Violita and Hadi BMC Public Health (2019) 19:286

https://doi.org/10.1186/s12889-019-6587-6

RESEARCH ARTICLE Open Access

Determinants of adolescent reproductive

health service utilization by senior high
school students in Makassar, Indonesia
Fajrin Violita and Ella Nurlaela Hadi*

Abstract
Background: Adolescents face many problems due to risky behavior. As a result, they require special consideration
through the administration of health education and reproductive health services. However the utilization of
adolescent reproductive health service programs in Makassar is still relatively low. The purpose of this study,
then, was to identify the rates at which adolescent reproductive health services are utilized and to analyze
the determinants affecting such utilization.
Method: This research was a quantitative project with a cross-sectional design, and it was conducted in
March to May of 2018 in Makassar City. Data were collected via the independent completion of questionnaires by 383
senior high school students randomly selected from a total of six schools. Data were analyzed using chi-square testing
and multiple logistic regression using SPSS.
Results: This study found that only 24.3% of the students took advantage of adolescent reproductive health services.
The results of the analysis proved that knowledge of reproductive health and available services (OR = 1.74; 95% CI = 1.
040–2.911) are related to the utilization of those services. It was found that students with high levels of knowledge are
nearly twice as likely to utilize adolescent reproductive health services as those with low levels of knowledge after the
results were controlled for the variables of family and peer support.
Conclusion: It is necessary to promote socialization between students and parents on a regular basis, disseminate
information through online media/social networking, administer peer educator training, and establish school
organizations in the field of reproductive health to increase awareness and utilization of adolescent reproductive
health services.
Keywords: Utilization, Reproductive Health, Adolescents, Makassar

Background Adolescents as a state asset have become a group re-

Approximately 16.8% of the world’s population are ado- quiring special attention. Certain health issues among
lescents, with as many as 80% of those are from develop- adolescents are often ignored, such as those involving
ing countries [1]. In 2016, according to that year’s reproductive health, HIV-AIDS, and maternal death, the
National Labor. leading causes of morbidity and mortality among adoles-
Force Survey (Sakernas), 62.89% of Indonesian adoles- cents to date [3].
cents aged 15–19 years were still in school. In fact, In Indonesia, risky adolescent behavior begins with
population projections indicate the possibility of a dating from the ages of 15–19. The rate is quite high at
demographic surge in 2030, at which time these adoles- 33.3% for girls and 34.5% for boys [4]. In 2015, it was re-
cents will be at a reproductive age [2]. ported that 8.26% of adolescent boys in the cohort, and
4.17% of girls had engaged in premarital sex [5]. Pre-
marital sex can lead to an increased risk of contracting
* Correspondence: [email protected]
Department of Health Education & Behavioral Sciences, Faculty of Public
sexually transmitted diseases, the most devastating of
Health Universitas Indonesia, D Building Kampus Baru UI, Depok 16424, which is usually HIV-AIDS. In fact, the proportion of
Indonesia

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Violita and Hadi BMC Public Health (2019) 19:286 Page 2 of 7

HIV infection among those aged 15–24 years continues City. The population consisted of senior high school stu-
to increase in Indonesia, from 18.4% in 2014, to 19.3% dents who were located in the sub-districts of the
in 2015, and 21.0% in 2016 [6]. targeted area of community health centers which imple-
Efforts to overcome adolescent reproductive health is- menting the PKPR and having PIK-R. Randomly selected
sues have been endorsed since the Adolescent Friendly schools from each sub-district included SMAN 9 in the
Reproductive Health Service (AFRHS) program was Rappocini sub-district, SMAN 2 in the Mamajang
established in 1994 at the International Conference on sub-district, SMAN 17 in the Tallo sub-district, SMKN 1
Population and Development (ICPD) meeting in Cairo in the Tamalate sub-district, SMA Muhammadiyah 6 in
[7]. In Indonesia, version of the program has been in the Wajo sub-district, and SMKN 7 in the Ujung
place since 2003 under the name of Adolescent Care Pandang sub-district.
Health Service (PKPR). In addition to PKPR, National The minimal sample group of 372 subjects was calcu-
Family Planning Coordinating Board (BKKBN) has also lated by using a two-proportion hypothesis test and ran-
established a risky behavior prevention program for ado- domly chosen from the selected schools. The inclusion
lescents through an organization called the Adolescent/ criteria were that they be active students and willing re-
Student Information and Counseling Center (PIK R/M). spondents. Students in the first and third grades were
The group trains adolescents to act as peer educators [4]. excluded from this study due to the fact that for
However, the utilization of adolescent reproductive first grade students, their time spent in school had
health services tends to be low. Research in Ethiopia has not yet reached 12 months, while the measurement
found that as many as 62.8% of adolescents aged 15–24 for utilization of adolescent reproductive health ser-
years had never utilized adolescent reproductive health vices was based on participation or use of service
services [1]. Such is also the case in Indonesia. Sitorus during the last 12 months. For third grade students,
reports that in Bali, 62.0% of adolescents have never uti- exclusion was a result of intense preparation require-
lized PKPR [8], and Wulandari, in Tanjung Balai City, ments for the national exam.
North Sumatra, found that 53.5% of students have never The data were provided independently by the respon-
taken advantage of PIK-Adolescent services [9]. dents (self-reported) using a questionnaire that was
Makassar City has six Community Health Center im- tested for validity and reliability with 34 students from
plementers for its Adolescent Care Health Service/ MAN 2 Model Makassar. It consisted of eight points of
PKPR, and 62 schools with Information and Adolescent inquiry: (1) respondents’ demographic data, (2) inde-
Counseling Center/PIK-R facilities [10, 11]. Yet, the pendent variables including knowledge of reproductive
utilization of reproductive health services is low, based health issues and available services, (2) perceived sus-
on the results of a December 2017 preliminary study ceptibility to adolescent reproductive health issues, (3)
with senior high school students in Makassar City. The perceived severity and seriousness of adolescent re-
same preliminary study also found that only 48.6% of productive health issues, (4) perceived benefits from
the participating students used PIK-R services, while and (5) perceived barriers for utilizing such services,
none of them had ever utilized PKPR’s services. (6) family support, and (7) peer support, as well as
The low utilization rates of reproductive health services (8) the identification of dependent variable such as
by adolescents is influenced by many factors. Several stud- the utilization of adolescent reproductive health ser-
ies have found that knowledge [12, 13]; individual percep- vices. The questionnaire was developed by modifying
tions such as susceptibility, severity, and seriousness a WHO [19] questionnaire in terms of the knowledge
[13, 14]; perceived benefits and barriers [13, 15]; and variable and utilization of adolescent reproductive
support of family and peers [16, 17] have an effect on health services. The Champion’s HBM Scale [20] ques-
utilization rates. These factors are components of the tionnaire was modified. Categorization of independent
Health Belief Model (HBM) that is often used to deter- variables used the median value as a cut-off point, since
mine why people do oe do not participate in health pro- the could not be precisely distributed. The data collected
grams [18]. Identifying factors affecting the health service were then analyzed by using chi-square testing and mul-
use is important for the improvement of services. There- tiple logistic regression with SPSS software.
fore, the purpose of this study was to a) assess utilization Prior to data collection in the field, the study was ap-
rates of adolescent reproductive health services by senior proved by the Health Research Ethics Committee of the
high school students in Makassar City, and b) analyze the Faculty of Public Health University of Indonesia (Certificate
determinants affecting such utilization. Number 75/UN2.F10/PPM.00.02/2018).

Method Results
This was a quantitative study with a cross-sectional de- Makassar City has 46 community health centers spread
sign conducted from March to May of 2018 in Makassar over 14 sub-districts, but the implementation of PKPR
Violita and Hadi BMC Public Health (2019) 19:286 Page 3 of 7

as of 2017 was reported only in six community health Table 2 Distribution of independent variables
centers. Those were Kassi-Kassi, Cendrawasih, Jumpan- Variable Total Percentage
dang Baru, Jongaya, Andalas, and Makassau Community N %
Health Centers. The 383 student respondents were from Utilization
six senior high schools in the work area of the PKPR
Yes 93 24.3
community health centers with PIK-Adolescents. The
No 290 75.7
majority (81.5%) were 16–17 years old with an average
age of 16.48 years, 68.1% were female, and the majority Knowledge
(89.3%) were Muslim (Table 1). High 226 59.0
The utilization of adolescent reproductive health ser- Low 157 41.0
vices was first measured by asking subjects about their Perceived Susceptibility
use of service components such as education, consulta-
High 192 50.1
tions, examinations, and treatments during the last 12
Low 191 49.9
months. Based on the analyzed results, the utilization of
the services by senior high school students in Makassar Perceived Severity and Seriousness
was still relatively low at 24.3% (Table 2). High 200 52.2
Controlling for independent variability, about half Low 183 47.8
(59.0%) of the students had high levels of knowledge Perceived Benefit
about reproductive health and the services available.
High 315 82.2
Based on the variable of individual perception, 50.1% of
Low 68 17.8
students had high rates of perceived susceptibility to re-
productive health issues, 52.2% had high rates of per- Perceived Barriers
ceived severity and seriousness of reproductive health High 166 43.3
issues, 82.2% had high rates of perceived benefits, and Low 217 56.7
43.3% had low rates of perceived barriers to utilizing the Family Support
adolescent reproductive health services. Meanwhile,
Enough 265 69.2
with respect to the variables of family and peer sup-
Less 118 30.8
port, 69.2 and 56.1% of the students reportedly had
sufficient levels (Table 2). Peer Support
In Table 3, bivariate analysis showed that knowledge of Available 215 56.1
reproductive health and available services (p = 0.010; OR Unavailable 168 43.9
= 1.986; 95% CI = 1.200–3.288), family support (p = 0.018;
OR = 2.019; 95% CI = 1.154–3.352) and peer support
(p = 0.007; OR = 2.032; 95% CI = 1.238–3.335) were
Table 1 Characteristics of respondents both (1) factors related to the utilization of adolescent
General Total Percentage reproductive health services and (2) candidates entering
Characteristic
N % into multivariate modeling. By contrast, the variables of
individual perception (perceived susceptibility to adoles-
Age
cent reproductive health issues, perceived severity and
15 years old 34 8.9
seriousness of adolescent reproduction, and barriers
16 years old 168 43.9 to using services) were insignificantly associated with
17 years old 144 37.6 the utilization of health services (p-value > 0, 05).
18 years old 37 9.7 Multiple logistic regression analysis demonstrated that
Average 16.48 knowledge of reproductive health issues and available
Sex
services (p = 0.035; OR = 1740; 95% CI = 1.040–2.911)
was a significant factor related to the utilization of ado-
Female 261 68.1
lescent reproductive health services, while the variables
Male 122 31.9 of family and peer support showed confounding vari-
Religion ables. Students with high levels of knowledge about re-
Muslim 342 89.3 productive health and available services were nearly
Protestant 30 7.8 twice as likely to utilize adolescent reproductive health
services as compared to those with low levels knowledge
Catholic 9 2.3
after the results were controlled for family and peer
Hindu 2 0.5
support (Table 4).
Violita and Hadi BMC Public Health (2019) 19:286 Page 4 of 7

Table 3 Determinants associated with the utilization of adolescent reproductive health services by senior high school students in
Makassar City
Independent Utilization of Adolescent Reproductive Health Services Total OR (CI = p-
Variable 95%) value
Yes No
n % n % n %
Knowledge
High 66 29.2 160 70.8 226 100 1.986 0.010*
(1.200–3.288)
Low 27 17.2 130 82.8 157 100
Perceived Susceptibility
High 46 24.0 146 76.0 192 100 0.965 0.977
(0.605–1.540)
Low 47 24.6 144 75.4 191 100
Perceived Severity and Seriousness
High 53 26.5 147 73.5 200 100 1.289 0.348
(0.805–2.064)
Low 40 21.9 143 78,1 183 100
Perceived Benefit
High 76 24.1 239 75.9 315 100 0.954 1.000
(0.502–1.750)
Low 17 25.0 51 75.0 68 100
Perceived Barriers
Low 38 22.9 128 77.1 166 100 0.874 0.664
(0.544–1.405)
High 55 25.3 162 74.7 217 100
Family Support
Enough 74 27.9 191 72.1 265 100 2.019 0.018*
(1.154–3.352)
Less 19 16.1 99 83.9 118 100
Peer Support
Available 64 29.8 151 70.2 215 100 2.032 0.007*
(1.238–3.335)
Unavailable 29 17.3 139 82.7 168 100
*Related to the utilization of adolescent reproductive health services and candidates into multivariate modelling

Discussion education being the most widely-used type of service

The utilization of adolescent reproductive health services (52.7%). The most frequently visited service provider was
by senior high school students in Makassar City was still PKPR (46.2%), and doctors/ and/ or nurses were the most
low (24.3%). In fact, the result was lower than those in common service providers seen (61.3%). Regarding the
the Rokan Hulu district, Pekanbaru and the Gianyar quality of service, the majority of students stated that the
district, Bali, which reported that 33.6% of adolescents service was good enough and that there was good material
had used PIK-Adolescent reproductive health services satisfaction (80.6%), friendly service providers (93.5%), suf-
in schools and 38% had utilized PKPR, respectively ficient numbers of personnel (74.2%), appropriate and
[9, 17]. Meanwhile, research in Kenya, Africa con- comfortable service times (61.3%), and guaranteed confi-
ducted in 2017 reported similar findings, with only dentiality throughout (64.5%) (Table 5).
38.5% of adolescents having utilized adolescent repro- Knowledge is one of the driving factors in behavioral
ductive health services [21]. change. Several studies have shown that adolescents with
Looking more closely at the utilization of reproductive good knowledge of reproductive health will benefit from
health services, most students (63.4%) utilized the services available services [12, 22, 23]. These studies generally re-
once in the last 12 months, with NAPZA and cigarettes ported similar results: knowledge of reproductive health
and available services is a factor related to the utilization
Table 4 Multivariate result of adolescent services. Indeed, students with high levels
Variable B p-value OR CI (95%) of knowledge of reproductive health and available ser-
Knowledge 0.554 0.035 1.740 1.040–2.911 vices were nearly two times more likely to utilize adoles-
cent reproductive health services than those with low
Family Support 0.456 0.129 1.577 0.875–2.843
levels of knowledge after controlling for the variables of
Peer Support 0.613 0.055 1.664 0.988–2.802
family and peer support.
Violita and Hadi BMC Public Health (2019) 19:286 Page 5 of 7

Table 5 Distribution of frequency, type and quality of services used One organization was the Center of Information and
Frequency, Type and Quality of Total Percentage Counseling (PIK-R/M) under BKKBN, another was PERA
Services Used (Anti-Drug Adolescent Association) and the thirds was-
N %
Frequency of Utilization 59 63.4 GANAS (National Anti-Drug Movement). Formed by the
Unavailable 1x BNN, which designate students as cadres to disseminate
NAPZA & Cigarettes Education as the 49 52.7 information about reproductive health. Training adoles-
most used services cents to be peer educators and providing organizations or
PKPR as the most frequently visited provider 43 46.2 extracurricular activities geared toward informing young
Doctor/Nurses as the most frequently met 57 61.3 people about their reproductive health, can be a means of
improving the utilization of health services.
Quality – Good Material 75 80.6
Another means of encouraging the use of the services
Quality – Friendly Providers 87 93.5
is individual perception. Interestingly, in the study, the
Quality – Sufficient numbers of personnel 69 74.2 four different perceptions, perceived susceptibility, sever-
Quality – Appropriate Service Times 57 61.3 ity and seriousness, benefits, or barriers, were found to
Quality – Guaranteed Confidentiality 60 64.5 be unrelated to the utilization of those services.
Both students with high and low perceived susceptibil-
ity tended to not utilize the services available. This result
The students with lower levels of knowledge tended to does not align with the findings of an Ethiopian study
not utilize the services because of a lack of information assessing reproductive health service utilization and per-
about the available services. Thus, regular guidance on ceptions among the same age group [24]. A possible rea-
socialization with respect to reproductive health and son for this different result is that the students in this
available services could be provided through online study had lower levels of knowledge regarding repro-
media to increase students’ knowledge levels. ductive health and available services, so it appears that
In this study, family support was determined to be a there are still many students who are unaware of the
confounding variable with respect to the association be- existence or location of such services. Ethiopian ado-
tween knowledge and the utilization of adolescent repro- lescents experienced sex as a normal part of their
ductive health services. More specifically, family support life and they were open to discuss it with their
can affect students’ knowledge of adolescent reproduct- mother [24]. Contrarily, in Indonesia disscussing
ive health and available services because the family is about that topic is still taboo. It can be a reason that
one of the key sources of such information. In their ehtiopian adolescent had higher knowledge about re-
questionnaires, some students admitted that they ob- productive health and available services than Indo-
tained information about reproductive health issues and nesian adolescents.
services from their families. The existence of such sup- In terms of perceived severity and seriousness, that
port has a positive impact on knowledge and the factor also appeared unrelated to the utilization of ado-
utilization of adolescent reproductive health services. lescent reproductive health services, a finding that once
Therefore, family support needs to be improved by pro- again contrasts with the Ethiopian study. The latter
viding socialization programs for parents of adolescents mentioned that adolescents with high perceived severity
and encouraging them to be more open to discussing and seriousness are twice as likely to utilize adolescent
their children’s reproductive health issues. Such informa- reproductive health services [13]. In the current study,
tion can be distributed with report cards at sessions this was not found to be the case. Rather, students felt
attended by parents. that if they had never engaged in risky behavior that
In addition to online media and family, peers are also could raise the likelihood of contracting a disease or
a source of health information. This is one reason why other reproductive health issue(s), then there was no
peer support can influence the knowledge levels of stu- need to take advantage of adolescent reproductive
dents while also encouraging students to utilize the health services.
available services. Thus, peer support in this study was a Most of the students perceived benefits in relation to
confounding variable with respect to the link between the utilization of adolescent reproductive health services.
knowledge and the use of adolescent health services. In However, perceived benefits were not a factor affecting
everyday life, most teenagers spend time in school with the actual utilization of adolescent reproductive health
others their age, so peers who become cadres/peer educa- services. This is in line with the research conducted in
tors can further encourage the utilization the adolescent Ethiopia [13]. One possibility leading to low utilization
services. Three of the six schools in which the present re- even with high-benefit perception, may be that the stu-
search was conducted had organizations or extracurricular dents believe they’re healthy so long as they show no un-
activities pertaining to adolescent reproductive health. usual signs or symptoms.
Violita and Hadi BMC Public Health (2019) 19:286 Page 6 of 7

Perceived barriers were also considered when looking Authors’ contributions

at the utilization of health services. Previous research in ENH: Developing study design, analysis and interpretation data of this study.
FV: Study design, implementation, data collection, analysis, and writing.
Nepal found that the many barriers encountered were All authors have read and approved the manuscript.
the cause of individuals not using the services [15]. The
results of this study are not in line with those conclu- Ethics approval and consent to participate
Approval was obtained from the Health Research Ethics Committee of the
sions because the perceived barriers here were not re- Faculty of Public Health at the University of Indonesia (Certificate Number
lated to the utilization of adolescent health services. One 75/UN2.F10/PPM.00.02/2018).
possible explanation may be the notion that reproductive Consent to participate was obtained from participants in written format. For
participants under 16 years old, written informed consent was obtained from
health services are unnecessary or are not considered as them, the school (written informed consent from the teacher), and also their
important to students. parents (verbal informed consent) obtained.

Consent for publication

Conclusion Not applicable.
The utilization of adolescent reproductive health services
Competing interests
by high school students in Makassar City in 2018 was Not applicable.
still relatively low (24.3%). Knowledge of available ser-
vices was a driving factor in positively influencing their Publisher’s Note
utilization rates. Well-informed students were nearly Springer Nature remains neutral with regard to jurisdictional claims in
twice as likely to utilize adolescent reproductive health published maps and institutional affiliations.
services after controlling for both family and peer sup- Received: 9 July 2018 Accepted: 22 February 2019
port. The four perceptions of students (susceptibility, se-
verity and seriousness, benefits, or barriers) were not
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