This cross sectional study assessed level of in-school adolescents’ SRH services utilization in Harmaya district, east Ethiopia, and identified factors associated with service utilization. The level of SRH services utilization was estimated at 23.5% (95% CI: 20.4, 27.0). Factors significantly associated with the in-school adolescents’ utilization of SRH services include exposure to SRH information, awareness of SRH services providing facility and service components, and distance from service providing facilities.

The level of SRH services utilization among in-school adolescents in the study setting was 23.5%. This finding was consistent with similar studies among in-school adolescents in Ethiopia and elsewhere where SRH services utilization reports ranged from 21.2 to 24.6% [18,19,20,21]. However, compared to other similar studies in Ethiopia, magnitude of the SRH services utilization observed in the study setting was low. For example, a study in southern Ethiopia reported an SRH services utilization of 33.8% among high school adolescents in youth friendly service implemented areas [22]. Similarly, a study in Debre Tabor town among high-school- and preparatory-students reported an SRH service utilization of 28.8% [23]. The SRH services utilization in the study setting, however, was high compared to adolescents in the general population (8.6%) [24] and those who reside in areas where youth friendly services are not implemented (9.9%) [22]. Part of the variation could be explained by differences in terms of factors related to service delivery like friendliness, negative attitude from service providers and feasibility of service hours; factors related adolescents’ perception (fear of being seen while using SRH services); and socio-cultural barriers [21, 25].

The most utilized SRH services components include information, education, and counseling (80.1%) where previous studies also reported a similar services utilization pattern that was largely limited to information seeking and counseling services [26]. The percentage of utilization of other services including contraception (28.5%), STI treatment (13.9%), pregnancy testing (13.2%), and safe abortion care (7%) were also comparable with previous studies [26]. However, this study did not assess adolescent’s unmet need of important services which might have shed light on the potential gaps to be addressed pointing to the services that adolescents seek but did not use.

Adolescents who previously had exposure to SRH information were significantly associated with current service utilization. Previous studies also reported consistent reports that adolescents who had multiple sources of SRH information including discussion with family members, friends, healthcare providers, and schools were more likely to use SRH services [22, 27, 28] as these may improve adolescents’ awareness on SRH related issues.

Adolescents who were aware of the specific SRH service components were more likely to utilize the services than those who did not know. Due to the nature of the study, however, it was not possible to state whether awareness of the specific SRH services components had led to service utilization or the reported awareness was secondary to the service utilization itself. Previous similar studies elsewhere emphasized the importance of adolescents’ awareness of SRH services providing facilities, particularly for rural adolescents [29]. It was further emphasized that lack of awareness of SRH service components and knowledge about youth friendly services among adolescents and where to go to use those services were the main reason for the low uptake of adolescent SRH services [29, 30].

Interestingly, in this study, adolescents who were far from health facilities that provide SRH services were two times more likely to utilize SRH services than those who lived close to SRH services providing facilities. This finding was against the reports in previous studies that indicated availability of service providing facilities in close by facilitated SRH services utilization [17, 19]. A systematic review by Nisiima et al. reported that facilitators of utilization of SRH services were mostly structural in nature including the quality of health services and clinics for adolescents to fit their needs and preferences [30]. Due to reasons related to confidentiality, availability of needed service, attitude of service providers, and shyness [17, 21], adolescents may prefer to use services from facilities where they could not be easily identified and find services of their preference. Poor understanding of the adolescents’ reproductive health needs in the community due to socio-cultural norms (not approving sexuality discussion during adolescents and hence utilization of services) and fear of adolescents to be seen by community members are big challenges impeding SRH use that need critical attention. In this study, for 58.9% of adolescents, their parents lived in rural areas and 18.5% of the adolescents lived alone in order to attend their high school study in the town of the Haramaya district. Consequently, the perceived freedom of living alone and confidentiality may have contributed to the observed association of distance and SRH services utilization.

Our study was not without limitation. Pertaining to sensitive nature of the topic studied, respondents may not give honest responses as required. This might underestimate the prevalence of SRH service utilization. We have tried to reduce issues related to confidentiality by making the data collection anonymous and using a self-administered structured questionnaire in the local language for data collection obtain information. This study cannot indicate the direction of the causal relationship.