Reproductive Health Literacy and Associated Factors Among High School Adolescents in Boke District, Eastern Ethiopia
Abstract
Background: In recent years, the importance of health literacy in public health has attracted global interest as it affects people’s ability to make health decisions and is associated with health outcomes. Reproductive health literacy (RHL), in particular, affects adolescent’s ability to make sound sexual and reproductive health (SRH) decisions and is shown as a strong predictor of adolescent’s RH outcomes. This study aimed to determine the RHL status and associated factors among high school adolescents in Eastern Ethiopia.
Methods: Institutional-based cross-sectional study was conducted among 403 randomly selected secondary school adolescents in Boke District, Eastern Ethiopia, from January 1–5, 2021. Data were collected through pretested, structured, and self-administered questionnaires, entered into Epidata version 3.1, and analyzed by Statistical Package for the Social Sciences (SPSS) version 23. A comprehensive questionnaires were designed to measure adolescents’ RHL in four functional dimensions (access, understand, appraise, and apply information). A participant’s RHL was categorized as limited or adequate, based on a transformed scale of measurements from 0 to 50. The predictors of the outcome variable were assessed using a logistic regression model and reported using adjusted odds ratio (AOR) with 95% confidence interval (CI). A statistical significance was declared at a p value of <0.05.
Results: The overall prevalence of limited RHL among adolescents was 81.6% with a 95% CI (77.5%−85.2%). In-school male adolescents were 52% less likely to score in limited RHL status than their female counterparts (AOR = 0.48, 95% CI = 0.26, 0.88). Adolescents who reported attending reproductive health (RH)–related topics in class were 56% less likely to score in limited RHL status than their counterparts (AOR = 0.44, 95% CI = 0.23, 0.84). Furthermore, adolescents who reported using at least one RH service component were 60% times less likely to score in limited RHL status compared to their counterparts (AOR = 0.40, 95% CI = 0.23, 0.70).
Conclusion: A high proportion of school adolescents have limited RHL, suggesting school adolescents are at higher risk of RHL–related problems. Improving adolescent RHL with due attention to school, SRH education is warranted.
1. Introduction
Health literacy refers to social and cognitive skills that entail an individual’s motivation and competencies to access, understand, appraise, and apply information in healthcare decisions, disease prevention, and health promotion [1]. Health literacy is a multidimensional concept [2] that can be learned and developed over time [3]. It is not merely about personal capability to utilize information provided externally, however, consider other abilities such as understanding one’s preferences in health issues and the ethical consequences of one’s actions on others and the world [4]. In recent years, the importance of health literacy in public health has attracted global interest, essentially in adolescent health [5, 6]. Studies have reported the link between health literacy levels and health outcomes; with people who have limited health literacy experiencing adverse health outcomes, poor reproductive health (RH) decisions, and higher financial costs of health care [7–9].
Adolescent sexual and reproductive health literacy (SRHL) is of particular, affects their ability to make sound SRH decisions and shown as a strong predictor of adolescents’ SRH outcomes [10, 11]. Adolescents are at a critical stage when new and different health problems related to the onset of sexual activity, emotional control, and behavior typically emerge and pose a major threat to their current and future health and well-being [12]. Notably, adolescents are at a crucial developmental stage when advances in cognitive abilities, information-processing capacities, and reasoning skills are achieved [13]. Based on these vulnerabilities and opportunities, adolescence is a suitable developmental stage to promote health literacy, especially in the domain of SRH, as health literacy interventions during adolescence have a positive health impact on an individual’s future life [3].
Low health literacy is a global problem. For instance, according to a recent systematic review, approximately 48%, 64.8%, and 67.5% of adults in Europe, Sub-Saharan Africa, and Southern Asia are thought to have limited health literacy, respectively [14–16]. In Ethiopia, adolescents face numerous risks to their SRH including teenage pregnancy, sexual violence, early marriage, unintended pregnancy, and sexually transmitted infections including HIV [17]. One of the contributing factors to the rising SRH burden among the adolescent population is low SRHL [10].
Considering adolescent health as a priority concern for social, political, and economic development, the government of Ethiopia has been undertaking different initiatives over the last two decades [18, 19]. Numerous policies and guidelines to support implementing youth-friendly services have been developed. One of the intervention modalities suggested to promote adolescents’ health was innovative health education and prevention information through the school systems, since a venue to reach the majority of adolescents [11, 19]. Furthermore, the newly adopted strategy calls for a new intervention to continually improve the health and development of adolescents through participation [19]. Thus, SRHL is crucial for adolescents to actively participate in their SRH care, interact with the health system, and access health information to mold their actions and behaviors.
Despite, schools being considered a critical setting for health literacy development; however, the extent to which health literacy is recognized and prioritized varies considerably within and between countries and schools [4]. It is also important to note that institutional commitment and priority, workplace culture, and awareness of needy people can influence the level of health literacy [20, 21]. Given that health literacy is a new concept and has been positioned as a means to promote adolescent health [22], there is a paucity of evidence regarding the level of SRHL among in-school adolescents in Ethiopia, particularly in the Boke District of Eastern Ethiopia. Indeed, it is vital to generate evidence regarding SRHL level and its predictors among in-school adolescents. Therefore, this study aimed to determine the level of RH literacy (RHL) and its associated factors among in-school adolescents in the Boke District of Eastern Ethiopia. This study will contribute to the design of intervention strategies aimed at improving the SRH of adolescents.
2. Methods and Materials
2.1. Study Setting and Period
The study was conducted in Boke District, Oromia Region, Eastern Ethiopia. The district is 372 km away from Addis Abeba, the capital city of Ethiopia, and 69 km from the Zonal capital, Chiro. The altitude ranges from 750 to 2400 Km above sea level. Administratively, the district is divided into 23 Kebele (one urban and 22 rural; the smallest administrative unit in Ethiopia). Regarding the health and education infrastructure, the district has 27 health facilities (five health centers and 22 health posts) and 56 schools (Four high schools and 52 primary schools). In 2020, the total population of the district was 144,658 (based on the projection of the 2007 national census, Central Statistical Agency (CSA)). The study was conducted from January 1–5, 2021.
2.2. Study Design, Population, and Eligibility Criteria
Institutional-based cross-sectional study design was conducted on high school adolescent students. All adolescent students aged 15–19 years attending their education in secondary schools of Boke District were considered a source population; whereas, all adolescent students attending public secondary schools in Boke District and available during the data collection were regarded as the study population. The study excluded those students who were critically ill, visually impaired, unable to fill out the questionnaire during data collection, and who could not provide formal informed consent from their parent or guardian (if their age was less than 18 years).
2.3. Sample Size Determination and Sampling Technique
The sample size for this study was calculated by a single population proportion formula (n = (Z α/2)2P (1-P)/d2) considering the following assumptions: 50% prevalence of adequate RHL, 95% confidence level, 5% tolerable margin of error, and 5% expected nonresponse rate. The final sample size was 403.
A stratified multistage sampling technique was used to select the study participants. First, three high schools were randomly selected from four secondary schools in the district. To achieve representativeness, the study participants were stratified based on their academic level (Grades 9,10, 11, and 12) in each randomly selected school. Then, the total number of students aged 15–19 years in each stratum was identified based on their registration numbers. Accordingly, a total of 2368 adolescent students were identified. Next, the probability to proportional sampling was used to allocate the total sample size proportional to the size of study participants in each stratum. Finally, eligible study participant was selected using a systematic sampling technique. A sampling interval (K) was calculated by dividing the total number of adolescents by the total sample size; K = N/n, 2368/403 = 5.9 Thus, the sampling interval (K) became 6 and the first eligible participant was selected by lottery method (Figure 1).
2.4. Measurements and Variables
In this study, the dependent variable was RHL status. It was assessed by comprehensive questionnaires designed from related literature by the investigator. The measurable outcome was dichotomized as limited and adequate RHL. Adolescents were asked to rate their perceived ability to access, understand, appraise, and apply RH information using a five-point Likert scale scored from 0 to 4, which stands for a scale of do not know = 0′ to very easy = 4′. A total of 31 questions were measured and transformed into a scale from 0 to 50, where 0 represents the lowest and 50 is the highest RHL score level. Based on this score, RHL was categorized into four levels: inadequate (0–25), problematic (>25–33), sufficient (>33–42), and excellent (>42–50). Finally, those who scored inadequate or problematic RHL were defined as limited health literacy and those with sufficient and excellent health literacy were defined as adequate health literacy.
2.5. Data Collection Tools
Due to the lack of a standardized and validated tool to measure in-school adolescent’s SRHL at the national level, the researcher designed questionnaires (measuring RHL in four functional areas of health literacy) based on the adolescent health literacy framework [21] and Health Literacy Measure for Adolescents (HELMA) which is a valid and reliable tool for the measurement of the health literacy of adolescents aged 15–19 years, and validated RH questionnaires among unmarried youth in China [23, 24]. In addition, the researcher designed questionnaires reviewing related literature and validated questionnaires in another area [25–28] and contextualized them to the study objectives. Finally, in alignment with the objectives of the study, the tool was divided into four sections: sociodemographic, adolescent information-seeking behavior, and RH service utilization, and items for measuring RHL in four functional dimensions (access, understand, appraise, and apply RH information).
2.6. Data Quality Control
Data were collected by pretested, structured, and self-administered questionnaires. A pretesting was conducted to check the content validity and consistency of the collection tools before the actual data collection commencement. The data collection instrument was pretested on 5% of the sample in Bedesa High School adolescents (near nonstudy adjacent districts school). Six nurses and two public health officers who were fluent in the local language were assigned as data collectors and supervisors, respectively, after having 2 days of training on the study objectives, responsibilities, and rights of respondents. At first, the questionnaire was prepared in English. Then it was translated into Afan Oromo (the local language) by a language expert who fluently speaks both English and Afan Oromo language. To ensure translation consistency, the Afan Oromo version was translated back into English by another language expert who fluently speaks both languages being blind to the original version. All completed questionnaires were checked daily to ensure completeness and consistency at all stages of the data collection period. Furthermore, double data entry was done for 20% of the questionnaire to see consistency using an Epi-Data version 3.1 software package before report writing.
2.7. Operational Definitions
Adequate RHL status: those respondents with sufficient or excellent RHL scores.
Limited RHL status: those respondents with inadequate RHL or problematic health literacy.
Inadequate health literacy: a literacy status marked for a respondent with a mean index score of 0–25.
Problematic health literacy: a literacy status marked for a respondent with a mean index score of 26–33.
Sufficient health literacy: a literacy status marked for a respondent with a mean index score of 34–42.
Excellent health literacy: a literacy status marked for a respondent with a mean index score of 43–50.
2.8. Data Processing and Analysis
Data was collected, cleaned, coded, and double-entered into Epidata 3.1, then exported into Statistical Package for the Social Sciences (SPSS) version 23 for statistical analysis. Descriptive statistics were used to calculate the frequency distribution. Descriptive statistics were computed and mean (standard deviation (SD)) for continuous data and frequency and percentage for categorical data were used to describe adolescents’ characteristics. A logistic regression model was used to examine the association between outcome and interested independent variables. First, binary logistic regression analysis was executed. Then, independent variables that showed association with the outcome variable at a p value less than or equal to 0.20 in the binary logistic regression model were preceeded into a multivariable logistic regression model, to identify predictors of adolescent RHL. Regarding the suitability of the statistical model, model fitness was done using Hosmer–Lemeshow model fitness. A multicollinearity test was also carried out to check the presence of correlation between independent variables using the variance inflation factor (VIF). All VIF values were less than 1.10 which has no significant issue. Finally, the significant statistical association was declared at a p value less than 0.05 and reported using an adjusted odds ratio (AOR) with 95% confidence interval (CI).
2.9. Ethical Approval and Consent to Participate
The study obtained ethical clearance from the Institutional Health Research Ethics Review Committee (IHRERC) of Haramaya University, College of Health and Medical Sciences (Ref. No. IHRERC/247/2020). A supporting letter received from Haramaya University was submitted to the Boke District, West Hararghe Education Office, and the respective School. After getting permission from all concerned bodies, written informed consent was obtained from study participants. For participants below the age of 18 years, written informed consent was obtained from their parents or legal guardians and assent was obtained from the participants for their participation. To preserve participant confidentiality, names and other forms of personal identifiers were coded and anonymized throughout the study.
3. Results
3.1. Sociodemographic Characteristics of the Study Participants
In total, 403 in-school adolescents were targeted to participate in the study and 391 of them were interviewed, resulting response rate of 97.02%. The mean age (±SD) of the participant was 17.21 (±1.22) years. Male participants accounted for 247 (63.2%). The majority of the participants, 325 (83.1%) belong to the Muslim religion. Most of the study participants, 367 (93.86%) were single or never married. Nearly a third (33.5%) of participants were Grade 9 attendants. The detailed distribution of sociodemographic characteristics of the participants is shown in Table 1.
| Variables | Frequency | Percent |
|---|---|---|
| Age (in years) | ||
| 15–16 | 120 | 30.7 |
| 17–19 | 271 | 69.3 |
| Sex | ||
| Female | 145 | 37.08 |
| Male | 246 | 62.92 |
| Marital status | ||
| Married | 24 | 6.14 |
| Single | 367 | 93.86 |
| Religion | ||
| Muslim | 353 | 90.28 |
| Non-Muslim | 38 | 9.72 |
| Level of education | ||
| Grade 9 | 131 | 33.5 |
| Grade 10 | 108 | 27.6 |
| Grade 11 | 87 | 22.3 |
| Grade 12 | 65 | 16.6 |
3.2. Source of RH Information and Information-Seeking Behavior Among the Study Participants
Slightly more than a third (34.8%) of the adolescents had never attended RH subjects in class, and more than three-quarters (76%) of them tend to have learned more RH topics in school. The majority of adolescents (69.1%) had never used any RH services, and more than a third (37.9%) participated in school adolescent SRH club activities. Concerning the source of RH information, the most preferred source of information for adolescents was health workers (40.9%), followed by school teachers (28.6%; Table 2).
| Characteristics | Frequency | Percent |
|---|---|---|
| Ever attended RH subject in class | ||
| Yes | 255 | 61.2 |
| No | 136 | 34.8 |
| Tend to learn more RH topics in class | ||
| Yes | 297 | 76.0 |
| No | 94 | 24.0 |
| Ever used SRH services | ||
| Yes | 104 | 26.6 |
| No | 287 | 73.4 |
| Participated in school adolescent and youth SRH club | ||
| Regular | 156 | 39.9 |
| Never/rare | 235 | 60.1 |
| Preferred source of RH information | ||
| Books/magazine | 16 | 4.1 |
| Health workers/doctors | 160 | 40.9 |
| Friend/peer | 34 | 8.7 |
| Internet | 13 | 3.3 |
| Parent | 56 | 14.3 |
| School teacher | 112 | 28.6 |
- Abbreviations: RH, reproductive health; SRH, sexual and RH.
3.3. Reproductive Health Literacy (RHL) Status Among In-School Adolescents
Concerning the prevalence of RHL, above three-quarters of adolescents have limited RHL status (81.6% with a 95% CI (77.5%−85.2%); Figure 2). Based on the analysis of four RHL score classifications, the results of this study showed that 16 (4.1%), 56 (14.3%), 88 (22.5%), and 231 (59.1%) adolescents had excellent, sufficient, problematic, and inadequate RH literacy, respectively. Moreover, based on four health literacy domains, the overall average RHL score was 23.9/50. The highest score (26/50) was related to understanding RH information, whereas the lowest score (22.4/50) was related to appraising RH information (Figure 3).
3.4. Factors Associated With RHL Among High School Adolescents
In this study, multivariate logistic regression analysis revealed, that the sex of adolescents, ever-attended RH topics in class, and ever-use of RH services were significantly associated with RHL status.
In-school male adolescents were 52% less likely to have limited RHL compared to their female counterparts (AOR = 0.48, 95% CI = 0.26, 0.88). On the other hand, in-school adolescents who reported ever attending RH–related topics in class were 56% times (AOR = 0.44, 95% CI = 0.23, 0.84) less likely to have limited RHL status compared to their counterparts. Furthermore, in-school school adolescents who reported using at least one RH service component were 60% times (AOR = 0.40, 95% CI = 0.23, 0.70) less likely to have limited RHL status compared to their counterparts (Table 3).
| Variables | RHL status | COR (95% CI) | AOR (95% CI) | |
|---|---|---|---|---|
| Limited | Adequate | |||
| N (%) | N (%) | |||
| Sex | ||||
| Male | 191 (77.6) | 55 (22.4) | 0.46 (0.25,0.83) | 0.48 (0.26,0.88) ∗ |
| Female | 128 (88.3) | 17 (11.7) | 1 | 1 |
| Marital status | ||||
| Single | 68 (18.5) | 299 (81.5) | 0.88 (0.32,1.28) | 1.0 (0.32,3.15) |
| Married | 4 (16.7) | 20 (83.3) | 1 | 1 |
| Religion | ||||
| Muslim | 289 (81.9) | 64 (18.1) | 1.2 (0.53,2.74) | 1.48 (0.61,3.60) |
| Non-Muslim | 30 (78.9) | 8 (21.1) | 1 | 1 |
| Ever attend RH topics in class | ||||
| Yes | 197 (77.3) | 58 (22.7) | 0.39 (0.24, 0.73) | 0.44 (0.23,0.84) ∗ |
| No | 122 (89.7) | 14 (10.3) | 1 | 1 |
| Ever use SRH service | ||||
| Yes | 71 (68.3) | 33 (31.7 | 0.34 (0.2, 0.58) | 0.40 (0.23,0.7) ∗ |
| No | 248 (86.4) | 39 (13.6) | 1 | 1 |
| Participated in SRH club | ||||
| Regular | 118 (75.6) | 38 (24.4) | 0.53 (0.31,0.88) | 0.71 (0.41,1.23) |
| Never/rare | 201 (85.5) | 34 (14.5) | 1 | 1 |
- Note: ∗Significant at p value <0.05 for AOR.
- Abbreviations: AOR, adjusted odd ratio; CI, confidence interval; COR, crude odd ratio; RH, reproductive health; RHL, reproductive health literacy; SRH, sexual and reproductive health.
4. Discussion
The study aimed to determine RHL status and associated factors among high school adolescents. Our findings revealed that more than three-quarters of in-school adolescents have limited RHL (81.6%, 95% CI [77.5%−85.2%]). In particular, the study found that the sex of adolescents, ever attending RH subjects in class, and utilization of SRH services were identified to be factors significantly associated with the limited RHL status of adolescents.
The present study revealed that the proportion of limited RHL among high school adolescents was high (81.6%). The finding was in line with the study done on youth in Bander Abbas, Iran (85%) [29]. Although comparable studies are lacking on SRHL among school-based adolescents in low-income countries, by proxy, the proportion of limited RH literacy in the current study is higher than comprehensive health literacy measurement among undergraduate students in Ghana (54.6) [30] The high proportion of limited RHL in the current study might be related to the difficulty of adolescents in accessing the right RH information and poor habits of applications of RH information.
In the present study, sex was found to be significantly associated with the RHL status of school adolescents. The odds of scoring in limited RHL were lower among male adolescents by 52% (AOR = 0.48, 95% CI = 0.26, 0.88) compared to their female counterparts. Even though comparable literature is lacking specific to RHL, the present finding is supported by previous studies [31, 32], which reported higher odds of limited health literacy among female participants. However, this finding contrasts with the study conducted in Iran which reported no association between RHL with gender [29]. The possible explanation for the link between gender and RHL may be due to gender inequalities and roles that hinder female students’ access to appropriate RH information. Restrictions on women’s movement, participation in politics, and social affairs limit their access to various sources of health information [33], which might in turn contribute to their lower health literacy status.
Ever attending RH–related subjects in class was another factor found to be significantly associated with the RHL status of school adolescents in the present study. Accordingly, adolescents who reported ever attending RH–related subjects in the class were 56% times less likely to score in limited RHL status compared to their counterparts (AOR = 0.44, 95% CI = 0.23, 0.84). The finding is consistent with previous studies [26]. This may be possibly due to access to RH information from educational sources in advance, which may contribute to better health literacy.
Utilization of SRH services was also found to be significantly associated with adolescents’ RHL status. Adolescents who reported ever use of at least one of the SRH service components were 60% less likely to score in limited RHL status than nonusers (AOR = 0.40, 95% CI = 0.23, 0.7). This is in alignment with the previous study [33] and the authors’ expectations. It is logically anticipated that people with high health literacy scores have better decision-making capability; and thus, better healthcare seeking than those with low health literacy scores [10, 34].
4.1. Implication for Practice and Limitations of the Study
This study sheds light on the level of RHL and associated factors among in-school adolescents. Therefore, it could aid in school-based intervention for secondary school students in the study area. Despite the valuable findings, this study has admitted a few limitations. First, since data were collected through self-administered questionnaires and with not validated domestically, the study may be subjected to self-reporting and social desirability bias. Second, as it was a cross-sectional design, the study cannot recognize or establish the cause–effect relationship between outcome and independent variables. Finally, due to the limited sample size, the findings of this study may not be generalizable to school adolescents in Ethiopia.
5. Conclusion
This study showed that a large proportion of school adolescents have limited RHL, suggesting school adolescents lack adequate competencies in RHL; and thus, are at higher risk of RHL–related problems. Respondent’s sex, ever attending RH–related subjects in the class, and utilization of SRH services were found to be predictors of RHL status among school adolescents in the study area. Thus, efforts should be made to improve adolescent RHL with due attention to school SRH education.
Disclosure
The first version has been partly available online as a preprint in Research Square [35].
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
G.B.B., L.O., M.S., and J.Y.K. made significant contribution to the conception of the idea and design, participated in proposal development and data collection, and analyzed and interpreted the data. J.Y.K. wrote the original draft of the manuscript. M.S., J.Y.K., and L.O. reviewed and edited the manuscript for important intellectual content. All authors have read and approved the final manuscript.
Funding
No funding was received for this research
Acknowledgments
The authors would like to thank Haramaya University, College of Health and Medical Sciences for providing an opportunity to conduct this study. The authors also would like to thank West Hararghe Zone Health Bureau and Boke District Health and Education Office staff for their genuine help throughout the data collection process. Finally, we would like to acknowledge that this article is the final and original version.
Open Research
Data Availability Statement
The data analyzed and reported in this study will be available from the corresponding author upon reasonable request.
