ODO et al.

BMC Health Services Research (2018) 18:92

DOI 10.1186/s12913-017-2779-x

RESEARCH ARTICLE Open Access

Sexual and reproductive health services

(SRHS) for adolescents in Enugu state,
Nigeria: a mixed methods approach
Amelia Ngozi ODO1*, Efiong Sunday SAMUEL1, Evelyn N. NWAGU1, Petra Obioma NNAMANI2
and Chiemezie S. ATAMA3

Abstract
Background: Availability and accessibility of sexual and reproductive health services for adolescents are very crucial
for prevention and control of sexual and reproductive health problems. These services also play vital roles in the
promotion of adolescents’ sexual and reproductive health generally. The main purpose of the study was to
determine the availability and accessibility (geographical and financial) of sexual and reproductive health services
(SRHS) among adolescents in Enugu State, Nigeria.
Methods: A mixed methods approach was adopted for the study. 192 health facilities were reached to check
availability of SRH services. Randomly sampled 1447 adolescents (12–22 years) completed the questionnaire
correctly. Twenty-seven interviews and 18 group discussions were conducted. Instruments for data collection
consisted of a checklist, a questionnaire, a focus group discussion guide and an in-depth interview guide. All
instruments were pre-tested. Quantitative data were analyzed using descriptive statistics and Chi-square tests.
NVivo 11 Pro software was used to code and thematically analyze the qualitative data.
Results: A total of 1447 adolescents (between 12 and 22 years) completed the questionnaire correctly. Among
these adolescents, males constituted 42.9% while females were 57.1%. The majority (86.7%) of the adolescents
reported availability of safe motherhood services, and 67.5% reported availability of services for prevention and
management of STIs and HIV and AIDS. The majority reported that these services were geographically accessible
but few were financially accessible to adolescents. However, qualitative data revealed that available services were
not specifically provided for adolescents but for general use. Age (p = ≤ .05), education (p = ≤ .05) and income
(p = ≤ .05) were found to be significantly associated with access to SRHS.
Conclusion: SRHS were generally physically available but not financially accessible to adolescents. Adolescents’
clinics were not available and this could affect the access of SRHS by adolescents. Education and income were
significantly associated with access to SRHS.
Keywords: Availability, Accessibility, Sexual and reproductive health services, Adolescents, Mixed method

* Correspondence: [Link]@[Link]; zikaodo@[Link]

1
Department of Human Kinetics and Health Education, University of Nigeria,
Nsukka, Enugu 410001, Nigeria
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
([Link] applies to the data made available in this article, unless otherwise stated.
ODO et al. BMC Health Services Research (2018) 18:92 Page 2 of 12

Background commit induced abortion yearly by unskilled providers

The sexual and reproductive health needs of adolescents and many have serious complications without obtaining
are often underserved in many societies [1], yet adoles- the post abortion care needed [15]. These indicate that
cents constitute large proportion of the population. They the utilization of SRH services by the adolescents in
represent 25% of the world population [2] and are charac- Nigeria is low, arising from disparities in both provision
terized by series of physiological, psychological and social and accessibility of the services and also lack of priority
changes that expose them to unhealthy sexual behaviour to adolescents’ SRH [16]. Availability and accessibility of
such as early sex experimentation, unsafe sex and multiple quality and affordable SRHS ensure adolescents’ sexual
sexual partners [3]. These put them at high risk of sexual and reproductive health wellbeing [17].
and reproductive health (SRH) problems [1]. Such prob- Despite the global promotion of availability of SRH
lems include early marriage, teenage pregnancies, unsafe services, most rural areas still lack these services [18].
abortion, sexually transmitted infections (STIs), HIV and Moreover, both geographical and financial accessibility
AIDS, and other life threatening SRH problems [4]. to SRH services by the adolescents in low and medium
The high increase in the rate of these SRH problems income countries are influenced by different socio-
among young people in sub-Saharan Africa is alarming demographic factors [19, 20]. Age and educational status
[5]. This suggests the need for adequate attention of adolescents were found to affect their use of repro-
towards adolescents’ sexual and reproductive health. ductive health services [21]. This study therefore,
Adolescents’ SRH needs and problems are yet to receive assessed the availability and accessibility of SRHS and
adequate attention especially in the developing countries association between access to SRHS and age, gender,
like Nigeria, despite the recognition of youth-friendly level of education, location and income among adoles-
reproductive health services as a way of improving their cents in Enugu State, Nigeria.
access and utilization of SRH services [6] in order to
achieve quality SRH. Methods
Efforts to attain quality sexual and reproductive health Study area and period
are constrained by inadequate access to and inequitable This study was conducted in Enugu State, Southeast
distribution of quality SRH services especially in sub- Nigeria between January 2015 and July 2016. The state
Sahara African countries. These contribute to poor comprised 17 Local Government Areas (LGAs) with an
utilization of SRHS among young people in sub-Saharan estimated total population of 3,267,837 [22]. Of this
African countries [7], resulting to high prevalence of population, 734,297 (22%) were people of age group 12–
sexual and reproductive health problems especially 22 years; 343,037 (47%) were males and 388,260 (53%)
among the adolescents [8]. An estimate of 333 million were females. Some of these LGAs have commercial
new cases of curable STIs occur mostly in developing areas like big markets and hotels that attract visitors
countries with the highest rate among 20–24 years old, who come for one business or the other. Adolescents in
followed by those within the ages of 15 and 19 years [9]. these areas unlike those in non-commercial areas,
It was also estimated that 1.3 million adolescent girls engage in a lot of business such as hawking and even
and 780,000 adolescent boys were living with HIV commercial sex working. Their males also engage in
worldwide, and 79% of new HIV infection among commercial motor-cycle riding (okada) which exposes
adolescents were in Sub-Saharan Africa [6]. them to rough or unhealthy lifestyles. Such activities ex-
Nigeria has an estimated population of 191, 835, 936 pose them to unsafe sex and early marriage predisposing
[10] with 22.3% adolescents [11]. One in 20 of these ad- them to sexual and reproductive health problems like
olescents contracts a sexually transmitted infections STIs, and HIV and AIDS, teenage pregnancy, abortion
each year, and half of all cases of HIV infection take and their consequences. These unhealthy life styles and
place among people under the age of 25 years [12]. SRH problems may arise because the young people in
About 40% of new HIV infection occurs among young this area do not utilize SRH services due to some social
people in Nigeria [13]. This could result from early and demographic factors. The availability and accessibil-
sexual debut and early marriage which increase adoles- ity of these services to this group of people remained
cents’ HIV vulnerability. The median age at first sexual uncertain and therefore, necessitated the present study.
intercourse is 17.6 and 21.1 years for women and men
respectively, while the median age at first marriage is Design and sampling techniques
18.1 and 27.2 years for women and men respectively A mixed method (quantitative and qualitative) approach
[14]. Teenage and unwanted pregnancies are also prob- was employed. The cross-sectional design was adopted
lems of adolescents especially the unmarried. Although, to assess the availability and accessibility of SRH services
the abortion law and policy in Nigeria prohibits legal ac- to adolescents in Enugu State, Nigeria. The sample was
cess to legal abortion services, about 1.25 million 1620 adolescents; 756 (47%) males and 864 (53%)
ODO et al. BMC Health Services Research (2018) 18:92 Page 3 of 12

females, and 217 public health facilities. The sample size questionnaire respondents in each of the nine LGAs se-
was determined using Cohen, Manion and Morrison’s lected for focus group discussion. This gave 2 groups (1
sample size chart [23] which suggests that when a popu- male group and 1 female group) from each LGA, giving
lation size is five hundred thousand (500,000) and above a total of 18 focus groups. Convenience sampling
at (95%) confidence level and (5%) interval level, the technique was also used to select 3 (1 male and 2
sample size should be three hundred and eighty-four female) interviewees from each LGA for In-Depth
(384) and above and when a population size is five hun- Interview (IDI). This gave a total of 27 interviewees.
dred (500) and above at (95%) confidence level and (5%)
interval level, the sample size should be two hundred Data collection procedure
and seventeen (217) and above. Checklist, questionnaire, focus group discussion guide
Part one: sampling of questionnaire respondents to as- and in-depth interview guide were used to collect data
sess accessibility of SRHS. from the respondents on both personal and group con-
Sampling occurred in three stages. First stage sampling tacts. The checklist was adapted from WHO’s service
involved stratifying the LGAs in each senatorial zone availability and readiness assessment core instrument
into urban and rural LGAs (2 senatorial zones have six [24]; and was used to collect data and measure availabil-
LGAs each, while one senatorial zone has 5 LGAs). The ity of SRHS for adolescents in the health facilities. Only
second stage involved selecting one urban and two rural the sections that elicit information on availability of the
LGAs each from the three senatorial zones using simple SRHS studied were adapted. The health officers-in-
random sampling technique of balloting without re- charge of the health facilities sampled were interviewed
placement. This is because each senatorial zone is made with the Checklist.
up of at least one urban LGA. Two senatorial zones had Structured questionnaire was prepared through review
only one urban LGA each; therefore, the urban LGA in of related literature. The questionnaire which contained
the zone was purposively picked. This sampling gave a two parts was used to measure accessibility of SRHS.
total of nine (3 urban and 6 rural) LGAs out of the Accessibility in our study was measured based on prox-
seventeen LGAs. In each LGA selected, the target sam- imity of health facilities (can walk to the health facility
ple of adolescents was 84 males and 96 females, which within 30 min or not; or less than 1 mile) and affordabil-
gave a total of 252 males and 288 females from each sen- ity of the services to adolescents. First part contained
atorial zone. The third stage involved selecting six polit- the socio-demographic characteristics of the respondents
ical wards (a geographical area made up of few while the second part contained both geographical and
communities) from each LGA using systematic sampling financial accessibility of related components of adoles-
technique so as to spread the sample selection to a rea- cents’ sexual and reproductive health services (sexuality
sonable representation of the LGA. This gave a total of education, family planning services, safe motherhood
fifty-four (54) wards. The target sample at this stage was services, post abortion care and prevention and
14 males and 16 females from each of the six wards treatment of STIs and HIV and AIDS). Validity of the in-
using convenience sampling technique based on accessi- struments was established by five experts. The reliability
bility and willingness of the adolescents to participate. of the questionnaire was established by pre-testing the
This gave the grand total of 1620 (756 males and 864 fe- questionnaire on 20 adolescents in Anambra State (out-
males) being the sample size used for the study. side the study area but with the same characteristics
Part two: sampling of health facilities to assess avail- with the respondents under study). Kudder-Richardson’s
ability of SRHS. formula 21 (K-R 21) was used to determine the reli-
In Enugu State, public health facilities are distributed ability. A reliability coefficient index of .86 was
in LGAs by wards. Every ward therefore, has at least one obtained and the instrument was judged reliable for
public health facility. Public health facilities (which were the study. Researchers and nine trained research as-
used to check the availability of SRHS) were purposively sistants administered the questionnaire. The research
selected for the study since they attract both government assistants used were below 25 years of age. This was
and non-governmental support for reproductive health to avoid much age disparity between the research
services more than the private facilities. From the 508 assistants and the respondents in order for the re-
public facilities, 217 were selected using proportionate spondents to communicate freely.
sampling technique thus ensuring that at least one Focus Group Discussion (FGD) and In-Depth
health facility was selected from each ward. Interview (IDI) were conducted using already prepared
Part three: selection of interview and focus group FGD Guide and IDI guide. The FGD and IDI provided
participants. detailed information on accessibility of SRHS and
Convenience sampling technique was used to select addressed issues not covered by the questionnaire. The
6–10 male and 6–10 female adolescents from the discussions and interviews were recorded with digital
ODO et al. BMC Health Services Research (2018) 18:92 Page 4 of 12

tape recorders. In addition, non-verbal cues from partici- More participants viewed sexuality education to be geo-
pants were recorded through note taking. graphically (66.7%) and financially (58.7%) accessible.
Family planning was viewed to be only geographically
Data processing and analysis accessible (51.9%). Safe motherhood services were con-
Data collected were cross-checked for completeness. sidered by majority to be accessible geographically
Logical techniques were employed to identify errors (70.6%) and financially (61.7%). Post abortion care ser-
during data cleaning. Out of 1620 copies of questionnaire vices were viewed by 51.0% to be geographically access-
and 217 checklists used for data collection, only 1447 ible and prevention and management of STIs and HIV
copies of questionnaire and 192 checklists did not have and AIDS services were considered geographical access-
errors and were used for data analysis. The Statistical ible by 51.6% of the respondents.
Package for the Social Sciences (SPSS) version 20.0 was Table 4 shows that there is significant association be-
employed for statistical analysis of quantitative data. tween both geographical and financial access to sexuality
Percentages were used to assess the availability and acces- education, family planning, and safe motherhood ser-
sibility of SRHS to adolescents, while Chi-square statistic vices and age (p ≤ .05), level of education (p ≤ .05), and
was used to test association between the variables at .05 income (p ≤ .05). Older adolescents (17–22 years) had
level of significance. Data from the checklist on availability more access to the services than the younger adoles-
were presented in Table 2, while data from the question- cents. There is also significant association between both
naire on accessibility were presented in Tables 3 and 4. geographical and financial access to post-abortion
Accessibility in our study was measured both geo- care and age (p ≤ .05), level of education (p ≤ .05) and
graphically and financially. Adolescents who lived not income (p ≤ .05). There are variations in the levels of
more than one mile from or could walk to any public education and income of the respondents and their
health facility where SRHS were provided within 30 min access to the services.
were regarded as having geographical access to SRHS.
Affordability (which was reported by the respondents) Qualitative data
of travelling cost and costs of services as perceived by Availability of SRHS for adolescents
the respondents were used to determine the financial In-depth interview reveals that adolescents interviewed
accessibility. agreed that some of the SRHS were available but not
The responses from focus group discussion and IDI particularly for adolescents. The available services for
were transcribed in English language while maintain- adolescents reported were: sexuality education which is
ing the contexts of the responses. The NVivo 11 Pro provided in the secondary schools through other health-
software was used to code and analyze the data related subjects, and services for prevention and man-
thematically. The data are presented alongside the agement of STIs and HIV and AIDS, which are mainly
quantitative findings. provided by churches and schools during youth week. In
the words of some interviewees:
Results “I get sexuality education services and services for pre-
Table 1 shows the socio-demographic data of the study vention and management of STIs and HIV and AIDS in
sample that responded to the questionnaire. Among par- the school and church during youth’s week but for others,
ticipants (n = 1447), males constituted 42.9% while fe- I don’t know about them” (Udenu 002). On the issue of
males constituted 57.1%. Their age ranged from 12 to family planning and safe motherhood services, partici-
22 years with a mean age of 16.9 years. Most of the par- pants were of the view that the services were only avail-
ticipants had secondary education (54.0%) and most able for married women. One of the interviewee said “I
were Christians (96.3%). Greater proportions of the par- have not received such (family planning services), and I
ticipants were living with their parents (62.3%) and were don’t think it is made for adolescents. It is only for mar-
single (86.8%). Majority had a monthly income less than ried couples” (Enugu-North 003). Another interviewee
₦5000.00 (1 USD = 199.3 NGN). said “safe motherhood services are for married mothers
Table 2 presents data from the health facilities on not for us but I know that the services are available in
availability of SRHS. The table shows that 55.8% of the the health centers for all pregnant women” (Isi-Uzo 001).
health facilities had sexuality education services, 57.1% Interviewees reported non-availability of post-abortion
had family planning information and services, 86.7% had care. An interviewee said “I have not heard of post abor-
safe motherhood services, and 67.5% had services for tion care services and I know there is nothing like that in
prevention and management of STIs and HIV and AIDS. the health centers” (Igbo-Eze South 001).
Tables 3 and 4 present data on accessibility of SRHS. Similarly, focus group discussion revealed that partici-
Table 3 shows that overall geographical and financial ac- pants in the 18 groups (male and female) reported that
cessibility of SRHS was 58.4 and 50.5% respectively. the available SRHS for adolescents are sexuality
ODO et al. BMC Health Services Research (2018) 18:92 Page 5 of 12

Table 1 Socio-Demographic Characteristics of Adolescents that Table 1 Socio-Demographic Characteristics of Adolescents that
Responded to the Questionnaire on Accessibility of SRHS (n = 1447) Responded to the Questionnaire on Accessibility of SRHS (n = 1447)
S/N Characteristics % (Continued)
1 Gender 1000.00 k- 4000.00 k 19.8

Male 42.9 5000.00 k- 10,000.00 k 16.0

Female 57.1 11,000.00 k- 20,000.00 k 8.8

Total 100.0 Above 20,000.00 k 8.6

2 Age Total 100.0

12–16 48.2 Note: 1 USD = 199.3 NGN; for parity, N = 826

17–22 51.8
Total 100.0
education and services for prevention and manage-
3 Education
ment of STIs and HIV and AIDS which they receive
Primary 2.2
in schools and churches. One participant said “Yes
Secondary 54.0 sexuality education services and screening services for
Tertiary 42.0 STIs and HIV/AIDS are being provided for us in
None 1.8 school and church during youth week” (Ezeagu Male
Total 100.0 FGD-P1). The participants had not heard of post--
abortion care (PAC). A participant said “Am hearing
4 Religion
the PAC services for the first time”(Nsukka Female-
Christianity 96.3
FGD-P4) and another male participant from FGD said
Islam 1.5 “No o! There is nowhere these services are provided
African Traditional Religion 2.1 for the adolescents. I have not seen” (Nsukka Male
Total 100.0 FGD-P1).
5 Location
Accessibility of SRHS to adolescents
Urban 43.3
In-depth interview show that interviewees have geo-
Rural 56.7
graphical access to public health facilities that provide
Total 100.0 general SHRS, as they indicated that they can walk to
6 Living Status the health facility within 30 min. One interviewee said,
With parents 62.3 “Yes for me I can trek within 30 minutes because I stay
Alone 20.4 near the hospital” (Enugu-North 001). However, partici-
pants revealed that not all the SRHS were available in
With friends/husband 3.2
the health facilities and the accessible SRHS were not for
In school 14.1
adolescents alone. On financial accessibility, few inter-
Total 100.0 viewees indicated that they could afford the cost of the
7 Marital Status SRHS. An interviewee said “…these services are not fully
Married 12.4 accessible to me because I can’t afford the cost of the ser-
Single 86.8 vices”(Isi-Uzo 003).
FGD participants indicated that available SRHS were
Divorced .4
geographically accessible except in rural areas where
Separated .3
some accessible health facilities do not provide some
Total 100.0 of the SRHS but no affordable. In their words, “Some
8 Parity (females only) are cheap while some are not like services for preven-
None 81.5 tion and management of STIs and HIV and AIDS”
1–3 13.8 (Nsukka Male FGD-P5). “……but the ones I have
accessed are not cheap to me, may be because I am a
4–6 3.0
student” (Isi-Uzo Female FGD-P1).
7 and above 1.7
Total 100.0 Discussion
9 Monthly Income For adolescents to use SRHS and lead a healthy sexual
Below 1000.00 k 46.8 and reproductive live, SRHS have to be available and ad-
equately accessible. Addressing the problem of availability
ODO et al. BMC Health Services Research (2018) 18:92 Page 6 of 12

Table 2 Percentage of sampled facilities that report availability of SRHS in Enugu State (n = 192)
S/N Items
%
Sexuality Education Services
1 Trained sexuality education provider 60.9
2 Education on human biology 51.0
3 Education on puberty and menstrual hygiene practices for youth 73.4
4 Education on skills to overcome sexual desires for youth 42.7
5 Education on healthy Associations for youth 42.7
6 Education on dangers of premarital and unsafe sex for youth 72.9
7 Information on reproductive rights and policy for youth 34.4
8 Information on harmful cultural practices like female circumcision 65.6
9 Information on prevention of non-infectious conditions of reproductive health such as fistula and cancers 58.9
Cluster % Total 55.8
Family Planning Information and Services
10 Trained family planning provider 59.9
11 Family planning information 80.7
12 Oral pills 61.5
13 Injectable contraceptives 52.6
14 Male condoms 81.8
15 Female condoms 70.8
16 Intrauterine contraceptive device (IUCD) 27.1
17 Emergency contraceptives 22.4
Cluster % Total 57.1
Safe Motherhood Services
18 Trained midwife 62.5
19 Antenatal services for pregnant youth 92.7
20 Safe delivery services for youth 92.7
21 Postnatal services for youth 87.5
22 Immunization services 92.7
23 Growth monitoring services 93.2
24 Information on infant feeding practices 85.9
Cluster % Total 86.7
Post Abortion Care (PAC) Services
25 Trained PAC provider 19.3
26 Emergency health care, in cases of bleeding and shock 69.8
27 Manual vacuum aspiration (evacuation) of retained product of conception 30.7
28 Information on prevention and management of STIs and HIV and AIDS for youth 71.4
Cluster % Total 47.8
Prevention and Management of STIs and HIV and AIDS Services
28 Trained HIV and AIDS services provider 63.0
29 Information on prevention and management of STIs, HIV and AIDS for youth 89.6
30 Voluntary counseling and testing for youth 83.3
31 Antiretroviral therapy for youth 35.4
32 Services for the prevention of mother-to-child transmission of HIV and other STIs 64.1
33 Condoms for sexually active youth 69.3
Cluster % Total 67.5
ODO et al. BMC Health Services Research (2018) 18:92 Page 7 of 12

Table 3 Percentage of Sampled Adolescents that Reported Accessibility of SRHS in Enugu State (n = 1447)
S/N Items Geographical Access % Financial Access %
Sexuality Education Services such as education on
1 human biology 70.0 60.8
2 Puberty 72.3 62.4
3 menstrual hygiene 70.4 63.2
4 skills to overcome sexual desires 61.2 56.4
5 healthy Associations 61.2 52.8
6 dangers of premarital and unsafe sex 65.2 56.5
Cluster % Total 66.7 58.7
Family Planning Information and Services such as
7 Condoms 72.8 65.9
8 Oral pills 52.6 44.9
9 Injectable contraceptives 45.0 35.0
10 Intrauterine contraceptive device (IUCD) 37.2 29.2
Cluster % Total 51.9 43.8
Safe Motherhood Services such as
11 Antenatal 75.5 63.9
12 Safe delivery 69.8 60.5
13 Postnatal 66.3 57.1
14 Immunization 77.2 69.5
15 Infant feeding information 64.2 57.7
Cluster % Total 70.6 61.7
Post Abortion Care (PAC) Services such as
16 Emergency care during bleeding 50.5 41.2
17 Manual removal of retained product of conception 35.9 30.2
18 Information on the prevention of unwanted pregnancy 59.0 52.1
19 Information on prevention of abortion 58.7 51.8
Cluster % Total 51.0 43.8
Prevention and Management of STIs and HIV and AIDS Services such as
20 Voluntary counseling and testing 67.0 56.3
21 Provision of antiretroviral therapy (ART) 36.0 32.9
22 Treatment of STIs 49.1 41.1
23 Supply of condoms 54.0 47.3
24 prevention of mother-to-child transmission of HIV and other STIs 52.0 45.5
Cluster % Total 51.6 44.6
Overall % Total 58.4 50.5

and accessibility of SRHS for adolescents is essential to in- The secrecy accorded to sexual issues in the study area
creasing adolescents’ utilization of SRHS. Most peer was a challenge to this study and might be the reason
reviewed literature used quantitative data only. Quantita- for some differences in qualitative and quantitative data.
tive data only seem not to get adequate SRH information The study was delimited to adolescents in Enugu State,
from adolescents especially in developing countries like and therefore, may not be used to generalize to all
Nigeria, where culture and tradition still affect adoles- adolescents in a multi-ethnic country like Nigeria.
cents’ SRH. This study was therefore, aimed at assessing The available SRHS were sexuality education, family
SRHS available and accessible to adolescents in Enugu planning, safe motherhood, and prevention and manage-
State, using mixed method (quantitative and qualitative). ment of STIs, and HIV and AIDS, most of which are
Table 4 Association between Socio-Demographic Factors and Access to SRHS among Adolescents in Enugu State (n = 1447). Socio-Demographical Factors Associated with SRHS
Factors Sexuality Education Family Planning Safe Motherhood
Geographical Access Financial Access Geographical Access Financial Access Geographical Access Financial Access
% χ2 P % χ2 p % χ2 P % χ2 P % χ2 p % χ2 p
AC AF AC AF AC AF
Gender
Male 72.6 7.477 .006* 69.6 .921 .337** 61.7 .587 .443** 53.9 5.748 .017* 71.8 1.144 .285** 62.0 .176 .675**
Female 78.8 67.2 59.7 47.6 74.3 63.1
Age
12–16 72.9 7.937 .005* 65.6 4.333 .037* 52.7 34.996 .000* 41.6 40.753 .000* 66.1 34.741 .000* 55.8 26.576 .000*
17–22 78.8 70.7 67.9 58.4 79.9 68.9
Level of education
Primary 53.1 26.417 .000* 46.9 22.245 .000* 56.2 45.767 .000* 37.5 47.201 .000* 65.6 29.136 .000* 50.0 26.711 .000*
ODO et al. BMC Health Services Research (2018) 18:92

Secondary 73.0 64.8 53.1 43.0 68.5 57.4

Tertiary 81.9 74.2 70.7 60.9 80.4 70.2
None 65.4 57.7 50.0 38.5 57.7 57.7
Location
Urban 77.4 .870 .351** 64.0 9.237 .002* 61.9 .835 .361** 50.2 .002 .962** 71.6 1.527 .217** 54.4 31.985 .000*
Rural 75.2 71.5 59.5 50.4 74.5 68.9
Income(₦)
<1000 72.4 11.193 .024* 65.7 9.765 .045* 54.1 42.677 .000* 45.2 32.052 .000* 65.6 38.675 .000* 57.0 19.113 .001*
1000–4000 78.7 71.7 59.1 47.6 80.4 70.3
5000–10,000 79.7 66.8 62.9 51.3 78.4 67.7
11,000–20,000 78.1 78.1 78.1 65.6 80.5 64.8
>200,000 76.6 66.1 76.6 66.1 81.5 63.7
Page 8 of 12
Table 4 Association between Socio-Demographic Factors and Access to SRHS among Adolescents in Enugu State (n = 1447). Socio-Demographical Factors Associated with SRHS
(Continued)
Factors Post Abortion Care Prevention and Management of STIs, HIV and AIDS
Geographical Access Financial Access Geographical Access Financial Access
% χ2 P % χ2 P % χ2 P % χ2 p
AC AF AC AF
Gender
Male 63.4 .145 .704** 57.5 .831 .362** 55.1 2.122 .145** 50.9 11.561 .001*
Female 62.9 55.1 51.2 41.9
Age
12–16 59.8 5.398 .020* 51.1 13.871 .000* 51.2 1.467 .226** 42.0 7.468 .006*
17–22 65.7 60.8 54.4 49.2
Level of education
ODO et al. BMC Health Services Research (2018) 18:92

Primary 46.9 16.076 .001* 43.8 26.103 .000* 37.5 4.405 .221** 34.4 4.764 .190**
Secondary 59.8 51.0 52.0 44.3
Tertiary 68.3 63.8 54.9 48.5
None 50.0 46.2 50.0 38.5
Location
Urban 65.7 3.773 .052** 55.3 .269 .604** 58.1 11.943 .001* 44.5 .699 .403**
Rural 60.7 56.7 48.9 46.7
Income(₦)
<1000 57.3 19.573 .001* 53.2 10.363 .035* 54.8 7.277 .122** 47.9 10.349 .035*
1000–4000 66.4 57.0 49.7 44.4
5000–10,000 65.5 54.7 48.3 38.4
11,000–20,000 73.4 67.2 50.8 43.0
>200,000 69.4 61.3 60.5 54.0
AC Accessible, AF Affordable, χ2 = Chi-square, p = p-value, *significant, **Not significant, at .05 level of significance, 1USD = 199.3NGN
AC Accessible, AF Affordable, χ2 Chi-square, p p-value, *significant, **Not significant at .05 level of significance
Page 9 of 12
ODO et al. BMC Health Services Research (2018) 18:92 Page 10 of 12

provided in schools and churches. Previous studies also Statistically significant associations exist between
reported schools and churches as most important com- both geographical and financial access to sexuality
munity sources of sex education [25, 26]. Moreover, education, family planning, safe motherhood services
family planning and safe motherhood services were pro- and post-abortion care and age, level of education
vided in almost all the primary health centers in the and income. This implies that age, education and in-
state. However, these services were general services and come can influence adolescents’ access to sexuality
not specifically for adolescents as revealed by qualitative education, family planning, safe motherhood and post
data and absence of youth clinic or unit in all the health abortion care. Older adolescents accessed the services
facilities visited. The finding was at variance with previ- more than the younger ones. Older adolescents are
ous studies that reported lack of SRHS [27, 28]. Qualita- more independent than the younger ones and so
tive data revealed that the most available SRHS for could decide to access or not to access SRHS. The
adolescents were sexuality education services and ser- finding is consistent with previous assertion that level
vices for prevention and management of STIs, HIV and of access of health services is lower in younger ado-
AIDS provided in schools and churches during youth lescents [35]. It was also observed during in-depth
weeks and not in the health facilities [29]. This finding interview and focus group discussion that younger
could be due to the fact that adolescent/youth clinics or participants were silent and of little knowledge of majority
units were lacking in the political wards and health facil- of issues discussed [36]. The finding could also be related
ities visited. The qualitative data were therefore, in sup- to poor sexuality education at home and even in
port of the findings of similar studies which stated that schools. Some parents may not give their children age
only few health facilities provided the essential SRH ser- appropriate sex education which should begin at home.
vices for young people [7, 27]. It has also been observed by that some schools do not
All the available SRHS were geographically accessible teach sex education as a separate subject but subsumed
while only two (sexuality education and safe motherhood under other subjects.
services) were financially accessible. Every political ward Our study found that respondents with secondary
we visited had at least one primary health facility. Sexu- education accessed SRHS more than those with other
ality education was financially accessible because it was levels of education, even tertiary. This was at variance
provided mainly in the churches and schools and no fur- with the assertion that more educated people are
ther payments apart from school fees were required. Safe more likely to access health care and understand with
motherhood services were also financially accessible be- self-confidence to act on them [37]. Similar study
cause government provided these services at a much re- opined that education can lead to higher ability to
duced price and sometimes free. The finding was process health-related information and also influence
consistent with the assertion that young people should an individual’s preference for future, which in turn
have universal access to SRHS [30, 31]. The finding was, improves his or her health behaviour and health
however, at variance with the finding of low accessibility outcomes [38–40].
of SRHS to adolescents reported by previous studies that Furthermore, the significant association between
utilized quantitative data [18, 32]. income and access (financial) to SRHS in this study is
Our qualitative findings from IDI revealed that more uncommon. Respondents with income between ₦5000
than half (55.6%) of the interviewees had geographical and ₦10,000 had more financial access to SRHS than
access to SHRS as they indicated that they could walk to those with income above ₦10,000. Previous studies show
the health facility within 30 min. However, most of the higher access with higher income levels [41, 42]. How-
interviewees revealed that not all the SRHS were avail- ever, lower income negatively influenced adolescents’
able in the health facilities [33] and some of the access- access to the services [43]. Our qualitative data revealed
ible SRHS were not for adolescents alone, but rather for that sexuality education and prevention and manage-
everybody. On financial accessibility, slightly more than ment of STIs and HIV and AIDS were provided mostly
one third (37.0%) of the interviewees indicated that they in schools and churches for both male and female ado-
could afford the cost of the SRHS. Data collected lescents. However, some male participants in the FGD
through FGD revealed that majority of both male and fe- were of the opinion that SRH services were meant for
male participants indicated that available SRHS were geo- girls only. Boys perceived SRHS as designated for girls
graphically accessible except in rural areas where some [44]. This finding is however, similar to the findings of
accessible health facilities do not provide some of the studies conducted in Nigeria [45] and Ethiopia [21] that
SRHS. This finding opposes previous assertion that costs of reported association between gender and access and
services were barriers to adolescents’ access to SRHS [34]. utilization of health services. The finding is not consist-
Though, these services according to the participants are ent with a study that reported no difference between
affordable, they are provided free to only pregnant women. gender and access to SRHS [18].
ODO et al. BMC Health Services Research (2018) 18:92 Page 11 of 12

Conclusions Received: 22 April 2017 Accepted: 6 December 2017

We found that the majority of the SRH services were
available and geographically accessible, but very few were
financially accessible to adolescents. These services were References
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