STRENGTHS AND LIMITATIONS OF THIS STUDY
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Multistage sampling ensured diverse representation across schools and student populations, reducing sampling biases.
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A substantial sample size increases the statistical power of the study and improves the findings’ generalisability to the intended population.
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Since the data were collected through self-administered questionnaires, it may be subjected to self-reporting bias.
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Some sensitive questions about sexual and reproductive behaviours might introduce social desirability bias.
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Also, we did not include adolescents already out of school who might have very different knowledge and experiences.
Background
The second sensitive period of human growth and development is adolescence, during which a person experiences profound changes in their biology, physiology, emotions and cognitive abilities.1–3 Additionally, it is the time when sexuality and reproduction begin to mature, especially in late adolescence.4
The decisions that are made by the late adolescent population regarding sexuality and reproduction have a lasting impact on both their general health and those of the next generation.5 6 However, these groups often do not have the knowledge and skills necessary to maintain and promote a healthy lifestyle, particularly because social skills and competencies are insufficiently developed. It is known that these competencies, skills, and knowledge constitute health literacy.7 8
Reproductive and sexual health literacy (RSHL) is the application of the health literacy idea, more especially connected to sexuality and reproduction.9–11 RSHL encompasses not only the acquisition and comprehension of reproductive and sexual knowledge but also the integration of that knowledge into the processes of decision-making that dictate behaviour.11 Adolescents who have limited RSHL abilities make harmful decisions, participate in dangerous sexual activities, have poorer health and exhibit less self-management.9 12 13
Globally, adolescents bear an unacceptably high burden of reproductive and sexual morbidity and death.14 In developing nations, such as Ethiopia, 21 million pregnancies among teenagers aged 15–19 were recorded as of 2019, half of which were unplanned, and 5.6 million abortions, of which 3.9 million were unsafe.15 16 Regarding HIV/AIDS, 150 000 (44 000 to 310 000) new infections among adolescents were reported worldwide in 2020.14
Making educated decisions based on an accurate understanding of reproduction and sexuality is necessary to mitigate problems related to reproductive and sexual health in adolescents.6 Thus, research in the field of RSHL is highly sought-after since it has a direct bearing on adolescents’ capacity to obtain, comprehend, evaluate and apply reproductive and sexual information to preserve their reproductive health.9 15
Adolescence presents an opportunity to act and influence health-related knowledge, attitudes and practices concerning reproduction and sexuality.2 It is particularly important to enhance RSHL, which directly affects a person reproductive and sexual health for the remainder of his or her life as well as the generation after them.3 16 To provide prompt intervention, it is crucial to evaluate RSHL and relevant factors among the adolescent population.
Ethiopia, a highly religious country, adopted sex education into school curricula later than anticipated, initially suggesting sex education in 2009 as a strategy for HIV/AIDS prevention.17 Sexuality education is being suggested as part of the latest version of the national adolescent and youth health strategy (2016–2020).18 However, the absence of age-appropriate, culturally sound and legally sensitive comprehensive sexuality education (CSE) accepted within the school curriculum was cited as a cause for the recommendation of intersectional collaboration in the National Adolescent and Youth Health, Implementation Guideline, Standards and Minimum Service Delivery Package 2017.19
The UNESCO Global Status Report on Sexuality Education highlighted that Ethiopian laws and policies do not include a CSE curriculum. Instead, sexuality education is addressed in secondary schools through life skills-based HIV education, with an estimated 51%–75% of students receiving this form of instruction.20
Numerous investigations have been carried out to evaluate sexually risky lifestyles, awareness of SRH, SRH behaviour and communication, and utilisation of SRH services among high school adolescent students throughout Ethiopia, pointing to the importance of studying RSHL.21–24 Nevertheless, no research has been done in Ethiopia, specifically in the region of study, to produce data on RSHL and the factors influencing it. The goal of the current study was to ascertain the students’ RSHL status and identify the factors that influence it. This kind of research will assist in changing the emphasis from knowledge gaps to literacy, or the capacity to critically evaluate information, examine trustworthy sources and make decisions regarding one’s sexual health. Will also assist in locating knowledge application gaps, misconceptions and barriers to accessing SRH information.
Methods
Study design and setting
Between 20 May and 20 June 2023, a cross-sectional survey was carried out at Sawla town and Arba Minch town high schools. The town of Arba Minch is situated 489 kilometres (km) from the capital, Addis Ababa, in the southern region of Ethiopia. There are 52 elementary schools and 8 high schools in the town. The town has five public high schools and three private ones. It is projected that 11 690 adolescents attend the town’s high schools combined. About 511 km south of Addis Ababa, in the southern region of Ethiopia, sits Sawla town, the administrative centre of the Gofa Zone. The Sawla Town Education Administration reports that approximately 4150 adolescents are enrolled in public three high schools.
Patient and public involvement
None.
Population
All regular late-adolescent high school students at Arba Minch and Sawla town high schools were the source population. Randomly selected late-adolescent students from each high school at Arba Minch and Sawla were our study population.
Inclusion and exclusion criteria
Regular (daytime) high school late-adolescent students who were present in the school on the dates of data collection were included. Students who were not able to complete the questionnaire due to serious illness were excluded.
Sample size determination
The sample size was calculated using the single population proportion formula, assuming a proportion of limited RSHL of 65.5% from a study conducted in Lao with a parallel objective,25 with a 95% level of confidence, and a 5% margin of error as shown.
After considering 1.5 design effects and a 10% non-response rate, a sample of 577 students was taken for the study.
Where n=required sample size, Zα/2=critical value for normal distribution at 95% confidence level, which equals 1.96 (Z-value at α=0.05), p=proportion of late adolescents with a limited RSHL of 65.5%, and d=margin of error of 5%.
Sampling technique
Students from Arba Minch and Sawla town high schools were chosen using a multistage sampling approach. There are three high schools with 4150 late adolescent students in Sawla town and eight high schools in Arba Minch town, for a total of 11 434 late adolescent students. All of the towns’ high schools were included, and a predefined sample was distributed proportionately to each town and school. Using the lottery approach, the grade and section (if any) were chosen at random. Next, using the students’ IDs or registration numbers, a sampling frame was created for the chosen grade. At last, 577 students were chosen from each section of the chosen grade using a computer-generated simple random sampling procedure.
Definitions and measurement
Late adolescents
In this study, the students, aged 15–19, are considered late adolescents.26
The mean index score
It is calculated as the RSHL score adjusted to a scale of 50 using the formula (total score) * 50/124 based on the European health literacy index, which reflects a study participant’s access, understanding, appraisal and utilisation of reproductive and sexual health information. Thus, the mean RSHL score has four levels, as follows:27
Excellent RSHL
An RSHL status marked for a respondent with a mean index score of 42<50.
Sufficient RSHL
An RSHL status marked for a respondent with a mean index score of 33<42.
Problematic RSHL
An RSHL status marked for a respondent with a mean index score of 25<33.
Inadequate RSHL
An RSHL status marked for a respondent with a mean index score of 0–25.
Desired RSHL
Those respondents with a sufficient and excellent RSHL score, which means a score greater than 33.
Limited RSHL
Those respondents with inadequate and problematic RSHL scores, which means a score of 33 or less.
Knowledge about sexuality and reproduction
Four specific questions targeted at measuring knowledge about sexuality and reproduction were used, and participants who scored 3 and above were said to have good knowledge about sexuality and reproduction.
Knowledge about condoms
Three specific questions targeted at measuring knowledge about condoms were used, and participants who scored 2 and above were said to have good knowledge about condoms.
Knowledge about STI and HIV
Six specific questions targeted at measuring knowledge about sexually transmitted infection (STI) and HIV were used, and participants who scored 4 and above were said to have good knowledge about sexuality and reproduction.
Data collection procedure
The study employed a standardised self-administered questionnaire to gather data on many topics, including sociodemographic traits, family and behavioural factors, sexuality and reproduction-related factors and knowledge of reproductive and sexual health. Several works of literature were reviewed to create the questionnaire. First, it was written in English, and then it was translated into the Amharic dialect spoken there. Before giving consent (or assent for those under the age of 18) for the data collection, each participant was properly briefed and oriented about the goal and purpose of the study. To prevent information cross-exchange, the questionnaire was given to each study participant after the students had been gathered in a classroom. Supervisors meticulously monitored the entire data collection process regularly.
Data quality control
The Health Literacy Measure for Adolescents (HELMA) is a valid and reliable instrument that may be used to assess various levels of functional, interactive and critical health literacy in teenagers between the ages of 15 and 19.27 In the current study, we used a modified version of the HELMA to assess adolescents’ sexual and reproductive literacy. The English version of the HELMA tool was translated into Amharic, and then it was backtranslated to English by different translators and reproductive health experts to check for and ensure accuracy, cultural relevance and any inconsistencies. The items were adjusted to align with local norms and culture to assess RSHL status. Before the data collection pilot study was done, the internal consistency of the scale was checked on 10% of the sample (58 students), not the study site, and we found a Cronbach’s alpha test of 0.88. Students were asked to take separate seats with an adequate distance between chairs and desks to maintain confidentiality before the distribution of questionnaires in the classrooms. The overall activity of data collection was supervised by supervisors. The collected data were reviewed and checked for completeness and consistency before data entry.
Data processing and analysis
After the actual collection of data, the data were checked and entered using Epi-data software V.3.1. Then, for statistical analysis, the data were exported to the SPSS V.25 statistical package. According to the nature of the data, descriptive statistics were computed (for continuous variables, mean and SD were produced, and for categorical variables, frequencies and proportions were assessed). The outcome variable is divided into two categories: desired and limited RSHL. A χ2 was conducted to identify the association between RSHL and each categorical independent variable in sequence. As a result, variables that violated the χ2 assumption were not transferred to logistic regression.
A binary logistic regression model was employed to identify factors associated with limited RSHL. A 95% CI and the crude OR were used to present the bivariable analysis results. All variables with a significant association in a bivariable logistic regression analysis at a p value <0.25 were entered into a multivariable logistic regression analysis. An enter method was used to fit a multivariable logistic regression model to identify independent factors of limited RSHL. In multivariable regression, the strength of the association was reported using an adjusted OR (AOR) with a 95% CI. In the final model, a p value of 0.05 or less is used to declare statistical significance. Model fitness was satisfied (p value=0.99) using the Hosmer-Lemeshow goodness-of-fit statistic. Multicollinearity among responsible variables was checked by looking at the variance inflation factor (VIF) score, and the highest observed VIF value was 4.65, signifying no threat of multicollinearity.
Ethical considerations
This study was carried out after obtaining ethical clearance from the Arba Minch College of Health Science institutional research ethics review board with a reference number AMCHS/02/20/5026 the IRB reviewed and approved the consent procedure for minors involved in the research. This approval ensured that the process of obtaining consent adhered to ethical guidelines and protected the rights and welfare of all participants. A formal letter of cooperation was written to Arba Minch and Sawla High Schools from the Arba Minch College of Health Sciences. Official permission was obtained from the Arba Minch and Sawla town education offices and respective high schools before conducting the study. Before any data was collected, participants received an information sheet regarding the questionnaire, which included details about its goal, advantages, method, length, alternative to participation, and confidentiality. Students were allowed to ask questions and get clarification. Consent was obtained from school principals, and individual written consent for those 18 and 19 years old and assent for those less than 18 were obtained before the questionnaire was delivered to the participants. To protect the privacy of data and enable students to fully disclose their information, parental consent was not sought. No personal identifiers were used to collect the data to maintain the confidentiality of the information and privacy during data collection.
Results
Sociodemographic characteristics
A total of 573 students completed the questionnaire in the current study, yielding a response rate of 99%. The mean age of respondents is 17.25 (± SD 1.27). In this study, 269 (46.9%) participants represent female students. The majority of study participants, 496 (86.6%), live in urban areas (table 1).
Sociodemographic characteristics of study participants at Arba Minch and Sawla high schools, Southern Ethiopia, 2023
Family-related factors
Nearly 75% of study participants claim their housing is privately owned. The majority 522 (91.1%) of study participant live with their biological parents. Sixty-five (11.3%) of study participants reported having health-related relatives (online supplemental file 1).
Supplemental material
General health and behavioural-related factors
Nineteen (3.3%) study participants rated their general health as very bad. Nearly one-tenth of the participants, 41 (7.2%), claimed that they had used cigarettes in the past 12 months. Twenty-two (3.4%) study participants reported using alcohol at least once per week. More than one-third (35.8%) of the study participants had no regular physical exercise (online supplemental file 2).
Sexuality and reproductive behaviour-related factors
Most of the study participants, 238 (41.5%), prefer healthcare workers as sources of reproductive and sexual health information. More than a tenth (13.8%) of study participants reported having a history of sexual intercourse. The minimum age for the initiation of sexual debut was 12 years (online supplemental file 3).
Knowledge related to reproductive and sexual health
Nearly 70% of study participants had poor condom-related knowledge; more than half (52.4%) of the study participants had poor STI/HIV-related knowledge; and 58.8% had poor knowledge related to sexuality.
Score of RSHL and status of RSHL
In the current study, the proportions of participants with varying levels of literacy in reproductive and sexual health were as follows: excellent (4.90%), sufficient (25.50%), problematic (35.60%) and inadequate (34.00%). Additionally, the study found that the majority of participants (69.6%) had limited RSHL.
Factors associated with limited RSHL among late adolescents in Arba Minch and Sawla town high schools
Binary logistic regression was performed to assess the association of each independent variable with the outcome variable. In bivariate analysis, 13 variables, namely age, grade, place of residence, type of school, father’s occupation, mother’s occupation, mother’s educational status, monthly income, access to general health, alcohol use, physical exercise >30 min in the last month, preferred source of reproductive and sexual information, and knowledge about condoms, had an association at p value <0.25 with the outcome variable and were eligible for multivariable logistic regression analysis. After controlling the cofounding effect in multivariable logistic regression analysis, a statistically significant association was observed between type of school, mother’s occupation, monthly income, physical exercise >30 min in the the past month, and knowledge about condoms. The odds of limited reproductive and sexual health literacy were 28% (AOR 0.28 (0.17 to 0.46)) times lower among students who attend public schools. The odds of limited reproductive and sexual health literacy were also 42% (AOR 0.42 (0.23 to 0.76)) times lower among students whose mother’s occupation is a merchant. The odds of limited reproductive and sexual health literacy were 45% (AOR 0.45 (0.22 to 0.95)) times lower among students whose family income monthly is 10 000–20 000 birr. The odds of limited reproductive and sexual health literacy were 44% (AOR 0.44 (0.23 to 0.84)) times lower among students who had physical exercise >30 min more than once per week, and among those with poor knowledge about condoms, the odds of limited reproductive and sexual health literacy status increased by 2.24 (AOR 2.23 (1.38 to 3.64)) (table 2).
Bivariable and multivariable logistic regression analysis for factors associated with limited reproductive and sexual health literacy of study participants at Arba Minch and Sawla high schools, Southern Ethiopia, 2023
Discussion
Proficiency in reproductive and sexual health literacy refers to the capacity to obtain, comprehend, evaluate and implement knowledge concerning sexuality and reproduction in one’s day-to-day existence. The findings are discussed below in light of the current study’s assessment of the proportion of limited RSHL and associated factors among late-adolescent high school students.
The study’s findings showed that 69.6% of limited RSHL (35.6% problematic and 34.0% inadequate) existed. The results show that high school students lack the necessary skills to acquire, comprehend, evaluate (judge) and apply critical information on sexuality and reproduction to make responsible choices in their day-to-day lives. Likewise, a systematic review found that most school-age adolescents have low health literacy.22 In comparison to research done in Uganda, Lao PDR (92.4%), Iran (85%) and Indonesia (81.3%), our results are lower.25 28–30 However, compared with studies conducted in Iran and Australia, which discovered restricted RSHL in just 1.2% and 35.6% of study participants, respectively, the current study yields a greater proportion.12 29 Variations in the sociodemographic attributes of research participants may account for the discrepancy. For instance, age and educational attainment differences may play a role in explaining the discrepancy, given that multiple studies have demonstrated a robust correlation between RSHL and age and educational attainment.28 31–33 The other possible cause could be variations in the availability of different sources of reproductive and sexual health information. Increased RSHL in later studies makes sense because diverse sources improve understanding of reproductive and sexual issues. An alternative explanation for the discrepancies could be that the instruments used to measure reproductive and sexual health literacy differ. The populations in this group have not developed to the point where they can look for, understand and evaluate reproductive and sexual health information because sexual sensations and desires during adolescence seem immature and unconstrained. Adolescents’ reproductive and sexual health behaviour and health may be impacted by limitations in their capacity to evaluate, comprehend, appraise and apply reproductive and sexual health knowledge. The idea of RSHL should be more widely implemented in schools, so that it can be incorporated into the curriculum and help adolescents find, comprehend, evaluate and use reproductive and sexual health material more easily.
According to this study, there is a lower likelihood of limited RSHL among students who attend public schools. Since this is one of the few studies that evaluated RSHL, there is not much similar research. The study, which involved high school students in Iran, provides support for our findings by revealing a favourable correlation between general health literacy and public school learning.34 The explanation might be that, in contrast to private schools, public schools are the initial focus of various stakeholders, such as governmental and non-governmental organisations, while reproductive and sexual health and other program-related initiatives are being implemented. This could increase understanding of reproductive and sexual health and facilitate access to various reproductive and sexual health services. Additionally, reproductive and sexual health clubs and other activities are more frequently offered and structured in public schools. On the other hand, RSHL was found to benefit from attending urban schools, the majority of which were private, according to a Loa PDR study.25
The mother’s occupation is the other significant factor associated with RSHL in the present study. There was a lower likelihood of limited RSHL among students whose mother is a merchant. This may be because merchants are making more money, which has a favourable impact on RSHL.28
The current study’s result showed that family monthly income is related to RSHL, as corroborated by a systematic review that found family monthly income positively affects school-aged adolescents’ health literacy.35 Additionally, comparable results were observed in a single study that involved students from Nepal.36 One possible explanation for this relationship is that higher parental education levels are strongly associated with family money, and these factors have an impact on teenagers’ self-reported RSHL. There could be a greater prevalence of positive parent-child communication among parents in this group, particularly when it comes to reproductive and sexual health aspects. The utilisation of reproductive and sexual health services and information is also influenced by one’s financial situation. On the other hand, a study done on Iranian students revealed no meaningful correlation between RSHL status and economic level.32
Regular physical activity lasting longer than 30 min was the other element that was associated with RSHL in this research; however, no significant association was discovered in a study carried out in the Lao PDR.25 Our results make sense in the following ways: individuals who regularly work out are typically more concerned with their health, participate in sports more actively, and look up and read information about health issues, including reproductive and sexual health.37 Therefore, it makes sense that there would be a correlation between physical activity and reproductive and sexual health literacy since healthy lifestyle choices increase access to information about health issues and reproductive and sexual health services.38 Improving reproductive and sexual health literacy among adolescents, therefore, requires fostering an interest in regular physical activity and incorporating it with health education (including reproductive and sexual health). We recommend that proper planning and integration of physical education into school activities are important for fostering in adolescents an interest in and habit of exercising, both of which will improve their RSHL.
This study indicates that high school students with poor awareness about condoms are more likely to have limited RSHL, which is supported by a study conducted in Laos.25 A strong understanding of condoms may be linked to improved access to and application of reproductive and sexual health information. Age also influences condom knowledge, and it has been shown that RSHL and age have a positive correlation.
Strengths and limitations
This study assessed the level of reproductive and sexual health literacy status and associated factors where evidence was lacking in our country. While most sexual and reproductive health research concentrates on STIs and related behaviours, this study specifically focuses on school-aged teenagers, an age range that has not been the subject of any global reproductive and sexual health literacy investigations. Since the data were collected through self-administered questionnaires, it may be subjected to self-reporting bias. Respondents may increase their sexual and reproductive health literacy scores. Some sensitive questions about sexual and reproductive behaviours might introduce social desirability bias. Also, we did not include adolescents already out of school who might have very different knowledge and experiences. As we used a cross-sectional method, this study pictures the reproductive health literacy statuses of school adolescents at a point in time. So we cannot recognise changes in RSHL over longer periods.
Conclusion
A notable segment of adolescent students exhibited inadequate literacy regarding reproductive and sexual health. Independently responsible factors included the mother’s occupation, the family’s monthly income, the type of school, regular physical activity lasting longer than 30 min and condom knowledge. The result emphasises the necessity of thorough work by all relevant parties to guarantee that information about reproduction and sexual health for adolescents is easily accessible, understood, evaluated and used.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Arba Minch College of Health Sciences Institutional Review Board, Ref. No. AMCHS/01/20/5026. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
First and foremost, we would like to extend our deepest gratitude and appreciation to Arba Minch College of Health Sciences for the facilitation and support of the study. Our deepest gratitude goes to Arba Minch and Sawla town education offices and high schools for their unreserved cooperation during data collection. We are also grateful to the study participants and data collectors. The preprint of this article can be found on R Square at the following link: https://doi.org/10.21203/rs.3.rs-3699332/v1.
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