reproductive health needs of adolescents: Evidence from a formative evaluation in Wakiso district, Uganda. Reprod Health 2015;12:35.
Envuladu EA. Exploring the influencing factors on adolescent sexual behaviour and reproductive health challenges in Nigeria: A case study of plateau state. Public health dissertation. 2016.
Challa S, Manu A, Morhe E, Dalton VK, Loll D, Dozier J, et al
. Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana. Women Health 2018;58:434-50.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]