Addressing the deprived: need and access of sexual reproductive health services to street adolescents in Ethiopia. The case of Nekemte town: mixed methods study

Objectives Globally, the research knowledge gap exists in the sexual reproductive health (SRH) services of street adolescents. The intensity of the problem is high in settings like Ethiopia, where there are limited access and integration of services. This study aimed at exploring risky sexual behaviors, needs, and barriers of SRH services among street adolescents in Nekemte town. A community-based cross-sectional study design with mixed approaches was used on a sample size of 219 street adolescents. Supplementary qualitative data of 24 in-depth interviews were collected from the street adolescents and SRH service providers. Time-location sampling or venue sampling technique (VDT) was used for a quantitative study. Quantitative data were analyzed by SPSS version 24.0. Results About 93% of street adolescents reported difficulty in accessing contraceptives. Behavioral change and sustainable access to SRH services are lacking among street adolescents. The Knowledge gap is more evident in early adolescents (10–13) period than the other classes. In general, street adolescents are deprived of access to SRH services. Mobile and flexible access to contraceptives should be designed targeting street adolescents.


Introduction
Adolescence is a transition period between childhood to adulthood (10 to 19 years), which is marked by a continuum of physical, mental, behavioral, emotional, and social changes. Streetlife is a global phenomenon and increasing in urban areas of developing countries like Ethiopia. Adolescents on streets are neglected in policy and action to access SRH services [1,2].
Street adolescents are pushed to street life by complex factors: socioeconomic, political, cultural, and global opportunities and challenges. The intensity of the problem is high in settings like Ethiopia [3][4][5]. Systemic reviews and studies in Africa show that street children are exposed to street life, mainly due to poverty and abuse. There are more girls on the street than boys [6,7,22].
Despite global support and attention, there has been historical neglect of adolescent SRH that exposed the adolescents to risky sexual practice and early parenthood in developing countries [8][9][10][11][12][13]. As evidence shows, poor adolescents, including street adolescents, are exposed to marginalization in social, political, and economic aspects and face discrimination, stigmatizations, isolations, and violations [14,15].
Globally, about 13,000,000 women aged 15-19 years give birth annually. Pregnancy and childbirth-related deaths are the primary cause of women's death in this age group. Furthermore, neonatal mortality of teenage Open Access BMC Research Notes *Correspondence: melese_chego@yahoo.com 2 Wollega University, Institute of Health sciences, Nekemte, Ethiopia Full list of author information is available at the end of the article mothers is also higher than adult mothers [2,13,16,17]. In Sub-Saharan Africa, Children and adolescents are among high risk and vulnerable groups for sexual abuse, violence, and HIV/HIDS, and there is a downgrading of vulnerability perception to HIV/AIDS among adolescents [18][19][20][21][22][23][24][25].
Qualitative and quantitative studies also indicate a low level of knowledge of street children on SRH issues, including HIV/AIDs and different forms of violence of abuse to street children, especially girls. As indicated in the studies, street adolescents are engaged in sexual activities early, and they have multiple sexual partners in most of the cases [26][27][28][29][30].
In developing countries, a research knowledge gap exists in addressing access to SRH services to populations, particularly the adolescents, despite the increase in demand and challenges. The specific objectives of the study are exploring risky sexual behaviors, SRH needs, and barriers of SRH services utilization among adolescents (10-19 years) in Nekemte town [3,31]. The conceptual framework of the study is indicated as follows (Fig. 1).

Study setting and study population
The study was conducted from April to June 2018 in Nekemte town, East Wollega Zone, Ethiopia. The town has an estimated total population of 115, 741 in 2016 [32]. The town attracts many adolescents and youths from different urban and rural areas of Ethiopia. The source population for this study was street adolescents aged (10-19 years) who are living or working on the street in Nekemte town.

Study design
A community-based cross-sectional study design with mixed methods was used. The study is primarily quantitative, and the qualitative approach is used to accompany the quantitative findings.

Sample size determination
The sample size for the quantitative data was determined using a single finite population proportion formula. The assumptions for the sample size (n) calculation were: Proportion (P) of barrier to SRH services among street adolescents in Addis Ababa city in Ethiopia which was 84.7%, confidence level for study 95%, non response rate of 10%, standard error (d) of 5%, and two-sided Z score at 95% confidence interval, 1.96.
Adding a 10% response rate to the initial sample size (n), the total number of employed street adolescents was 235. For supplementary qualitative data, 20 in-depth interviews were proposed initially, and 24 in-depth interviews were conducted from the street adolescents and different SRH service providers.

Sampling procedure
A sampling of street adolescents for the quantitative study was conducted by time-location sampling or venue sampling technique, which is recommended for enrolling research participants in special situations like street adolescents in which there is no clear formal structure of the study population to apply the usual probability sampling techniques. The units of the sampling were venue day time units (VDT). Venue day time unit implies the period of some time in a particular venue in a day.
This sampling technique is a probability sampling approach provided that the units are well studied and identified before actual sampling. Individuals included in day time units have an equal chance to be selected in the study. Accordingly, before data collection, some street adolescents and local administrative, religious, and community members were interviewed to identify the day time units and make arrangements. In the study area, 88 venues/locations were identified, and the average number of street children identified in each place for 2 h (VDT) was 12. Based on these the total venues divided by the average number of street adolescents in each VDT gives the number of locations, venues for the study, which are 20 VDTs. Finally, the Street adolescents found in selected VDT were interviewed, for qualitative data participants were purposely selected from street adolescents and reproductive health service providers. The service providers for in-depth interviews were selected based on the information obtained from the Family Guidance Association of Ethiopia Nekemte area coordinator and other key informants about service providers.

Data collection procedure
Quantitative data were collected by interviews guided by structured questionnaires after 2 days of training for data collectors. For qualitative data, in-depth interviews were conducted by trained masters level data collectors in the local language, and notes were taken manually with maximum effort.

Data processing and analysis
Quantitative data were analyzed using SPSS version 24.0. Descriptive statistics like frequency, percentage, mean, standard deviation were used to describe the findings, and the summary findings were presented by textual, tabular, and graphic presentations. Qualitative data from the in-depth interview were analyzed by thematic analysis approach after translated to English from the local languages, and the responses were coded and sorted to identify themes. The result was presented triangulating and accompanying the quantitative findings. Direct quotes of the respondents were also used.

Socio-demographic and economic characteristics of street adolescents
About 219 adolescent street adolescents were interviewed, making a 93% response rate. The age range of those adolescents included in this study was between 10 and 19 years, with a mean age of 16.82 (SD ± 1.73) years (Table 1).

Substance use behaviors
Different types are substances that are used by street participants. About one-third of the participants use compound or many kinds of substances at a time (Table 2).

Practice towards SRH issues among adolescents
About 185 (84.5%) know the means of prevention of HIV/ STI. Among those 3 (1.4%), 174 (79.5%), 34 (15.5%), and 3 (1.4%) mentioned abstinence, use of a condom, remaining faithful to a partner, and avoiding casual sex, respectively. About 127 (58%) of them reported that they know at least one means of preventing pregnancy. Oral pills, condoms, and injection were the most recognized contraceptive methods that were reported by 95%, 43%, and 93% of the interviewee, respectively. From in-depth interview awareness about un-intended pregnancy, STI/HIV, their transmission and prevention methods are fair, especially for older adolescents. There is a considerable concern to early adolescents (10-13) as this seems to have low decision making power and compression of life matters. It cannot be said that street adolescents do not know SRH issues.
The majority of street adolescents 160 (73.1%) had ever practiced sexual intercourse, 49 (63%) of boys and 111 (79%) of girls. The overall mean age at first sexual initiation was 15.18 years (16.25 years for boys and 14.44 for girls). The main reasons for sexual activity among sexually active Street adolescents were peer pressure 81 (50.6%), and 79 (49.2%) exchange for money. Of those sexually active, the first sexual partner includes causal partner 57 (26%), steady boy/girlfriend 73 (33.3%), and commercial sex worker 16 (7.3%). Sexually active street children were also asked about their sexual experience within the last 12 months. Of those who are currently sexually active, 134 (83.75%) of them reported that they had sexual intercourse with two and more than two partners and the mean number of sexual partners for them was 2.85 (SD ± 0.4) while only 20 (12.5%) have a single sexual partner. Of those sexually active street adolescents, 105 (79.04%) had ever used modern contraceptives, out   of which, Condoms 83 (79.04%), Pills 13 (12.3%) injectable 13 (8.12%) were reported to be the most frequently used methods of contraceptives. As reasons mentioned for not using contraceptives include (multiple responses considered): Lack of adequate knowledge 28 (51%), unplanned sex 31 (56%), too far to get contraceptive (not accessible) 32 (58%) and having infrequent sex 19 (35%). Among the street girls who participated in this study, more than half 80 (57%) reported that they had ever been pregnant, and all 80 (57%) of female respondents said that pregnancies were unwanted. Further, the reasons for pregnancies were accidental 45 (56.25%), unavailability of contraceptive 29 (36.25%), failure of contraceptives 3 (3.75%) was mentioned as the main reasons for the occurrence of unwanted pregnancies.
An in-depth interview with a service provider, FGAE, Nekemte branch claims: "Trading sex is found to be a serious and growing problem in Nekemte town for street children, particularly amongst street girls. Besides education and service provision, the basic thing is social and financial support".

Access to SRH service
From who was not seeking SRH care, about 93% reported difficulty in getting contraceptives/condoms. The reasons mentioned for the difficulty were lack of money (89%), too far to get it (86.5%), inconvenience of distribution places (67%), expensive (7.3%), and provider disapproval (15%).
From an In-depth interview, although they use a condom on occasions, it is difficult for adolescents to maintain consistent use of condoms as there are different level barriers. Male, 17 years says, "Even though they (street adolescents) have enough knowledge on pregnancy, STI/ HIV, they don't stay in safe sexual practice because of peer pressure, negligence, lack of hope, substance abuse, and lack of continuous education on this issue. " They have also reported that in terms of access to SRH services, they are disconnected from the existing service stream. A 17-year-old male child suggests, "…. When we visit health facilities, they don't cooperate well. The workers are usually busy, and you don't get adequate service for your needs. Most of the street children's attention is dominated by another issue like cloth, food, and shelter, and they also seek care rarely." Program coordinator of FGAE Nekemte branch states, "The reality of providing such service (facility-based service) is that many street children clients will not attend arranged appointments and may disengage entirely for periods. In these stages, the clients can be most vulnerable, and despite not looking for it, they are often most in need of a sexual health service. It is, therefore, crucial to offering outreach and support to access sexual health services for those children who are most vulnerable and at risk." The government health facility director also says, "Street adolescents had very limited access to reproductive health services. The main reasons were location of the reproductive health facilities and the service providers. The facilities are mostly in residential areas, and the street children mostly operate from Central Business area, therefore crucial to offer outreach and support to access sexual health services".

Conclusion
The main barriers to access local SRH services among Nekemte town street adolescents are lack of information on available services for street adolescents, the behavior of adolescents, inaccessibility adolescent-friendly service. The finding implies that street adolescents are highly deprived and need a particular focus on intervention. Accessing mobile peer-based and friendly services at facilities and in the community should be focused, and rigorous qualitative and quantitative studies should be conducted at a large scale and large sample size to identify the root causes.

Limitation
The nature of the cross sectional study may not allow the cause-effect relationship and the statistical inference. Social desirability might have affected the responses of street adolescents. Statistical inference is also not reported. Besides, the study should have included the broader views of community, schools, religious institutions, and other relevant bodies. Considering these issues in further research will be helpful.
Abbreviations SRH: sexual reproductive health; VDT: venue day time unit; STI: sexually transmitted illnesses; ICT: Information Communication Technology; CSW: commercial sex workers; FGAE: Family Guidance Association of Ethiopia.