What do service providers in Southern Ethiopia say about barriers to using youth-friendly sexual and reproductive health services for adolescents?: Qualitative study

Background In Ethiopia, the utilization coverage of adolescent-friendly health services (AFSRHs) ranged only from 9 to 55% and it was the lowest of all Sub-Saharan African countries in 2016. Little is known why adolescents were not accessing the existing services to the side of healthcare providers. Objective The aim of this study is to explore contextual perceived and actual barriers to accessing AFSRHs by adolescents in Southern Ethiopia. Methods Phenomenological study design supplemented with observation was used to explore perceived and actual barriers to accessing AFSRHs in 2020. Criterion sampling was used to select study participants. In-depth interviews with healthcare providers and non-specialist sexual and reproductive healthcare providers were conducted. Transcribed interviews and observations were imported to Open Code 4.02 for coding, categorizing, and creating themes. Finally, barriers to accessing existing services were explained using thematic analysis. Results The study explores contextual barriers to accessing sexual and reproductive health services in five emergent themes. According to providers’ points of view, the barriers include ranging from providers (e.g. poor providers’ competency), health facilities (e.g. supply constraints and unsupportive environment), adolescents (e.g. perceived lack of information and attitude towards SRHs), community (e.g. lack of parental and social support), and broader health system (e.g. poor implementation and multi-sectorial engagement). Conclusion As to providers, adolescents face multiple barriers to accessing youth friendly sexual and reproductive health services. Healthcare facilities and all levels of the healthcare system should implement varieties of approaches to increase access to the services for adolescents. Given the lack of progress in utilization of adolescents- youth friendly sexual and reproductive services, the existing strategy should be re-evaluated and new interventions at all levels of the healthcare system are needed. Moreover, implementation research is required at system level factors.

behaviors often develop during adolescence and can progress into adulthood, which may lead to a lifetime of ill health and to death [2,3]. The risks of avoiding adolescent's sexual and reproductive health care exposes adolescents to both contextual as well as global health risks including unwanted pregnancy and bad parenthood, difficulties in accessing contraception and safe abortion, and high rates of HIV and other sexually transmitted infections, and sexual violence [3,4].
Over the past two decades, researchers and health programmers have been implementing youth-friendly model of health services in primary health care setting to address barriers to accessing health care for young people, including adolescents. This is part of the WHO's global call for the development of health services that are relevant to young people worldwide [4,5]. In general, the establishment of friendly adolescent health services is based on the principles of international human rights treaties, which are based on the principles of equality (including gender equality) and respect for human rights, and protection of human rights. As an important healthcare entity, the Global Adolescent and Youth Sexual and Reproductive Health Service is a framework designed to "safe, effective and affordable" approaches (meeting the personal needs of young people who come to any healthcare facility when they need services and recommend services for friends) [5] to protect young people from many sexually related health problems.
With some additional packages, the services include providing universal access to accurate sexual and reproductive health information; providing safe and affordable contraceptive methods; providing counseling, quality obstetric and antenatal care for all pregnant adolescents; providing safe abortion when unintended pregnancy happens; prevent and manage of sexually transmitted infections including HIV; treat violence against adolescents and manage risky behaviors [6]. As part of the global approach [4,5], Ethiopia has been striving to improve adolescents and youth health through ratifying national youth policy in 2004 [7]. Following the national youth policy, the country has been developed and implemented two national adolescents and youth reproductive health strategies: the pre-2015 strategy (2007 to 2015) [8] and the post 2015 strategy (2016 to 2020) [9]. This approach is being implemented through both stand-alone modality and integrating sexual and reproductive health services into the basic health services mostly at primary health care settings as well as sometimes at secondary and tertiary level healthcare settings. Although the country has made good progress in designing and implementing adolescent and youth-friendly reproductive health strategy, large number of evidences in almost all corners of the country [9], including the study area [10] showed the use of adolescent sexual and reproductive health services is very low. Studies indicate that the utilization coverage of youth-friendly health services in Ethiopia ranges from 9 to 55% [9] which was among the lowest score of all Sub-Saharan African countries in 2016 [9]. This service utilization coverage even could be likely lower particularly for adolescents because almost all studies cover the age range of 10 to 24 years. Therefore, if one had measured the service utilization among adolescents (10-19 years), the utilization would have been scored low than the above specified range of coverage.
Almost all studies in Ethiopia have reached approximately the same conclusion: low utilization coverage of the services and providing statistical association of some factors with low utilization. Quantitative research on the sexual and reproductive health of young friends in Eastern Ethiopia has shown that service providers' negative attitudes toward serving unmarried adolescents have been linked to the low utilization of the service [11]. Poor interpersonal relationships [12] and many other operational level factors like poor perceived support and poor communication [13,14] were also barriers to using adolescent and youth friendly sexual and reproductive health care access.
Barriers to using adolescents' sexual and reproductive health services may be resulted in a synergy of previously studied factors with unexplored contextual factors to the providers' point of view [14,15]. Unfortunately, tittle evidence is available about what contextual barriers to accessing adolescent and youth friendly sexual and reproductive health services to the perspectives of healthcare providers. In addition, we believe that a qualitative approach would explore more about the contextual barriers for low utilization than reinventing the wheel (measuring the same thing) using many quantitative approaches. Therefore, the purpose of this study was to explore contextual barriers to accessing the already established youth-friendly services for adolescents in Hadiya Zone, Southern Ethiopia.

Study setting and period
The study was conducted in selected health facilities providing youth friendly sexual and reproductive health services and specialized youth clinic and youth centers in Hossana Town, Hadiya Zone from 20 to 27 February 2020. Hossana city administration is a capital of Hadiya Zone in Southern Ethiopia. There are four government health facilities in the city administration: one referral hospital and three health centers. More than 30 private clinics and 1 private hospital were found in the city administration during the time of data collection. All of the government health facilities and youth centers are expected to provide youth-friendly sexual and reproductive health services according to the national strategy [9]. Accordingly, they provide services through home to home visits by HEWs (Health Extension Workers); population-oriented outreach services delivered by health workers through routine outreach programs; and individual-oriented clinical services that address the sexual healthcare needs of young people including adolescents in all health facilties.
According to department of city sexual and reproductive health services, there were about eight youth centers that have been providing community sexual and reproductive health services in the town before 2015. However, only one youth center is functional during data collection. Private clinics and hospitals are also expected to provide youth-friendly sexual and reproductive health services according to the national strategy. Currently, there are also two known NGOs (Non-Governmental Organizations) clinics that provide youth-friendly sexual and reproductive health services. One functional youth center; three primary health centers; one referral and teaching hospital; one specialized youth clinic; two student clinics; and one city administrative health office that have been providing ASRHs were purposely selected for our study.

Study design
We used phenomenological study design. We approached the research question from the providers' perspective regarding barriers to access friendly sexual and reproductive health services. In addition, observation was made by the investigators to supplement experiences of healthcare providers.

Study participants and sampling strategy
Three primary health care units, one referral hospital, one specialized NGO youth clinic, one city administration health office, one youth center and two educational settings were purposively selected for the study. Criterion sampling was used to select study participants. The criteria used were working at youth-friendly sexual and reproductive health unit of selected healthcare facilities /outreach programs; having better experience of serving at the selected healthcare facilities; being heads of sexual and reproductive health unit of city administration health office; and being coordinator/representative of adolescents at selected youth centers and school clinics/reproductive health clubs. Accordingly, one health professional from the department of sexual and reproductive health services of the city administration; three health professionals serving at youth friendly sexual and reproductive health services; two urban health extension workers who have been working at community level; one coordinator of urban health posts (Kebeles) who has supervising and supporting HEWs; two counselors who have beeen working at youth centers; one high school health and reproductive health club coordinator; and two representatives of college youths who have best experiences of participating in reproductive health clinic/ clubs were selected as key informant interviewees.

Data collection
In-depth interviews with key informants were used using a semi-structured interview guideline prepared to address barriers to accessing adolescent and youth friendly sexual and reproductive health services. The interviews were completed at a time and place to suit the participants and lasted between 33 and 90 min. Audio recordings were made using a digital recorder and transferred to personal computer for transcription. The recordings were erased from the digital recorder as soon as transferred to password protected personal computers. Collecting data was stopped when key informants fail to provide new information. Memos were used to understand contexts during interview and observation. Observation was made in five health facilities using checklists adapted from guidelines of adolescent friendly services [4,9,13] to identify potential barriers to accessing SRHs by adolescents and check general readiness of the health facilities (centers) to provide friendly services for adolescents.

Operational definition
Provider for this study applies to health professionals and non-specialists who were providing youthfriendly sexual and reproductive health services at selected health facilities (health posts, health centers, and hospitals); sexual and reproductive health units of health offices specialized youth clinics; and reproductive health and health related youth centers/clinics in school/college. Adolescent/youth-friendly sexual and reproductive health services (AFSRHs/YFSRHs) for this study apply to the services that are being provided either by integrated or stand-alone modalities through the guiding principles of youth friendliness (accessibility, availability, acceptability, equity, effectiveness and efficiency).
Adolescents for this study refer to young people who are in the age range of 10 to 19 years old according to WHO recommendation [4,6].

Data management and quality
Prior to data collection, readiness of digital audio recording tool was checked in subsequent interviews. The words of the participants were simultaneously recorded by the investigators to enable for later verbatim interpretation and translation into English. Immediately after completing each in-depth interview, observation of corresponding health facilities was followed through a checklist. Contextual data obtained from interviews and observations were immediately documented in memos to prevent loss on memory during data collection.

Data processing and analysis
Memos were written immediately after and/or during interviews, observations, and recording ideas as initial analyses. The recorded verbatim audios were immediately transcribed and translated to English. Again, interview transcripts were re-read line by line and listened to the recordings in order to match a sense of what has been said by each study participant. Phone calls and face to face briefing with study participants were made when some expressions in the audio seem to be confusing while transcriptions were made. Contradicting ideas in subsequent questions were validated during interview by the respondent's own word and crosschecked with memos. Memos of interviews and observations were crosschecked while transcribing to ensure credibility of data. Transcribed interviews and notes were imported to Open Code 4.02 [16] for coding data, categorizing codes, and creating themes. Initial coding was made from providers' understanding of the users (adolescents) and model of the service (AFSRHs/YFSRHs); and capturing providers' experience regarding barriers hindering adolescents from using SRHs. Coding, categorizing (subtheming) and theming data were carried out by the first investigator. Categorizing and theming procedures were cross-checked by the other investigators and agreed on common categories and themes. We invited an expert to put sample of codes and categories to the emerged corresponding categories and themes for triangulation, respectively. Finally, the phenomenon being studied was explained by emerging categories and themes. Explanations in themes were substantiated by participants' direct quotations when necessary.

Socio-demographic characteristics of participants
A total of 12 providers were participated in the study. The age of participants ranged from 22 to 49 years old with the mean age of 32.5 years old. A health professional from the city's department of sexual and reproductive health; three health professionals who have been working in the unit of youth-friendly sexual and reproductive health services; a high school reproductive health club coordinator; two urban health extension workers; a coordinator of urban health posts; two counselors who have worked in youth centers; and two adolescent representatives have experience of participating in reproductive health services in student clinics were participated in the study as key informant interviewees (Table 1).

Emergent themes and sub-themes
Barriers to using adolescent and youth-friendly sexual and reproductive services were addressed from the points of view of service providers. Five themes explaining barriers to using friendly-sexual and reproductive health services at various levels were identified in the data: provider, health facility, adolescents, community, and health system barriers. Themes were emerged as a result of coding and categorizing participants' responses to questions addressing barriers that hinder adolescents from using the services. Some of the phrases or sentences of quotes are illustrated from the corresponding codes in each emergent theme and sub-themes (Table 2).

Theme 1: Provider level barriers
Based on this theme, healthcare providers gave personal and collegial experiences that restricted adolescents from accessing SRH services. Under this theme, three subthemes were emerged: poor provider competency; confidentiality breaches, disrespect and discrimination of adolescents; and lack of provider follow-up.

Sub-theme 1.1: Poor provider competency
Under this sub-theme, participants discussed about knowledge, attitude, communication, and technical skill gaps of healthcare providers that may prevent adolescents from using sexual and reproductive health services.
One of the participants working in a specialized youth center noted knowledge gap as: "A male adolescent with a special need came to me. I was not familiar with that special need. [ Urban health extension workers and other participants realized that they did not have enough knowledge to promote and educate about sexual and reproductive health issues for students in schools and adolescents in the community during outreach activities. One of the health extension workers reflected her knowledge and attitude towards sexual health education for adolescents as: Nine out of 12 participants felt that the communication between providers and adolescents was influenced by a number of factors including cultural factors. The majority of the participants felt that adolescents did not talk openly to providers about sexual health problems for various reasons. This in turn prevented them from using SRH services. One of the participants said: "I saw a 10-years-old boy. The researchers' observation also confirmed that other health workers either hadn't knowledge or positive attitude towards youth-friendly services. During the interview, the investigators observed that other health care providers were disturbing both counselors and adolescents; moving in and out for their own purposes. Such phenomenon was common in almost all health facilities, with the exception of one specialized youth sexual and reproductive health center.

Sub-theme 1.2: Confidentiality breach, disrespect and discrimination of adolescents
This sub-theme discusses the experience of participants and their colleagues regarding breaching confidentiality as barriers to accessing sexual and reproductive health services. The sub-theme also explains disrespectful and discriminant behavior of healthcare providers.
One of the participants witnessed her own mistake how she was breaching confidentiality as: "

Sub-theme 1.3: Providers' lack of follow-up
This sub-theme explains providers' lack of follow-up as a barrier to accessing sexual and reproductive health services. Majority of the health care providers reported that they had not followed up adolescents once they had provided services.
One of the participants described the follow-up problem as: "

Theme 2: Adolescent level barriers
This theme was emerged to explain the experience of healthcare providers and their colleagues regarding barriers that prevented adolescents from using friendly sexual and reproductive health services. Four sub-themes were emerged: fear to violation of confidentiality and cultural taboos, lack of information and poor attitude towards SRHs, preference to seeking care and peer influence, and financial problems.

Sub-theme 2.1: Fear to violation of confidentiality and cultural taboos
Under this sub-theme, major misunderstandings, legitimate breaches and fears due to cultural taboos were explored. Most of the participants reported that adolescents perceived violation of confidential information by the healthcare providers. In addition, adolescents were also afraid of being seen by other people during their visit to youth friendly services. One of the participants gave an example of how adolescents were prevented from accessing nearby sexual and reproductive health care services.
" […] Overcrowding in the majority of our public health centers is not safe for adolescents. As

Sub-theme 2.2: Lack of information and attitude towards SRHs
This theme explores the experience of providers how adolescents' poor knowledge and attitude towards SRHs prevented them from accessing the service. Accordingly, ten participants reported information gap of adolescents regarding sexual health and services ranging from not knowing where to go for seeking help to developing negative attitude towards the service.
One of the participants exemplified adolescents' misconceptions and poor practice regarding contraception.
"Many teenagers often take post pills every morning at our clinic. [ Participants gave a testimony that many adolescents had developed negative attitude towards sexual health services. One of the participants stated the problem as: "

Sub-theme 2.3: Preference to seeking care and peer influence
This sub-theme explores providers' experience on how choice of care and influence of peers affect decision to use SRHs. Providers reported that adolescents seem to have concern on age and gender of healthcare providers to seek help from health providers. Healthcare providers had considerable dialogues about whether gendermatched providers were most appropriate. Half of the participants had mentioned that adolescents were influenced by their peers in decision making of accessing SRHs. Majority of the healthcare providers reported that peers had provided health information and had promoted where and when youth friendly services had been provided.

Sub-theme 2.4: Financial constraints
More than half of the participants believed that joblessness and limited access to household resources hindered many adolescents from accessing SRHs due to cost of service delivery, supplies, and transportation.
One of the interviewees described financial problems as: "Yea, many adolescents lived separately from their families for reasons such as education.

Theme 3: Health facility level barriers
This theme focuses on the experiences of participants and their colleagues concerning barriers for adolescents from using existing services. Three sub-themes were emerged: lack of supply and unsupportive environment, long waiting and inconvenient working time, and inadequate staff and training.

Sub-theme 3.1: Lack of supply and unsupportive environment
The sub-theme discusses providers' experience regarding unavailability/limitation of resources needed to perform key activities to meet the sexual and reproductive health needs of adolescents. On the other hand, unsupportive environment to responding to the needs of adolescents has been explored. The majority of participants strongly pointed out unavailability of supplies required to provide adequate and appropriate services for adolescents. Lack of written guidelines and lack of educational materials such as posters and flyers were also reported. One of the participants explained the problem as: " Providers cited inadequate physical space and privacy as institution-level barriers to using adolescent sexual health services. The service providers also pointed out that youth clinics did not have enough entertainment and spaces. The researchers' observation during the interview also proved that almost all YFS (youth-friendly service) clinics have only a single unit and is not separated from adult outpatient units. Some centers were also close to HIV/AIDS clinics.
Most participants agreed that the lack of privacy in health facilities and hospitals has resulted in fear of being seen by friends, relatives, or other community members. One of the participants described the situation as: "

Sub-theme 3.2: Inadequate staff and training
Providers felt that inadequate training on adolescent sexual and reproductive health was one of the barriers to providing quality sexual health services. In addition, inadequate number of trained staffs was also mentioned by the majority of the participants as a barrier to providing quality services. Participants described how they were facing challenges of providing services related to HIV/AIDS due to lack of technical updates. One of the participants said: "

Theme 4: Community level barriers
This theme explores the experience of providers alongside the community that prevents adolescents from accessing existing sexual and reproductive health services. Under this theme, five sub-themes were emerged: community's bad attitude and lack of information; lack of parental and social support; inadequate support to schools and youth centers; inadequate literacy of sexual health; and presence of unauthorized providers.

Sub-theme 4.1: Community's bad attitude and lack information
This sub-theme explains providers' points of view about community's knowledge and attitude towards sexual health services that hindered adolescents from accessing the service. Almost all participants agreed that community's negative attitude towards sexual health issues in one way or another has negatively affected adolescents from using the service. One of the participants stated the perception and attitude of the community as: "

Sub-theme 4.2: Lack of parental and social support
This sub-theme explores the experience of providers whether parents and other community members support for adolescents to use SRH services. Punishing, discriminating, and controlling decision making of adolescents for varieties of reasons were mentioned by the majority of participants that indicate the lack of parental and/or social support. In addition, eleven in twelve participants indicated that parents lacked discussion with their children about sexual and reproductive health matters. One of the participants clarified the idea as: " Another participant stated that lack of discussion with religious people prohibited adolescents from using sexual and reproductive health services. "

Sub-theme 4.3: Inadequate support to schools and youth centers
Under this sub-theme, majority of interviewees pointed out many barriers that may prevent adolescents from using existing services because teachers, community and other stakeholders had not sufficiently been supported by the health facilities and the health system. One of the participants clarified the situation as:

Sub-theme 4.4: Inadequate literacy of sexual health
This sub-theme focuses on the perspectives of health care providers regarding inadequacy of sexual literacy as barriers to accessing ASRHs. Half of the participants believed that absence of formal sexual health education in schools could also be a barrier to accessing ASRHs for adolescents.
One of the participants explained how the absence of formal sexual health education affected adolescents regarding SRHs utilization.
"I suggest that age appropriate sexual and reproductive health course should be given starting in primary schools.
[…] I remember my biology teacher when I was a student. He [teacher] called different parts of our body, but silent when he reached at our reproductive region. But, we know everything, even if teachers don't tell us. That would make students shy or fear to go to health facilities for help. " [Male,Psychologist].
One of the participants added the need of formal sexual health education in schools.
"I suggest that curriculum should be designed.

Sub-theme 4.5: Presence of unauthorized providers
This sub-theme mainly focuses on participants' experience whether the presence of unauthorized providers led adolescents not to use ASRHs. Five participants mentioned that adolescents used unapproved providers instead of accessing services from accredited health care facilities. One of the participants said: "

Theme 5: Health system level barriers
This theme explores experience of providers regarding a broader health care system that could negatively affect the use of services by adolescents. Two sub-themes were emerged: poor implementation and commitment, and low stakeholder engagement.

Sub-theme 5.1: Poor implementation and commitment
Providers described many health system level barriers that had prevented adolescents from accessing sexual and reproductive health services. Barriers mentioned by the participants in the study area included lack of funding, fail to job creation, and lack of attention to youth friendly-services.
One of the participants described unemployment as a barrier to accessing ASRHs as: " Two of providers complained that implementation of the national strategy of youth friendly sexual and reproductive health strategy was not adequately responding to the sexual health need of adolescents. One of the providers complained his doubt whether the strategy brought changes to adolescents' health seeking behavior as: "

Sub-theme 5.2: Poor multi-sectoral engagement
The sub-theme discuses opinion of participants regarding the lack of cooperation among stakeholders in addressing sexual and reproductive health needs of adolescents. Four participants complained the lack of cooperation among health professionals, health facilities, schools, youth centers, adolescents and youth-oriented sectors, and various governmental and non-governmental organizations. One of the participants described the problem as: "

Discussion
Despite many years had been counted in implementing a youth-friendly model of sexual and reproductive health services, many quantitative studies have shown low utilization scores among young people including adolescents in Ethiopia [9]. The services have been provided either through integrating into basic health services in the healthcare facilities or stand-alone modalities sometimes. This model of healthcare for adolescents might be ineffectively delivered so that unable to reach adolescents. Therefore, this study explored the perspectives of service providers regarding barriers to accessing adolescent sexual and reproductive health services.
The study has identified modifiable healthcare access barriers why adolescents had not used the services in five organized themes: providers, health facility, adolescents, community, and health system level (Table2). Barriers in each theme may at least affect one of the basic dimensions (accessibility, availability, acceptability, equity, effectiveness, and efficiency) of the youth -friendly model of care [4,14].
The study found that all providers outside health care facilities (health centers, youth centers, and school and college clinics/SRH clubs) and some health care providers felt that they knew how and what to do on sexual health services for adolescents. Although approaches vary, studies in Ethiopia [17], Ghana [18], South Kenya [19], India [20], and Vanuatu, the South Pacific Islands [21] show that such factors affect health care providers and in turn affect adolescents.
We expect urban health extension workers to serve the urban community where literacy is higher than the rural community in Ethiopia. Hence, Health Extension Workers (HEWs) need to have better technical updates/ qualification in SRH packages to gain acceptance in the community. However, the findings of this study -show that health extension workers even could not accurately identify adolescents and what services were appropriate for adolescents. Similarly, many participants reported having difficulty in communicating with adolescents while providing AFSRH services during the visit. The findings agree with other research conducted in primary care settings in South Africa [15] which found the relationship between providers and clients was limited to brief instructions and cursory explanations.
Our study explored the confidentiality and discrimination of adolescents by demographic backgrounds like sex and age. This may affect adolescents' choice of care (autonomy) and distance them from accessing the existing friendly sexual and reproductive health services. The findings of this study agree with studies conducted in the South Pacific Islands [21] and Bolivia [22] that sex and age were important factors to consider while reaching adolescents. Providers should closely follow-up adolescents regarding outcomes of the services such as changes in behavior after they provide services as shown by the WHO [23]. In addition, the healthcare system and key stakeholders need to work in collaboration with a healthcare provider to increase health-seeking behaviors of adolescents in the country. Unfortunately, as to the participants' witness in our study, almost all approaches were not effectively considered for the contexts as intended to reach adolescents for better SRH service utilization.
Adolescent side barriers like fear of confidentiality breach, cultural taboos, financial constraints, unmatched choice of care, peer influence, lack of information, and poor attitude towards SRHs were important challenges affecting service utilization. Awkwardly, the majority of providers in the study were mentioning the above challenges as limiting factors for utilization of the service. The findings of our study were also congruent with studies done in Ethiopia [24], Ghana [25], and Nepal [26]. In addition, according to our findings, adolescents wanted to be served by providers of older age and the same sex. According to WHO [23], these findings seem to have an inverse association.
Many of the participants in this study repeatedly complained shortage of supplies such as modern contraception methods, essential medicines, pregnancy, and STI test kits at youth clinics. Participants also criticized the service environment for its unfriendliness to adolescents to use the services more easily and equitably. Furthermore, the majority of participants identified the inconvenient work schedule, the inadequacy of trained staff, and limited training for providers. All the above challenges negatively impact principles of adolescent-friendly services that may lead to ineffective delivery of services. Although the circumstances somewhat vary, our findings are consistent with the studies conducted in Ethiopia [24] and Tanzania [27,28].
Under the theme of community-level barriers, participants raised many perceived and/or actual barriers to accessing sexual and reproductive health services.
Although identical studies to our study are difficult toget, this finding seems to be consistent with other findings in Ethiopia [24] and Rwanda [24],and Ghana [25]. Our findings imply that community sexual and reproductive health promotion is required to support adolescent-friendly services among the general population, teachers, religious followers, and other stakeholders. Creating supportive environment for adolescents at all levels of the broader health system to deliver an effective friendly SRH service model of care for the study area and the country at large [29]. Creating a supportive environement for adollescents is really contextual and needs involvement of multiple sectors, professionls, and other stakeholders that needs system level thinking [29].
Providers in the study repeatedly complained lack of discussion between adolescents and parents. The findings of this study agree with other studies in India [20], Kenya [30] and Nigeria [31], and Ethiopia [32,33]. In addition, studies also showed that lack of parental knowledge and positive control [32], gender-selective influence [34], and poor parental involvement in planning SRHs [35,36] are barriers to accessing AFSRH services. Our findings also suggest the need to revise the current strategy to include and collaboratively work with parents, teachers, and religious persons at the community level. This should be started at the early age of adolescents to help adolescents plan their sexual needs and use health services without fear and shame.
In our study, the majority of participants had perceived that poor sexual health literacy at and earlier age could be a barrier to knowing, planning, and accessing sexual and reproductive health services. Fear of encouraging earlier sexual activity [37] is one of the most cited reasons for not providing sexual education in formal settings. But, stop talking about sex and sexuality can't delay sexual initiation [35,37,38] because adolescents know everything about it in the age of health information technology. Instead, sexuality education or literacy may create a sexually healthy future generation and fulfills sexual health for all [35,37,38]. Therefore, we suggest schooling about sex, sexuality, and sexual health services through designing age-appropriate, context-based and need-based curriculums starting from medium cycle [above grade 5] education. Besides, outreach programs brought limited impact on healthy sexual health behaviors and practices among young people in Sub-Saharan Africa including Ethiopia [36,38], and hence should be done at school.
Our study showed that unauthorized providers were seriously accused of prohibiting adolescents from using friendly sexual and reproductive health services. This finding is consistent with the study conducted in Addis Ababa that found illegal providers like Pharmacies abundantly provide emergency contraception for teenagers [39]. This implies that the need to establish need-based SRH provision systems like establishing youth clinics in high schools and strengthening youth centers to have healthcare providers with sufficient supplies to make the service closer to adolescents. Broader system-level challenges also call for urgent actions through multi-sectoral collaboration to increase access to sexual and reproductive health services in the study area.
Although the revised national strategy of the country included service delivery modalities(integrated or stand-alone ASRHs in the house to house, outreach programs,and individual clinics settings) [9], the need for trained staff, community link, parental and community support, developing need-based sexual education curriculums, working with private ASRHs providers, technological and material supplies and usage should further be included in the service standards and packages of the coming revised national adolescent strategies.

Conclusion
As to providers, adolescents face multiple barriers to accessing youth-friendly sexual and reproductive health services. Barriers exist at the levels of providers, health facilities, adolescents, community, and broader health system. Because of the complexity of barriers hindering adolescents from using friendly sexual and reproductive health services in primary care settings, multiple adolescent oriented approaches should be implemented. Given the lack of progress in the utilization of adolescents-friendly sexual and reproductive services, the existing strategy should be re-evaluated and new interventions at all levels of the healthcare system are needed. The findings of this study in each theme could also help the zonal health office to review its adolescent health services at health facilities and improve mainly the availability of adolescent health services. The issues of capacity building; uninterrupted SRH commodities and supplies; and partnership should be given priority in addressing SRH services to make the service available. Moreover, implementation research is required at all levels of the health system in the country.