Unequal access: sexual and reproductive health services among agrarian and pastoralist adolescents in Ethiopia

Adolescents worldwide face significant sexual and reproductive health (SRH) challenges, including unintended pregnancies, unsafe abortions, and sexually transmitted infections. While many studies have focused on SRH service utilization in urban and well-served communities, evidence from underserved regions remains limited. This study presents findings on SRH service utilization among adolescents in remote rural and pastoralist communities of southern Ethiopia. We collected data from 493 adolescents, equally representing agrarian and pastoralist communities, between May and June 2023. Participants provided insights into their knowledge, acceptance, organizational and cultural influences, and SRH service utilization history. The data was entered using EpiData 4.6 and analyzed with SPSS version 25. Descriptive statistics were used to summarize key characteristics, while bivariate and multivariable logistic regression analyses identified determinants of adolescent sexual and reproductive health (ASRH) utilization. Results were reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI) to assess statistical significance. Nearly three-quarters of adolescents (369, 74.8%) reported that ASRH services were not accepted in their communities, with rejection rates higher among pastoralist communities. Nonetheless, slightly more than a quarter of adolescents utilized SRH services (27.4%, 95% CI: 26.9–27.8). A significant disparity in utilization was observed between agrarian and pastoralist communities, with 36% (95% CI: 35.5–36.5) utilization among agrarian compared to 18.7% (95% CI: 18.3–19.1) in pastoralist adolescents. Key determinants of ASRH service utilization included education level, as uneducated adolescents were significantly less likely to access services (AOR = 0.187, 95% CI: 0.065–0.536). Positive predictors of ASRH utilization included parental encouragement (AOR = 2.817, 95% CI: 1.120–7.089) and proximity to services (AOR = 3.645, 95% CI: 1.423–9.337). In a separate analysis of agrarian adolescents, those uneducated were 85.5% less likely to use ASRH services compared to their educated peers (AOR = 0.145, 95% CI: 0.045, 0.465). Among pastoralist adolescents, discussing SRH with parents increased the likelihood of ASRH service use by 3.7 times (AOR = 3.729, 95% CI: 1.315, 10.574), and living within 30 min of a health facility increased the likelihood by nearly 6 times (AOR = 5.913, 95% CI: 2.419, 14.451). ASRH service utilization is notably low among agrarian and pastoralist communities compared to urban and semi-urban settings, pastoralists being more underserved. Promoting parental involvement, establishing SRH centers in schools and health institutions, and expanding access through mobile services for pastoralist communities are essential. Strengthened efforts by the health sector and stakeholders are critical to addressing gaps and ensuring equitable service availability.