Reproductive Health Knowledge and Services Utilization among Rural Adolescents in Rwamagana District, Rwanda

According to World Health Organization (WHO), adolescents are people between 10 and 19 years of age. Today there are 1.2 billion adolescents worldwide with nearly 90% of them living in developing countries. Adolescence is characterized by significant physiological, psychological and social changes that put adolescents for high risk sexual and reproductive health (SRH) problems. This has partially been because adolescents were considered to be relatively healthy, without a heavy “burden of disease” ^{1, 2}.

Adolescents are not quite capable of understanding complex concepts, or the relationship between behaviors and consequences, or the extent of control they have or can have over health decisions making including that related to sexual and reproductive behavior. This makes them vulnerable to sexual exploitation and high-risk sexual behaviors and reproductive health problems ^{2, 3}.

Previous studies demonstrated that the age at marriage for adolescents living in rural areas is quite low compared to their counterpart in urban area. For girls these situations predispose them to teenage pregnancy that may have more immediate effect on their life that any other problem. The changing moral & social values and shift in the standard of societal behavior from conservatism to liberal interaction between both sexes is attributed largely to exposure to the media especially television and movies. Adolescents find themselves sandwiched between a glamorous western influence and a stern conservatism at home, which strictly forbids discussion on sex. This dichotomy aggravates the confusion among adolescents have led to increase in premarital sexual activity, pregnancy among unmarried girls apart from the increasing incidence of abortion & STDs.

Early and unprotected sexual activity and misconceptions about HIV/AIDs are prevalent among rural adolescents⁴. It was previously reported that adolescent knowledge about sexual reproductive health affects the reproductive health services utilization⁵. The World Health Organization (WHO) estimates that in Africa, 60% of all new HIV-infection occur in adolescents who are 15-19 years old. In developing countries, there are about 12.8 million births by adolescents aged between 15-19 years, and a large proportion of these pregnancies are unplanned ⁶.

Adolescent’s sexual and reproductive health knowledge include knowledge about the female menstrual cycle and conception, ways to avoid pregnancy, methods of contraception, correct use of condoms and oral contraceptives, sexually transmitted infections and HIV, means of STIs transmission, ways to avoid STIs and symptoms of STIs. Those are the indicator that used to measure knowledge about SRH ¹.

A study conducted in Nigeria found that about half (51.0%) of the respondents had ever used SRH services. The same study showed less than 50% of adolescent were knowledgeable about STIs while 52.9% were knowledgeable about how to avoid unwanted pregnancy. Factors related to adolescent sexual and reproductive health knowledge were being male, having regular cell phone and access to internet ⁷.

One of the major causes of the high prevalence of STIs among the adolescent is poor utilization of sexual reproductive health services as well as poor knowledge. In developing countries, 20,000 girls of between 15 and 19 give birth every day, One-third these girls are married before 18 years old. Most of them are poor, less educated and living in rural areas ².

Data from Rwanda’s Ministry of Health indicate that adolescents and young adults comprise the majority of Rwanda’s population. For instance, young adolescents (10-14 years) make up about 17.1%, old adolescents (15-19 years) about 12.4% and young adults comprise 10.7% of the total population while another third of the population (32.1%) is under 10 years. The report showed that adolescents remain neglected group, in the country’s health care model this group is neglected because they are considered comparatively healthy with a low disease burden. Yet the choices adolescent make today affect their health and the health of their families in future, especially the choices related to family planning and STDs. It was reported that Rwandan adolescent lack the ability to negotiate safer sex or to seek the health of family planning services ⁸.

Due to the lack of knowledge and poor utilization of reproductive health services the number of unwanted pregnancies and STDs has been increasing in Rwanda. The number of teenage pregnancies in various parts of the country shows how government and parents need to put in more efforts to contain the issue which leads many young girls to drop out of school. For example, in 2016 some 17,000 young girls most of them under 18 years got pregnancy ⁹.

Teenage pregnancy has been described as a major challenge to Rwanda whose numbers are increasing, especially in the rural areas. Poor rural girls with limited or no access to sexual reproductive health services are at higher risk of becoming pregnant or falling victims to sexually transmitted diseases. On other hand, a report from UNICEF showed that young people in Rwanda remain at risk of contracting HIV virus , this is because a large number of young people in Rwanda, are unaware of the risks associated with HIV and particularly how to prevent against HIV. The same report showed that only 49% of males and 43% of female understand how to use condoms ¹⁰.

Knowledge and the utilization of reproductive health services are the important components in preventing adolescents from different sexual and reproductive health problems. Limited studies on adolescent knowledge and reproductive services utilization have been conducted in Rwanda. These studies were carried out mainly in urban areas among the general population. Therefore assessing factors affecting reproductive health services utilization within adolescent are very important to improve adolescent reproductive health services utilization and thereby reduce the burden of adolescent disease and disabilities associated with reproductive health.

Data was checked for completeness, cleaned, coded and entered into excel sheet, and then exported to SPSS version 22.0 for further analysis. Frequencies and percentage were used to summarize descriptive statistics. Percentages were used to assess the level of RH knowledge and services utilization among rural adolescents. A total of 19 questions were used to assess knowledge of adolescents about reproductive health services. The right answer was scored 1 and wrong answer was scored 0, total scores were 19. The respondents were classified as good knowledge with scores >10 equivalent to 53% and lower knowledge with scores of 9 and less. Data were presented using tables and graphs accordingly. To determine the association between different factors associated with reproductive health knowledge and services utilization, a logistic regression model was employed. First, each variable was entered into a binary logistic regression model. Second, variables which showed significant at p-value of 0.05 fitted into multiple logistic regression model to assess the relationship between reproductive health knowledge and services utilization. Variables that remained significant at p-value of 0.05 in the final multivariate logistic regression model were identified as independent factors associated with reproductive health knowledge and services utilization among adolescents in rural areas of Rwamagana District.

Ethical clearance was obtained from the Ethical committee of Mount Kenya University. Permission was obtained from Rwamagana District administration. The objective of the study was explained to the respondents. Respondents were free to decline or withdraw their participation in the study. Signed consent was obtained from the parents of caregiver for adolescents aged less than 18 years old. Data collection was conducted after verbal consent from the respondents.

Adolescent’s reproductive health knowledge are affected by different controversies including says that adolescents are not ready for sensitive sexual information, comprehensive sexual education promote early sex, reproductive health education makes young people promiscuous, reproductive health education does not fit with our culture or religion, adolescent should not use contraceptive methods and adolescent should abstain from sex until marriage ¹¹. Access and use of reproductive health services by adolescents, adolescents’ level of knowledge in RH is paramount. Increasing adolescent’s awareness about SRH and advocating for them is a crucial to the adolescent’s reproductive health effort. Hence, this study assesses the SHR knowledge and services utilization among adolescents in Rwamagana District.

The study found that more than a half of respondents 54.1% were not aware that reproductive health services are offered at health center. A total of 64.8% knew that a girl could become pregnancy after puberty, 73.5% knew that a male could get a girl pregnant during puberty. Adolescents in this study were knowledgeable about the signs of maturity for both girls and boys where 86.5% knew that breast development for a girl is a sign of maturity, 76.8% knew that appearance of public hair for both girls and boys is a sign of maturity, and appearance of menstruation for a girl is a sign of maturity. These findings are consistent with a study conducted in Ethiopia where 53.5% of the adolescents who participated in the study responded that a girl could get pregnant the first time she had sex and the age at which it could occur was mentioned as during puberty. The same study reported that the male counterpart could be mature of physically made a girt pregnant during puberty ³.

In contrast, a study conducted in China reported that the majority of adolescents had lower knowledge about fertility issues. The results from the Chinese study revealed that unmarried migrants demonstrated low levels of RH knowledge on pregnancy fertilization (29.4%) and contraception (9.1%). Females’ participants showed more knowledge about pregnancy, contraception and STDs, but with less knowledge on family planning policy than the male participants. Participants aged 15-19 years old had the least knowledge on pregnancy and family planning policy ¹².

Regarding the reproductive health utilization, this study found that the majority of adolescents 66.8% have ever utilize reproductive health service, 55.5% responded that they visited reproductive health center in the last 6 months prior to the survey. This study showed that there is a significantly higher RH services utilization rate among rural adolescents when it is compared with the study undertaken in Jimma where 41.1% ever experienced the services ¹³ even though the latter finding is not more comparable as it was undertaken in urban setting.

In bivariate analysis religion, occupation education level, age of mother and living status were associated with use of reproductive health services (P<0.005). This finding are consistent with that conducted in Ethiopia where in bivariate analysis, the factor found to be significantly associated with reproductive health service utilization were education level and living status. In contrast, the same study found that adolescents age, marital status ; mothers’ educational status; poor family communication habit on SRH issues; family monthly income; history of sexual intercourse; poor discussion on SRH matters with sexual partner, pears, and health workers; perception of risk towards HIV/AIDS were associated with reproductive health services utilization ¹³. The inconsistence may be due to that Ethiopian study was conducted only among female aged 15-24 while this study was conducted among both male and female aged 15-19 years old.

It was observed that adolescents who live with their parents were more likely to use reproductive health services compared to those who do not live with parents (aOR=2.161, 95%CI: 1.162-4.021, p=0.015). In contrast, a study conducted in Ethiopia found that factors such as age of 16–20 years (AOR = 1.85, 95%CI: 1.17–2.92), mother’s educational status (being illiterate (AOR = .33, 95%CI:. 14–.77)), discussion about reproductive health services with their family (AOR = 8.02, 9%CI:5.52–11.66), being Merchant (AOR = 2.7995%CI:1.11–6.96), unemployed (AOR = 2.90, 95%CI:1.19–7.06) or student (AOR:2.38, 95%CI:1. 04–5.42) in occupation, high perceived severity (AOR = 4.05, 95%CI:2.68–6.11), high perceived barriers (AOR = .44, 95%CI:.30–64) were independent predictors of reproductive health services utilization among female adolescents the study area ¹⁴. The difference may due to the methodology mainly sample size where 844 female participated in the study while in this study 392 adolescent from one district were included in the study.

Majority of the adolescents demonstrated higher knowledge about reproductive health services in the study area. Moderate reproductive health services utilization by adolescents in Rwamagana District was observed. This study indicates that less than 60% of adolescents have visited reproductive health center in the last 6 months despite the availability of the services in the study area. The findings from multivariate analysis showed that adolescents who are affiliated to Catholic Church were less likely to use reproductive health services compared to protestant. It was observed that adolescents who live with their parents were more likely to use reproductive health services compared to those who do not live with parents. Parents need to increase the time they spend with their adolescents at home, and improve the discussion on the issues related to reproductive health. Adolescents are encouraged to visit health centers and youth centers in order to be know the services that are available for them at those centers.

1. 1. (2005) WHO: World Health Organization and Deutsche Gesellschaft fuer Technische Zusammenarbeit (GTZ) GmbH. Sexually transmitted infections among adolescents: the need for adequate health services. Geneva: WHO Library Cataloguing-in-Publication Data.
   Search at Google Scholar

1. 2. (2016) WHO: World Health Organization: Adolescent development.
   Search at Google Scholar

1. 3.Abajobir A A, Seme A. (2014) Reproductive health knowledge and services utilization among rural adolescents in east Gojjam zone, Ethiopia: a community-based cross-sectional study.BMC Health Serv Res.14:. 138.
   Search at Google Scholar

1. 4.Butler. (2003) The reproductive health situation of adolescents, 64 edition. Progress in Reproductive Research; 21-23.
   Search at Google Scholar

1. 5.Ayalew T, Yeshigeta. (2009) Adolescent Reproductive Health Services. in Jimma City: Accessibility and UtilizationEthiop J Health Sci.19(2) .
   Search at Google Scholar

1. 6. (2007) WHO: Adolescent pregnancy-Unmet needs and undone deeds: A review of the literature and programmes: Issue in Adolescent Health and Development.
   Search at Google Scholar

1. 7.Abiodun O, Olu-Abiodun O, Ani F, Sotunsa O.. Sexual and Reproductive Health Knowledge and Service Utilization among In-school Rural Adolescents in Nigeria.J AIDS Clin Res2016 7-6.
   Search at Google Scholar

1. 8.MoH. (2017) Adolescent Sexual and reproductive health in Rwanda.
   Search at Google Scholar

1. 9. (2016) UNFPA: Teenage pregnancies in. , Rwanda
   Search at Google Scholar

1. 10.UNCEF. (2017) Developing an adolescent Operational Plan-Rwanda.
   Search at Google Scholar

1. 11. (2017) UNFPA: Integrating Comprehensive Sexuality Education (CSE) in Teacher’s Guides and Students Textbooks.
   Search at Google Scholar

1. 12.Liu Z, Zhu M, Dib H H, Li Z, Shi S et al. (2011) RH knowledge and service utilization among unmarried rural-to-urban migrants in three major cities, China.BMC Public Health11: 74.
   Search at Google Scholar

1. 13.Feleke S A, Koye D N, Demssie A F, Mengesha Z B. (2013) Reproductive health service utilization and associated factors among adolescents (15-19 years old). in Gondar town, Northwest Ethiopia.BMC Health Serv Res.13: 294.
   Search at Google Scholar

1. 14.Gebreyesus H, Teweldemedhin M, Mamo A. (2019) Determinants of reproductive health services utilization among rural female adolescents in Asgede-Tsimbla district Northern Ethiopia: a community based cross-sectional study. Reproductive health. 16(1), 4.
   Search at Google Scholar

1. 1.Yadavalli Chandra Sekhar, Upparahalli Venkateshaiah Sathisha, Kumar Sandeep, Kandikattu Hemanth Kumar, Oruganti Lokanatha, et al, 2023, Allergen-induced NLRP3/caspase1/IL-18 signaling initiate eosinophilic esophagitis and respective inhibitors protect disease pathogenesis, Communications Biology, 6(1), 10.1038/s42003-023-05130-4