Youths with disabilities: Utilization and predictors of Youths Friendly Reproductive Health Services in Dessie City Administration, North East Ethiopia, 2021: A cross‐sectional study

Abstract Background and Aims Younger generations with disabilities are more likely to be affected and have severe difficulties receiving specific services. Ethiopia is no exception to the global trend of poverty‐stricken countries with a higher frequency of illness or disability. This study aimed to assess the utilization of Youths Friendly Reproductive Health Services (YFRHS) and predictors among youths with disabilities in Dessie City, North East, Ethiopia, 2021. Methods A community‐based, cross‐sectional study was conducted. Data were collected from the literature using questionnaires. Bivariable analysis was performed for each independent variable with a p < 0.25 on the data imported to multivariate logistic regression analysis. Adjusted odds ratio (AOR) with a 95% confidence interval (95% CI) at a 5% level of significance has measured the strength of association between utilization of youth‐friendly reproductive services among disabilities and independent variables. Results Of 423 participants, 91% responded. About 42% of participants had used YFRHS. Youths in the age group of 20–24 years were 2.8 times more likely to use such services than 15–19‐year‐olds (AOR = 2.8, 95% CI: [1.04, 7.44]). Disabled youths living alone were 3.6 times more likely to use the services than those with parents (AOR = 3.6, 95% CI: [1.36, 9.35]). Youths with a visual impairment were 80% less likely to use the services than youths with hearing impairments (AOR = 0.2, 95% CI: [0.18, 0.30]), and disabled youths with poor knowledge were 90% less likely to use the services than participants with good knowledge (AOR = 0.1, 95% CI: [0.01, 0.61]) were statistically significant. Conclusion The utilization of YFRHS among youths with disabilities in Dessie Town was low. Participants aged 20–24 years, who lived alone, had visual impairment, and had poor knowledge, were found to be significantly associated.


| INTRODUCTION
Globally, youth with disabilities (YWDs) is estimated to be around 1.3 million, accounting for about 16% of the world's youth population affected by disability, with one in five Ethiopians under the age of 15 years having some form of disability. 1

,2 In
Nigeria, a 2021 estimate by the United Nations Population Fund suggested that~53.5% of people with disabilities were utilizing reproductive health services. 3 A study conducted in Ghana revealed that about 7 out of every 10 students aged [15][16][17][18][19][20][21][22][23][24] years had ever utilized sxual and reproductive health (SRH) services. 4 The SRH utilization among Arba Minch Secondary and Special Need Schools students with disabilities were 40.52%. 5 Disabled youths are expected to make use of these services more than the general population, as they are vulnerable to social stigma, unwanted pregnancy, unsafe abortion, lack of cognizance, poverty, depressive symptoms, poor self-image, poor esteem, and illiteracy. These barriers can have negative consequences for their physical, psychological, and social well-being, as well as for their reproductive rights and choices. 6 In Ethiopia, YWD is estimated to be around 2.4-4.8 million, representing about 3% of the youth population. However, Ethiopia also has low levels of reproductive health knowledge and awareness among the youth, especially among YWD and has limited availability and accessibility of Youths Friendly Reproductive Health Service (YFRHS) for YWD. 7 There is also a lack of research and data on the utilization and predictors of YFRHS among YWD in Ethiopia.
This study provides evidence-based information on the utilization of YFRHS among YWDs in Dessie City, Ethiopia, which can inform policymakers, stakeholders, and researchers on how to improve the quality and inclusiveness of these services. As a limitation, in Ethiopia, the majority of previous studies were conducted at the institutional level and among youths in the general population, whereas this study was conducted at the community level, and the study participants were exclusively youths with disabilities. In addition, there are no similar studies in Ethiopia or globally that assess the utilization of YFRHS among disabled youths. This is insufficient to completely recognize and explore utilization and predictors of youth-friendly reproductive services among youths with disabilities. [8][9][10][11][12][13][14][15] The clinical statement of the study's findings is that youth access to reproductive health services is essential for addressing the SRH needs of young people with disabilities, who are more vulnerable to a variety of barriers and disadvantages when trying to get high-quality care. In the study, factors such as youths in the age range of 20-24 years, disabled youths who live alone, disabled youths who have a visual impairment, and disabled youths with poor knowledge are identified as significant predictors. The study can guide policymakers, scholars, and stakeholders on how to improve the SRH interests of physically challenged youths and increase the accessibility and quality of YFRHS.

| Sampling technique and procedure
The list of the number of disabled youths and their corresponding house numbers/phone numbers were obtained from the Dessie City Administrative Office of the Disability Association, and 817 were registered in the 6 clubs with different disabilities, namely impaired mobility, visual impairment, hearing impairment, and multiple disabilities. After obtaining the sampling frame, the first participant was identified using the lottery method and then the systematic sampling technique was used using every two K th intervals (K/ n = 817/403 = 2). Youths who were available and provided verbal consent over the telephone were interviewed.

| Dependent variable
Utilization of YFRHS (Yes/No). Attitude: Study participants who scored greater or equal to the mean score were considered as having favorable attitudes.

| Independent variables
Hearing impairment: In this, it refers to the youths with disabilities, that is, partial or full loss of ability to hear in one or both of the ears.
Visual impairment: In this, it refers to the youths with disabilities, that is, the functional limitation of visualization in one or both of the eyes.
Mobility impairment: Refers to the inability of youths with a disability to use one or more of his/her extremities, or a lack of strength to walk, grasp, or lift objects, and utilizing a wheelchair, crutches, or a walker to mobilize.
Multiple impairments: It refers to the youths who have more than one kind of disability, which includes long-term mobility, hearing, and visual impairments.

| Data collection methods and procedures
A pretested, structured, face-to-face interviewer-administered questionnaire was used to collect the data. The questionnaires were close-ended, adapted by reviewing previous literature, and suited to the local situation. The Content validity of the tool was assessed by two experts who have a specialty in the field of reproductive health. The questionnaires were first written in English, then translated into Amharic, and then back into English. The data were collected by five trained data collectors with sign language and supervised by two clinical nurses.

| Data quality assurance
A questionnaire guide was created, and data collectors and managers received training. One week before the real data collection period, 5% of the youths in Kombolcha town participated in a pretest. The questionnaires were adjusted based on the results of the pretest.
Experts in reproductive health assessed the questionnaire's validity and content. The collected data were reviewed by the primary investigator and supervisors each evening of the data collection day for consistency and completeness.

| Statistical analysis
The data obtained from each respondent were entered using Epi-data

| Reproductive health service utilization and associated predictors
In a bivariable logistic regression analysis, age, occupation, type of disability, living alone, and poor knowledge about youth-friendly reproductive services were all associated with the use of these services. Those variables that have a value ≤0.25 were entered into a multivariable logistic regression using enter model to adjust for possible confounders. findings of this study discussed the universal realities and disabilities with reproductive age women. [16][17][18] Probable justification could be poor access to reproductive health choices from facility level barrier, social barrier, or provider level barrier. Another possible reason could be a lack of confidence and fear of being seen by friends or family, preferences, sexual activity status, childbearing status, the difference in socioeconomic condition, and lack of comprehensive knowledge and unfavorable attitudes. 19,20 The results of this study revealed that disabled youths aged 20-24 years were 2.9 times more likely to use YFRHS than individuals between the ages of 15 and 19 years. Consistently, a study conducted in the Gondar zone revealed that the utilization of SRH is more among the age of 18 years and above as compared with ages <15 years. This might be because this is the booming period of reproductive activities and this increases the demand for YFRHS. 16 In this research finding, disabled youths living alone were 3.6 times more likely to use YFRHS than those living with parents. The difference might be due to no parental pressure, autonomy to take decisions, differences in participants' perception level of stigma, and open discussion skills on SRH issues. 21 In this study, 53.2% of youths with a visual impairment utilized YFRHS, inconsistently in the Sidama state study 63% of youths with disabilities utilized YFRHS. Utilization of YFRHS among hearing impairment was 41.7% more than the study conducted in the Sidama state (30%). This is probably due to the visually functional impairment to access and make use of it, as they are unable to visit frequently and utilize the youth's SRH services centers. 17 In this study, 60% of participants with disabilities had poor providing services. In this way, disabled youths will be more likely to utilize these services.

| Limitations
The study was conducted only in Dessie town, so it is challenging to generalize the findings to the general population. It may not show a real cause-and-effect relationship and focused on individual perspectives.

| Recommendations
Researchers recommend increasing awareness and access among

ACKNOWLEDGMENTS
The authors thank Wollo University and also thank all youths with disabilities that participated in this study. This research was sponsored and granted by Wollo University, whereas the institution does not provide a publication fee. The funders have no role in the study design, data collection, and analysis, interpretation of data; writing of the report; and the decision to submit the report for publication.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author's Email greenwater3020@ gmail.com. The data are not publicly available due to privacy/ethical restrictions. It contains information that could compromise the privacy of research participants.

TRANSPARENCY STATEMENT
The lead author Prem Kumar affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.