Balancing youth friendliness of sexual and reproductive health service delivery and service utilisation among Ghanaian youth

TABLE OF CONTENT

DECLARATION

DEDICATION

ACKNOWLEDGEMENTS

ABBREVIATIONS

ABSTRACT

LIST OF TABLE

LIST OF FIGURES

CHAPTER ONE
GENERAL INTRODUCTION
1.0 Introduction
1.1 Background of the study
1.2 Problem statement
1.3 Objectives of the study
1.3.1 Specific objectives
1.4 Research questions
1.5 Research Hypotheses
1.5 Scope of study
1.6 Justification of the study
1.7 Significance of study
1.8 Definitions of Terms Used in this Research
1.8.1 Reproductive Health Services:
1.8.2 Youth-friendly reproductive health services:
1.8.3 Sexual and Reproductive Health (SRH) Behaviours
1.8.4 Youth
1.8.7 Boyfriend/Girlfriend(s)

CHAPTER TWO LITERATURE REVIEW
2.0 Introduction
2.1 Conceptual definition of Youth and Youth friendly reproductive Health Services
2.2 Youth Knowledge, Sexual Attitude and Practices concerning Sexual Reproductive Health Service Utilization
2.3 The Friendliness of Sexual and Reproductive Health Service Delivery to the Youth.
2.3.1 Static Facility Youth Friendly Sexual and Reproductive health Service Delivery
2.3.2 School and Community Youth Friendly Reproductive Health Service Delivery
2.3.3 Providing Youth Friendly Sexual and Reproductive Health Service through Peer Education and Counseling
2.4 Barriers that affect youth access and utilization of reproductive health facilities and services
2.5 Theoretical Framework
2.4.1 Conceptual Framework on relationship between youth friendly sexual reproductive health service and utilization of services.
2.5.1 Explanation of conceptual Framework
2.6 Interventions to improve Youth Friendliness of Sexual and Reproductive Health
2.7 Contribution to Knowledge and gaps in literature

CHAPTER THREE
RESEARCH METHODOLOGY
3.0 Introduction
3.1 Research Design
3.2 Population
3.3 Target population/Unit of analysis
3.4 Inclusion Criteria
3.5 Exclusion Criteria
3.6 Sample Size Determination and Sampling Procedure
3.7 Methods and Techniques
3.7.1 Pre-testing of Data collection Instruments
3.7.2 Data handling
3.7.3 Data Analysis
3.7.6 Qualitative Analysis of Interviews
3.7.7 Validity and reliability
3.7.8 Ethical considerations
3.7.9 Limitations of the study
3.7. 10 Field Problems
3.8 Research Setting

CHAPTER FOUR
PRESENTATION OF RESULTS AND DISCUSSION
4.0 Introduction
4.1: Descriptive background information on research participants.
4.2 Youth Knowledge, Attitude and Practices (KAP) Concerning Sexual and Reproductive Health Service Utilization in the Kwadaso Sub Metro District.
4.2. 1 Gender and sexual relationship
4.2.2 Sexual Attitudes of youth
4.2.3 Gender and sexual experience
4.2.4 Educational levels and Service Utilization
4.2.5 Relationship between sexual attitude and practices and utilization of sexual and reproductive health services
4.2.6 Awareness of Sexual and Reproductive Health Services
4.2.7 Sexual Education, Knowledge and reproductive Health needs of Youth
4.3 Youth Assessment of Youth Friendliness of Sexual Reproductive Health Services Delivery
4.3.1 Assessment of friendliness of Facility- based Sexual and Reproductive Health Services
4.4 Barriers to Sexual Reproductive Health Service Utilization by Youth.
4.5 Hypothesis Testing
4.6 Discussion of Results
4.6.1: Knowledge, Awareness and Practices (KAP) concerning Sexual and Reproductive Health
4.6.2: The Friendliness of Sexual and Reproductive Health Service Delivery to the Youth
4.6.3: Barriers that affect youth access and utilization of reproductive health facilities and services

CHATER FIVE
SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS
5.0 Introduction
5.1 Summary of findings:
5.1.1: Youth Knowledge, Attitude and Practices (KAP) concerning Sexual and Reproductive Health Service Utilization
5.1.2: Youth Assessment of Youth Friendliness of Sexual Reproductive Health Service Delivery
5.1.3: Barriers to Sexual Reproductive Health Service Utilization faced by the youth
5.2 Conclusion
5.3: Recommendations:
5.4 Areas for future research

REFERENCES

APPENDICES

DECLARATION

I, Seth Christopher Yaw Appiah hereby declare that this thesis is the result of my personal work. In exception for references to the works of other scholars which have been duly acknowledged, this thesis is the result of my personal research done at the Sociology and Social Work department, KNUST under the supervision of Dr. Jonathan Mensah Dapaah. This work has neither in part nor in whole been presented anywhere for another Master’s Degree or of a kind.

Seth Christopher Yaw Appiah (PG7481512) ... ..

Abbildung in dieser Leseprobe nicht enthalten

Dr. Jonathan Mensah Dapaah ... ..

Abbildung in dieser Leseprobe nicht enthalten

Certified by

Dr. Kofi Osei Akuoko ... ..

Abbildung in dieser Leseprobe nicht enthalten

DEDICATION

I wish to bless God for His faithfulness. The Lord God has sustained me. I dedicate this thesis to my mother Ama Serwaa and Apostle Dr. Michael Kwabena Ntumi (Immediate Past Chairman of The Church of Pentecost) for the care and foundation you offered me to have University Education when the times were though. I thank you.

ACKNOWLEDGEMENTS

Now unto him who is able to do exceedingly far beyond what we can think of and imagine, may His name be praised. I wish to acknowledge and thank God Almighty for being my joy, strength and source of power to bring me through to this far. A special thanks go to my to my Lecturers and supervisor Dr. Jonathan Mensah Dapaah for the guidance and as to complete this work

I thank my friend Asare Daniel for the tremendous support and time with me in the toughest periods of my life when I had to combine hope faith and pain to produce this work. Mention must also be mentioned of Abubakari Mohammed and Victoria Ampiah my assistants for the great and effortless assistance you offered me. I am equally grateful to my all lecturers in the Sociology and Social Work department not forgetting Mr Obeng Bernard.

Finally, my heartfelt thanks go to members of the Pentecost International Worship Centre for the support, and prayers you gave me when I needed it most.

ABBREVIATIONS

Abbildung in dieser Leseprobe nicht enthalten

ABSTRACT

Incidence and prevalence of reproductive health difficulties have been shown to be higher among younger people in the society. Preferences for youth friendly sexual and reproductive health services and facilities are very limited. This study examines youth assessment of youth friendliness of sexual reproductive health services and how it influences their services reproductive health services utilization. The study adopted both descriptive and analytical cross sectional survey designs. In all 170 youth aged 10-24 were sampled from the Kwadaso Sub Metro using multi-stage stratified random sampling techniques. Both Bivariate and Univariate analysis were conducted with Chi-square test of significance and Pearson moment correlation to establish relations and associations between and among variables of interest. The study found out that in 56.0% (84/150) of the 150 in-school youth had ever had a boyfriend/girlfriend with the majority 39.3%(33/84) not recalling the length of stay with partner whiles only 58% (87/150) have heard about sexual reproductive health services offered in the study area. In all 45.2% (77/170) of youth (10-24) had had sexual experience in life time. Among the in -school youth with sexual experience were 63(thus 42% of total) whiles out of school youth was 14(70%). A total of 69.9% (44/63) in-school youth had sexual intercourse in the last six months whiles only 35.7(5/14) out of school youth had sex in the last six months A total of 55.8% (95/170) of all categories of youth had used at least one or more reproductive health service in lifetime. However, a marginal 25.2% (43/170) of youth had used facility based sexual reproductive health services out of which 39% and 44% considered the services very friendly and friendly. There was statistically significant relationship between youth knowledge of the available sexual reproductive health service and reproductive health service utilization (X2=0.00, P≤0.05) and a strong positive correlation(r =0.5, R2=0.25). 25% of the relationship was explained by linear relationship. A stakeholder integrative and comprehensive approach is required scale up youth utilization of sexual reproductive health services especially facility based ones as friendliness is being improved upon and system barriers removed. This requires baseline survey of youth users of reproductive health services and the quality of services offered.

LIST OF TABLE

Table 3.1: Population and Employment Status of Kwadaso Sub Metro Council cross tabulated

Table 1: Background Characteristics

Table 2: Distribution by Gender and those who have ever been in relationship

Table 3: Sexual Attitudes of Youth

Table 4: Cross tabulation of Gender and youth life time sexual experience

Table 5: In-school youth and Service Utilization

Fig 1: Sexual experience of youth in the last six months and use of facility-based sexual reproductive health service

Table 6: Sexual Attitude and Practices and reproductive health services Utilization

Table 7: Respondent discussion of sexual and reproductive health matters with parents or adult family member

Table 8: Secondary sources of information about sexual reproductive health/STIs and HIV/AIDS

Table 9: Family planning method known by youth

Table 10: Family Planning method ever used by youth

Table 11: In-school youth history of Sexually Transmitted Infections in the past year

Table 12: Cross Tabulation of visit to Resource Centre in last six months and Purpose of Visit

Table 13: Friendliness assessment of Facility-based Services

Table 14: Barriers to service utilization

Table 15: Cross-tabulation of Service use and Awareness of Youth Friendly reproductive health services in the area

Table 16: Satisfaction with the attitude of service providers and services received and youth intention to revisit to access services

Table 17: Relationship between Gender and utilization of Sexual and reproductive health service

LIST OF FIGURES

Figure 1: Sexual experience of youth in the last six months and use of facility-based sexual reproductive health service

Figure 2: Awareness of any facility-based youth friendly sexual reproductive health service

Figure 3: Assessment of respondents Knowledge on Youth friendly Sexual and Reproductive Health Services

Figure 4: Peer Counselor level of Friendliness

CHAPTER ONE GENERAL INTRODUCTION

1.0 Introduction

This part of the study presents an overview of the research work. It details the background of the study, the problem statement, research question and objectives, research hypothesis, scope of the study and justification of the study, research methodology and design, sources of data and data collection and sample techniques. The rest include data analysis and organization of the study.

1.1 Background of the study

The WHO Regional Advisors meeting in Geneva (2000) defined reproductive health as a "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes”. Reproductive health can be extended to mean situations where people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so.

Implicit in the definition are the rights of men and women to be informed and have access to safe, effective, affordable and acceptable methods of family planning of their choice. The right of access to other methods of their choice for regulation of fertility, which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and providing couples with the best chance of having a healthy infant are not left out in the definition. Another dimension to reproductive health is sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases.

It is estimated that 85% of the world's young people live in developing countries where poverty levels remain high and resources are constrained (Kersterton & Cabral de Mello,2010). In the presence of such glaring picture, most will become sexually active before their 20th birthday. The common factors that are characteristic of this group are the high rates of early and unplanned pregnancies, unsafe abortions, maternal deaths and injuries, and sexually transmitted infections (STls), including the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) (Kersterton & Cabral de Mello,2010 ).

More than half of all new HIV infections are among young people, while between one quarter and one-half of adolescent girls become mothers before they turn 18 years globally. The (WHO, 2006a) reports that adolescent girls are two to five times more likely to die during pregnancy or childbirth than women in their twenties.

Young people can be defined as those aged 10-24 years; and this group combines adolescents ­aged 10-19 years - and youth - aged 15-24 years (Kersterton and Cabral de Mello, 2010). In 2006 the Joint United Nations Program on HIV/AIDS Interagency Task Team on HIV and Young People began to look into this problem, and a major review of available evidence on preventing HIV in young people in developing countries was carried out by WHO (Ibid 2010). Despite constraints imposed by the quality of the data, it concluded "if countries want to move towards achieving the global goals on HIV and young people, there is sufficient evidence to support widespread implementation of interventions”.

It is required for such interventions to include elements of training for service providers and other clinic staff. This will aid in making improvements to facilities, and informing and mobilizing communities to generate demand and community support" (WHO, 2006b) for fighting against the global pandemic. The Pathfinder International (cited from the AYA (2003) describes youth friendly SRH services as those services that are characterized by its ability to effectively attract young people; meet the varying needs of young people comfortably and responsively; and succeed in retaining these young clients for continuing care. The need for sexual and reproductive health service to be youth friendly is an approach that has its goals yet to be achieved. This is alarmed by the fact that, many young people, especially in Sub-Saharan Africa face the risk of HIV, sexually-transmitted infections (STIs), unplanned pregnancy, abortion, poor health seeking behaviour and other reproductive health related diseases.

Incidence and prevalence of reproductive health difficulties have been shown by a number of studies to be higher among younger people and the older people in the society (UNICEF ,2007; Odoi-Agyarko, 2003; Awusabo-Asare, Abane& Kumi-Kyereme, 2004).

Currently, in Ghana, comprehensive information on adolescents' perceptions of and preferences for sexual and reproductive health services and facilities is very limited. However, information on actual service utilization by the youth, friendliness of service delivery, preferences and perceptions concerning sources, availability, effectiveness and quality is critical for helping determine the types of interventions and policies that could be implemented to improve the sexual and reproductive health needs among the youth in the country.

1.2 Problem statement

The need to provide services that are specific and youth-focused has been recognized by several national agencies and non-governmental bodies. Young people face a broad spectrum of challenges and stand at risk from a broad range of health problems.

The main cause of youth mortality includes those related to sexual and reproductive health behaviors. The risk young people face range from unwanted pregnancy with related complications to STIs and HIV / AIDS, sexual assault to rape and domestic abuse.

The condition faced by young people in Ghana is worsened by their perception of being unwelcome in such facilities with judgmental service providers who treat them rudely and deny them services. Many young people are unable to rely on intergenerational relationships for information and guidance about responsible sexual behavior. The intergenerational gap between the generations of the youth and the adult is constantly being reinforced by cultural globalization. The global call for the integration of youth friendliness in reproductive health service delivery has been met with some considerable level of commitment in Ghana.

In 2005, the Africa Youth Alliance launched by the Pathfinder International sought to implement the youth friendly service component into the reproductive health service delivery to the youth in Ghanaian hospitals. The programme was implemented as planned by integrating youth friendly services into service delivery. The Kwadaso Seventh Day Adventist Hospital was selected as one of the hospitals where both staff training and youth friendly facility was refurbished. It was reported as the Christian Health Association of Ghana (CHAG) hospital where biases in service provision were absent. Despite the preliminary and post implementation success in the youth friendly service delivery resulting from the intervention, which has a potential in improving reproductive health of the youth and reducing risky sexual behaviour , utilization of reproductive health service for the youth continues to be minimal.

The reports of the Ghana Demographic Health (GDH) survey do not present much an improving picture in terms of comprehensive Knowledge of AIDS/AIDS prevention and transmission which is just 25% and 33% for females and males despite 98 percent of women and 99 percent of men having knowledge of HIV/AIDS. The reports add that Eight percent of women and 4 percent of men reported that they had sexual intercourse by age 15 with Forty-four percent of women and 28 percent of men having had sexual intercourse by age 18. More alarming is the fact that the proportion of women engaging in higher-risk sexual intercourse has increased slightly from 21 percent in the 2003 GDHS to 23 percent in the 2008 GDHS, whiles women who used a condom during their last higher-risk sexual intercourse decreased from 28 percent in the 2003 GDHS to 25 percent in the GDHS. The age cohort 15-24 years with comprehensive correct knowledge of HIV/AIDS is a minimal 34.2% with males and 28.3% for females. The prevalence of HIV among young people age 15-24, which is used as a marker for new cases, has decreased from 3.2 percent in 2002 to 1.9 percent in 2008 (GDHS, 2008).

The youth evaluation of youth friendliness of sexual reproductive health service delivery is critical for a holistic youthful development. This study draws on known aspects of youth friendliness to assess the sexual and reproductive health service delivery and its inf1uence on the reproductive health service utilization.

1.3 Objectives of the study

The study aims at assessing the youth friendliness of sexual and reproductive health services delivery and its relationship with reproductive health service utilization by the youth in the Kwadaso Sub Metro Council of Ghana.

1.3.1 Specific objectives

The specific of the study are:

1. To find out youth Knowledge, Attitude and Practices (KAP) concerning sexual and reproductive health service utilization in the Kwadaso Sub Metro Council.
2. To examine the youth friendliness of sexual and reproductive health service delivery in the Kwadaso Sub Metro Counsel of Ghana
3. To elicit the barriers young people face in accessing reproductive health care in the Kwadaso Sub Metro Council of Ghana.
4. To recommend from the findings interventions to help improve the youth friendliness of sexual and reproductive health needs of the youth and service utilization.

1.4 Research questions

1. What Knowledge, attitude, awareness and sexual practices do the youth in Kwadaso Sub Metro Council hold about their sexual and reproductive health?
2. How friendly are the sexual and reproductive health services delivered to the youth in the Kwadaso Sub Metro Council?
3. What factors accounts for the utilization or non-utilization of Sexual and reproductive Health Services in the Kwadaso Sub Metro Council?

1.5 Research Hypotheses

The study is based on the following hypothesis:

1. Ho: Young people's Knowledge and awareness of available youth friendly reproductive health services offered in the district has no relationship with the reproductive health service utilization.

HI: Young people's Knowledge and awareness of available youth friendly Reproductive health services offered in the district positively influence their utilization of Reproductive Health Services.

2. Ho: Youth satisfaction with reproductive health service utilization has no relationship with subsequent visit to a reproductive health Centre.

H1: Youth who are satisfied with reproductive health services provided are more

likely to revisit the reproductive health Centre's

3. Ho: There is no statistical difference between males and Females in terms of reproductive health service utilization.

H1: The gender of the youth influences their utilization of sexual and reproductive health services.

1.5 Scope of study

The scope of the study is defined both by its spatial and conceptual dimensions.

Geographical Scope: Spatially, the study is limited to the Kwadaso Sub Metro Council. The Sub Metro forms part of the nine Sub metro Councils in the Kumasi Metropolis. Its strategic location in terms of how centralized it is located and health facility availability makes it suitable for this study.

Contextual Scope: In respect of the conceptual dimension, youth friendly reproductive health variables that will be detailed will include Youth Knowledge , Experiences and Attitudes with HIV/AIDS and Other STIs, Voluntary Counseling and Testing (VCT), Sources of information for Youth Sexual and Reproductive Health, Availability and adequacy of youth friendly sexual reproductive, Barriers to accessing youth friendly reproductive health and Policies and Programs to improve utilization of service by the youth. The study looked at how safe and supportive environment, accurate information education and communication, counseling services are being offered to the youth in the District.

Time Scope: The study was conducted between the period of September 2013 and June 2014

1.6 Justification of the study

The future of every society depends on its youth. The youth grow to become adults of the nation. Reproductive health issues among the youth are very essential because they combine to determine the future of the youth. Despite the avalanche of research areas, the need to concentrate on youth friendly reproductive health was prioritize by the researcher. This is because challenges that cut short youth holistic development like STis, rape, teenage pregnancy, HIV/AIDS etc continue to battle the youth in their development process. The focus of reproductive health has been on women and more often on adolescents in Ghana. In almost all over the world crucial family life and reproductive decisions are made when people have the opportunity to live independently. In Ghana, the age for adulthood is eighteen (18). It is therefore necessary to examine the availability, friendliness and perceptions the youth hold in terms of the quality of Sexual and reproductive health services offered to the youth.

This study is justified on the basis that, it will add to the relatively little body of literature in the area of youth friendly sexual and reproductive health service. It is therefore justified to ascertain the youth assessment of friendliness of service delivery, their perceptions of barriers to youth friendly reproductive health service utilization.

Methodologically, the study is justified on the grounds that it employs a mixed method approach. Most research (Bankole, 2004; Chao-Hua et al, 2004; Bogale & Seme, 2014 ) have either been qualitative or quantitative by approach. The integration of qualitative and quantitative approaches to this study will be an addition to the already few works with such paradigms in youth friendly reproductive health. The study additionally is justified on the basis that, the call for the integration of youth friendliness to the sexual and reproductive service delivery (Ghana Health Service,MOH,2012) is long overdue. This study will explore the possible barriers, youth assessment of service quality and the availability of services to the youth. The research will especially help understand the perceptions that the youth hold, their evaluation of service quality and resources that are available.

1.7 Significance of study

The study will provide useful insight into youth friendliness of SRHS as it will bring on board knowledge which otherwise may not have been gained and plan on how to better their efforts in service delivery. The study will also help NGOs working in health related areas with valuable information about their reproductive health needs, so that they could work in alleviating the difficulties the youth have concerning their reproductive health.

The findings on the availability of youth friendly reproductive health services/facilities will offer ample data for the Ministry of health in evaluating the adolescent health and development programme which the ministry acknowledges an area they are interested in researching into (Odoi-Agyarko 2003) and the 2012 annual ADRD report (MOH, 2012). Other researcher’s in this area for purposes of borrowing a leaf could also benefit from the study.

1.8 Definitions of Terms Used in this Research

1.8.1 Reproductive Health Services:

An activity performed in relation to an individual that is intended or claimed (expressly or otherwise) by the individual or the person performing it to assess, record, maintain or improve the individuals reproductive health.

1.8.2 Youth-friendly reproductive health services:

These are health/institutional facility-based, outreach, home/church delivered sexual and reproductive health services provided to the youth in a youth-friendly manner. These services include provision of health educational services, contraceptives, STI treatment, post-abortion and antenatal services. It also includes Reproductive Health services offered by peer counselors at youth lCT/Resource Centre's, Church Counseling Centre's/rooms Schools, Clinics Health post and Hospitals.

These services are specifically designed to improve the quality of existing health services including reproductive health for young people. These means services offered to the youth are acceptable, appropriate, accessible, equitable, efficient and effective no matter the facility. They are services that effectively attract young people, are able to meet the varying needs of young people comfortably and responsively and succeed in retaining young clients for continuing care and use of the facility.

1.8.2.1 Facility-based Youth Friendly Reproductive health services

Youth- friendly Reproductive health services specifically designed to improve the quality of existing health services including reproductive health for young people. This type of services are offered in facilities like specialized counseling facilities, hospitals and clinics .The services offered to youth are thus acceptable, appropriate, accessible, equitable, efficient and effective no matter the facility (lCT /Resource Centre, Counseling Centre, and Health Care Centre like Hospital, Clinic, Peer educator office, School counselor office.

1.8.2.2 Non-Facility based youth friendly reproductive health services

Youth- friendly Reproductive health services specifically designed to improve the quality of existing health services including reproductive health for young people. This type of services are offered in in homes by family members, older peers in community, outreach youth reproductive health services delivery by health education promoters, church leaders at church meetings. The pivot of the services rendered to the youth is one that is acceptable, appropriate, accessible, equitable, efficient and effective

1.8.3 Sexual and Reproductive Health (SRH) Behaviours

SRH behaviours include use of modern contraceptives including condoms, pills, injectable, etc, and primary and secondary abstinence. Condom use in this study refers to both male and female use of condoms by a youth. Primary abstinence is defined as delaying initiating sex, while secondary abstinence means stopping having sex after one had already had the sexual debut.

1.8.4 Youth

This study views youth as those between 10-24 years. This covers both the term adolescent and "young persons" making the researcher sometimes use them interchangeably with terms such as 'adolescents and young people'. Adopted definitions for 'adolescents' are those aged between 10-19 years, and 'youth' as those between 15-24 years. The term 'young people' has been used to cover both the age groups, i.e. from 10-24 years (WHO, UNFPA ,UNICEF, 1989). However this study prefer to define "youth" as ranging from 10-24 years due to the interchangeable nature of the three terminologies; youth, young persons and adolescence.

1.8.5.1 In -school youth

These constitute the category of youth who were in school and engaged in the study whilst in school. They include junior high school students, senior secondary school students and Nursing Training students as the tertiary cohort

1.8.5.2 Affiliated Youth category

The youth in affiliated category are those that are in organized apprenticeship programs (e.g., hairdressers, dressmakers, carpenters, mechanics, wayside mechanics and Drivers,).

1.8.5.3 Unaffiliated youth category

They are the youth category who are generally difficult to reach--are floating, street-involved population that includes ice-water sellers, cart pushers, porters and vendors of audio cassettes and other small items.

1.8.6 Service Utilization:

This involves youth use or access to a reproductive health service either at a facility based service provider. It additionally includes any specialized counseling of reproductive health services offered or received by youth at church/mosque. It involves ever use of any reproductive health service of a kind.

1.8.7 Boyfriend/Girlfriend(s)

A male or female who is in a romantic/sexual relationship that may or may not involve sexual intercourse but has romantic attachment towards each other. This definition was limited to only heterosexual partners.

1.9 Organization of the study

The research work is presented in five chapters. Chapter One introduces the background of the study, the problem statement, leading research questions, objectives of the study, research hypothesis, justification, contextual and geographical scope and the organization of the study. Chapter Two constitute the literature review detailing scholarly works on youth reproductive health. The chapter examines available literature on youth friendly reproductive health services, its international perspectives, Sub- Saharan, national and local context as well as related conceptual definitions. The factors that influence youth behaviour in terms of access is critically evaluated. In this part the related literature was reviewed, theoretical framework and conceptual issues will be discussed to establish the linkages between availability of services, the factors that determine utilization, institutional settings readiness and arrangement that facilitate youth friendliness of health service provision.

Chapter Three of the study presents the methodology informing the study. This part of the study discussed the methodological foundation and data analysis techniques. It introduced the study area and describes the methodology that was to use to analyze the problems stated. It includes the methods used for data collection, sampling and procedure for data analysis. The ethical obligations' guiding the study is presented in the chapter three.

Chapter four is devoted to presentation and discussion of results. Summary statistics of the variables used in the study are presented and discussed into detail. Chapter five of the study covers the summary of key findings, conclusions and recommendations for policy implication.

CHAPTER TWO LITERATURE REVIEW

2.0 Introduction

This part of the study takes into account scholarly positions on the availability of youth friendly reproductive health services delivery, a critical examination of the friendliness of sexual and reproductive health service delivery in the body of the extant literature, the barriers faced by the youth in accessing sexual reproductive health care and the varying recommendations that make Sexual reproductive health service youth friendly so as improve youth sexual and reproductive health service utilization. A section is also provided under this part to detail the appropriate theories within which this study is situated.

2.1 Conceptual definition of Youth and Youth friendly reproductive Health Services

Youthful stage is both a period of opportunity as well as time of vulnerability and risk. It is a life phase involving the management of sexuality among unmarried individuals, social organization and peer group influence especially with adolescents training in occupational and life skills. It is the time when new options and ideas are explored. As such, it is a phase in life marked by vulnerability to health risks, especially those related to unsafe sexual activity and related reproductive health outcomes like unwanted and unplanned pregnancy and STIs, and by obstacles to the exercise of informed reproductive choice (Munthali et al., 2004).

Approximately 85% of the world's young people live in developing countries characterized by high incidence poverty levels and scarcity in resources (Kersterton & Cabral de Mello, 2010).

In this group rates of early and unplanned pregnancies, unsafe abortions, maternal deaths and injuries, and sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) are very high (Kersterton & Cabral de Mello,2010). It is estimated that more than half of all new HIV infections are among young people, while between one quarter and one half of adolescent girls become mothers before they turn 18. Adolescent girls are two to five times more likely to die during pregnancy or childbirth than women in their twenties (WHO, 2006).

Young people can be defined as those aged 10-24 years; and this group combines adolescents - aged 10-19 years - and youth - aged 15-24 years (Kersterton & Cabral de Mello,2010). In 2006 the Joint United Nations Program on HIV/AIDS Interagency Task Team on HIV and Young People began to look into this problem, and a major review of available evidence on preventing HIV in young people in developing countries was carried out by WHO (Kersterton & Cabral de Mello,2010).

Despite constraints imposed by the quality of the data, it concluded that "if countries want to move towards achieving the global goals on HIV and young people, there is sufficient evidence to support widespread implementation of interventions that include elements of training for service providers and other clinic staff, making improvements to facilities, and informing and mobilizing communities to generate demand and community support" (WHO, 2006).

The government of Ghana over the years has made the welfare of the youth a major concern in policy formulation and implementation. The 2010 Population and Housing Census reveals that Ghana’s population is generally a youthful one since the youth occupies a great portion of the overall population. The age range 10 to 24 alone occupies 31.8% of the total population (GSS, 2010). Even at the global perspectives; of the six billion world population, more than 50% is below the age of 25 years (UNFPA, 2003) and that majority of young people live in developing countries. That constitutes 86% of the 1.7 billion young people around the globe (Population Reference Bureau, 2000). A report by the Ghana Health Service (2006) revealed that the prevalence rate of HIV AIDs in Ghana between the age group of 15 to 24 years constitute 3.4% as at 2002. UNICEF (2007) adds that concern about Youth Reproductive Health has grown following reports that sexual related activities, early pregnancies and Sexually Transmitted Infection rates are continuously increasing among young people in developing countries.

The UNFPA (2003) indicates that in an attempt to improve Youth Reproductive Health Care, the Youth Friendly Reproductive Health Services that focuses on improving the availability, accessibility and quality of Sexual Reproductive Health services should be developed against the backdrop of inadequacies on the part of health systems to provide sexual and reproductive health services in an efficient, effective and equitable manner to young people (United Nations 1995a; 1995b;WHO 1998b; 2001b; UNFPA 2003).

According to the World Health Organization (2003a); many people become sexually active before the age of 20 and thus; need comprehensive health services, education and youth friendly sexual reproductive health delivery in order not to be exposed to sexual health risks of unintended pregnancies, Sexually Transmitted Infections including HIV AIDs, and early sexual debut (McIntyre, 2002; Dehne & Riedner, 2005).

Notwithstanding that, UNFPA (2000a) makes it obvious that the sexual activity amongst the youth is not always consented and as such exposes them to the risks of rape, sexual harassment and exploitation and physical and verbal abuse. It is therefore very imperative that social barriers that hinder the youths’ access to reproductive health services be eliminated so as to improve access to reproductive health services, and to modify policies and programs to meet the demographic realities of the century (Germain, 2000).

In Ghana, many people hold the view that the youth are healthy since they show low levels of illness compared to younger children and adults. However, Ghana Demographic Health Survey (2010) and other studies (Odoi-Agyarko, 2003; Awusabo-Asare, Abane& Kumi-Kyereme;2004, and MOH, 2012) reveal the magnitude of sexual and reproductive health problems of the youths with the problems ranging from inadequate knowledge of sexual and reproductive health, difficulty in accessing Reproductive health service to their negative effects on the development of the youths, families and society as a whole and these problems result from the responses to the developmental changes taking place with the youths and the society.

The AYA (2003), assert that sexual and reproductive health behaviors are among the main causes of death, disability and disease among young people. They are at particular risk for unwanted pregnancy and pregnancy related complications, STIs and HIV/AIDS. Other significant problems include: physical and psychological trauma resulting from sexual abuse, gender-based violence and other forms of physical violence and accidents. The youth are vulnerable to these problems because they often venture into sex unprepared; have sex with multiple partners; engage in alcohol and drug abuse that impairs judgment; have limited awareness of STI prevention; lack skills to negotiate safer sex; and have poor health-seeking behavior. With the advent of HIV/AIDS, coupled with the high rate of illegal cases of unsuccessful abortions and child abandonment, scholars all over the world have shown a great deal of concern to the changing dimension of young people sexuality and reproductive behaviors. According to Homans (2003), the habits and lifestyles that are established during this period have a profound effect on future health and development. As a result, it has been advocated that young people are an important resource for the future and as such investment in their health and development is very salient so they are able to fully participate and contribute to society.

Ngomi (2008) reports in his study in Botswana, known to be one of the countries with the highest HIV infections in the world with an estimated infection rate of 35.8%; that among pregnant women 60. 2% of those pregnant women in Sentinel Sites who tested positive were 24 years of age and younger. Pregnant adolescents 19 years and younger accounted for 21.5% of HIV positive in 1999 in an earlier study by the same author. He further reports that out of the current HIV infection prevalence rate of 17.1% for the general population, adolescents who make 25% of the population are also at high risk of sexually transmitted infections, HIV and unwanted pregnancies.

However, in most countries in sub-Saharan Africa, youth encounter significant obstacles to receiving sexual and reproductive health services and to obtaining effective, modern contraception and condoms to protect against sexually transmitted infections (STIs), including HIV. Youth-friendly services remove obstacles to sexual health care (Moya, 2002).

In the circumstance of Ghana, the Ministry of Health (MOH) has been concerned about quality of care, though improvements in quality have been slow partly because quality improvement activities have received inadequate priority ( Shaikh, Haran, & Hatcher, 2008). The concerns of the Ministry of Health have been driven by the fact that poor quality of healthcare results in loss of customers, lives, revenue, material resources, time, morale, staff, recognition, trust and respect and in individual and communities' apathy towards health services, all of which contribute to lowered effectiveness and efficiency.

The WHO (2006) defines Reproductive health as ‘A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes’. The implication is that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. The right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and child birth and provide couples with the best chance of having a healthy infants” ( Dabo,199) are pillars boldly enshrine in the definition.

Many of the young people across the world have had to navigate their way through sexual maturity without the benefit of any information or services which are known to promote healthy sexual and reproductive life. (De-Seta, et al, 2000). This implies that the availability of reproductive health service delivery matters a lot with regards to youths’ growth and development.

The Youths’ access to sexual reproductive health is partly determined by the availability of the health services and their procedures for utilization. Hock-Long, Herceg-Baron, Cassidy & Whitaker (2003) argue that factors that affect health service delivery despite their availability are the following which are high cost of care and services, inconvenience hours of operations, affordable transportation, travel time and opportunity cost linked to it and the perceived quality of care and provider behavior and thus, all these factors need to be considered in order to improve the youths access to reproductive health service delivery. In the opinion of Hock-Long et al (2003) that poor relationships between health care personnel and their clients, administrative red tape, long waits, lack of emotional supports and privacy, differences in languages and culture between health professionals and their clients, rude medical staff, and the often expected “gifts” for medical attention are negative factors that influence service delivery irrespective of whether they are available or unavailable.

Governments in many countries have failed to adequately address the needs of the youth for reproductive health services because Sexual Reproductive Health Services seem to be limited or are not adequately available both in the developed and developing countries. Reproductive health service should however not be viewed alone in the light of hospital based or facility based, but also those that are offer by counselors and peer educators in school and at resource centers. This is supported by Cernada, 1986; Baker & Rich, 1992; Carter et al., 1994; Hawkins & Meshesha, 1994; Nabila et al., 1996 and WHO, 1998 who hold similar view about the difficulties in addressing sexual and reproductive health services.

A synthesis of youth friendly reproductive health service requirements identifies provider characteristics, health facility features, programme design attributes and other factors. The provider characteristics include one with specially trained staff who have respect for young people, ensure privacy and confidentiality in service delivery with adequate time for client and provider interaction.

Youth friendly services also demand that there are available Peer counselors. The health facility based requirements range from separate space and special times set aside with convenient hours, convenient location as well as adequate space and sufficient privacy with comfortable surroundings.

In matters of programme design, the requirement span from involving the youth in the design and continuing feedback together with making drop-in clients welcomed and/or appointments arranged rapidly. It is therefore expected that there will be no overcrowding with short waiting times. The fees must therefore be affordable. The Publicity and recruitment should therefore inform and reassure youth so that both sexes will be welcomed, whiles ensuring that necessary referrals are available despite the wide range of services available. The other components to make a reproductive health service youth friendly are the availability of Educational materials, Group discussions or peer group, counseling information on sexuality, safer sex, and reproductive health , contraception usage , STI diagnosis and management , HIV /AIDS counseling, sexual violence and abuse, Pregnancy testing and antenatal and postnatal care, Post-abortion counseling(UNFPA 2005, ADH, 2010, GHS2012)

2.2 Youth Knowledge, Sexual Attitude and Practices concerning Sexual Reproductive Health Service Utilization

The sexual behaviour of youth has a relationship with sexual reproductive health service utilization. Stone and Ingham (2003) observed that many young conceptualize preventive actions make efforts, and initiates action to obtain adequate protection only after having sexual intercourse. Hock-Long et al (2003) in their article notes that three-quarters of female participants in the United Kingdom aged 21 or younger, who had not sought reproductive health care before first sex, did so within six months of sexual initiation. Further observation was made to the effect that adolescents who face greater sexual health risks have greater access challenges to services than their less exposed peers. They report, for instance, that youths in the United States were at greater risk of pregnancy and STDs than their British and other western Europeans peers. In a later study by the Pathfinder (2005) in Ghana, whiles 56% of youth used condoms to prevent HIV/AIDS transmission; to 44% it was to prevent pregnancy with 33% having no idea about condom use. The study further reports 59% of youth clients having had sex.

However, youth in the US were more likely to encounter access challenges than those in United Kingdom and other western European countries. Cohen (2002) indicates that adolescents also seek health care services less frequently than any other age group and are less likely to have health insurance than any other age group. He further argued that challenges of accessing reproductive health services are greater for adolescents living in developing countries where adolescent health care services are few or lacking, and there are no mandatory health insurance systems.

It was also observed by Frost & Driscoll (2006) that in sub-Saharan African, although adolescents face greater sexual health risks, they also face greater challenges in access to reproductive health services, including preventive care. They further submits that in Kenya, like in other developing countries, existing societal, cultural and external prohibitions affect provision of adolescent reproductive health services. The youth are often exposed to various forms of sexual and reproductive health risks.

The risk range from sexual coercion, female genital cutting, unplanned pregnancies early marriage or sexual debut, closely spaced pregnancies, abortion, sexually transmitted infections (STIs), to HIV/AIDS (Scholl et al 2004; Berhane et al 2008).

Bogale & Seme (2014) in a recent cross-sectional among 826 in school youths to assess premarital sexual practices and its predictors in North West Ethiopia reports that early sexual debut increases youth risk for infection with HIV and other STIs.

According to Rada (2014) sexual abstinence before marriage had been a common traditional custom in Romania, notably among rural dwellers, however there has been a persistent decline on abstinence resulting from weakening traditional norms, increase in levels of education, modernization, and population migration. Early sexual initiation of sexual activity has a potential of ending young persons into possible cervical cancer, breast cancer, early aging, infertility and infection with human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs).

In using multiple logistic regression analyses, Bogale & Seme (2014) report in their cross sectional study in North West Ethiopia that youth who have early sexual activity were more likely to be exposed to high-risk sex(Mitikie et al 2005; Asrat, 2009) and the premarital sexual practices ranged from 11.8% to 23.2% among in-school youths.

In the same study 157 (19%) of the participants reported having had premarital sexual intercourse, of which 91 (22.7%) were males and 66 (15.5%) were females. The mean (SD) age at first sexual intercourse was 16 .48 (1.59) for males and 15.89 (1.68) for females with more than 75% of sexually active in-school youths engaging in premarital sexual relationship before escaping eighteen years. In Romania using a quantitative cross-sectional design, Rada (2014) found out that 7.2% of youth who engaged in First intercourse were below the age of 15. Younger persons less than 14 years have difficulty of obtaining information about SRH.

Averagely first sexual experience was lower for men (18.08 years compared with that for women (18.97 years). This finding is supported by Faludi 2010; the Health Informatics & Integrated Surveillance Systems Divison of Disease Prevention, (2012). The reasons could be explained as resulting from the encouragement receive by men to demonstrate their manhood. On the part of young girls, a proof of obedience can only be known when they have been able to postpone first sexual intercourse.

The study further demonstrates that averagely, the youth first received information on SRH at 15.39 years of age. Only 120(10%) of the youth surveyed listed the school, doctors or medics as a source of SRH with 315(25.9%) of the youth sourcing sexual education classes in school. The proportion of youth who ever discussed ‘a lot’ with their parents about sexual abstinence before marriage, sexual problems, sexually transmitted diseases, menstruation/first spontaneous ejaculation, how pregnancy occurs were a marginal minority of 51(4.2% )

2.3 The Friendliness of Sexual and Reproductive Health Service Delivery to the Youth.

The UNFPA(2012A);Prata, Weidert & Sreenivas, (2013) in their recent studies using DHS data reports that huge number of young persons are sexually active. The report cite that in Mali and Zambia, a high 50 and 53 per cent of youth surveyed were sexually active. Notwithstanding, vast variations exist in modern contraceptive usage among the young people. In Zambia and Mali respectively, only 33 per cent and 7 per cent of sexually active youth use modern contraceptives. There was however a lower level in comparison of contraceptive prevalence rate for modern methods for the same countries (for all women aged 15-49).

This was at 6 percent in Mali and 27 per cent in Zambia. The report indicate that Teenage births and adolescent birth rates per 1,000 women aged between 15 and 19 ranges from a lower 70 in Ghana to 190 in Mali necessitating for services tailored to the needs of youth. Several policy-related barriers exist for young person’s placing them at a much greater sexual risk. In most countries, abortion services remain illegal despite the high levels of unsafe adolescent abortions. It is not surprising to find out that abortion constitute one of the leading causes of maternal mortality in Africa. The implication of this is a requirement for youth focused; youth oriented services to enable young people make healthy choices in the efforts towards reducing risk of pregnancy among young persons.

Sedgh (2010) reports an improvement in quality of service delivery to young people at the clinic in the areas of: privacy, respect, and emphasis on dual protection and condom use. Moreover youth who were engaged in the evaluation did indicate satisfactory services in 12 out of 18 clinics in all the facility.

In Ghana an earlier findings of the Pathfinder International (2005a) affirms positive change of attitude among members of the project communities towards condoms more especially among the youth. This study was not geared towards addressing how to prolong early sexual initiation but rather on how to reduce sexual risk of STi Infection, abortion and HIV AIDS and more especially towards condom use. The need to have a source reduction approach in risky sexual behaviour from the extant of literature has been poorly advocated and integrated in efforts towards reduction of risky sexual behaviour among youth. There has been a minimal education and recommendation by reproductive right activists and scholars on abstinence as a family planning option or method.

The message of abstinence though often cited in reproductive health education as the option one in the ABC of sexually transmitted disease infection contraction and averting risky sexual behavioural outcomes, has very limited prioritization and focus in terms of reproductive health campaigns and research. It has been left to the clergy to do the education which often is done without recourse to the medical and health benefits but rather grounding in religious and cultural values. The study (Sedg, 2010) additionally reports the role of religious and cultural values in shaping reproductive health utilization. In several instances, service providers in many countries continue to hold the view that young people should not be seeking or receiving reproductive health, especially family planning services.

In all matters relating to youth friendliness of reproductive health service delivery among youth, there is lack of reliable data at sub-national and facility levels on young people’s sexual and reproductive Health and family planning needs coupled with lack of clarity regarding what minimum criteria should be met to make reproductive health service youth friendly.

Youth friendly reproductive health services (YFRHS) have been recognized as an appropriate and effective strategy to addressing the Sexual and Reproductive Health (SRH) needs of the youth following the international Conference on Population and Development in Cairo; Egypt, 1994 (UNFPA, 2003).

Senderwitz, Gwyn & Cathy (2003) admit that the essence of the friendliness of Reproductive Health Services for the youth are because of the specific biological and psychological needs of the youth, the high risks of STIs, HIV, and pregnancy, disproportionately high risk of sexual abuse, importance of behavior related risks that are responsive to education and counseling, opportune age to learn good health practices and the severity of consequences from lack of Reproductive Health care during adolescence.

NYCOM (2001) defines Youth Friendly Reproductive Health Services as health facility-based sexual and reproductive health services provided to the adolescents or the youths in a Youth-friendly manner. These services include provision of educational services, contraceptives, STI treatment, post-abortion and antenatal services. It must however be acknowledge that what constitute a youth friendly manner is subject to national protocols. This is because the variety of reproductive health services offered across countries is limited in some extent due to legal boundaries that exist in some countries. In developing countries like Ghana, while the service protocols that define friendliness is all involving it differs in package and volume from that offered by Ethiopia, Kenya and Uganda and South Africa.

This is due to the fact that, youth friendliness as a concept is beginning to gain teeth in Ghana hence the need for systematic research to evaluate the intervention and improve upon if any (MOH, 2012) several years after the Africa Youth Alliance/Pathfinder (2005) intervention study was conducted in Ghana to integrate Youth friendly reproductive Services into existing reproductive health services offered.

2.3.1 Static Facility Youth Friendly Sexual and Reproductive health Service Delivery

The results on the static facility reassessment in Ghana by the Pathfinder International (2005) in 65 facilities operated by the Christian Health Association of Ghana (CHAG), The Ghana Health Service (GHS) and the Planned Parenthood Association(PPAG) of Ghana shows that despite the improvements in capacity of the five intervention facilities to provide youth friendly reproductive health service, through mystery client monitoring, client satisfaction was generally good. The study reports of provider biases, delays in service and lack of privacy.

Despite the classical nature of this study ,in respect of determining client satisfaction of youth friendly reproductive health service delivery in Ghana, the selection of twenty two(22) youth; nine(19) from CHAG, three(3) from PPAG was too small a sample size to generalize for service satisfaction for a national intervention programme. Even more, with respect to the interviews, on the nationwide, 180 youth were interviewed which is still considered too small for generalization purposes.

Again, the Ghana Health Service which provides health service to over 60% of the Ghanaian population was left out during the analysis of client satisfaction though some of its facilities formed part of the general intervention programme. Again the satisfaction levels of the youth between age 10 and 15 were not analyzed making it difficult to understand their assessment of youth friendliness of service delivery

It must be admitted that, the general satisfaction was achieved because health service providers were specially retrained to handle the youth amidst making repositioning the health facility to be youth friendly. The trend analysis of intervention showed 60% improvements in new youth visit to health facilities for reproductive health care .These findings support earlier researcher position that youth friendly reproductive health services influence service utilization positively.

It is widely acknowledged among reproductive health providers throughout the world that “Youth Friendly” services are needed if the youth are to be adequately provided with reproductive health care. Youth friendly services is able to effectively attract the youths, meet their needs comfortably and responsively, and succeed in retaining these young clients for continuing care. These services should however be characterized by specially trained providers, privacy, confidentiality and accessibility to the youths (Senderowitz, 1999).

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