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Abstract Background The burden of chronic illnesses, including cardiovascular disease and diabetes, is increasing in low- and middle-income countries. However, health systems often struggle to meet the needs of chronically ill patients. Affordability is crucial in ensuring access to quality healthcare for patients with diabetes mellitus (DM) and evaluating healthcare costs. Therefore, this study aimed to assess the affordability of health services and identify associated factors among DM patients receiving regular follow-ups at Dessie Comprehensive Specialized Hospital in Northeast Ethiopia, 2023. Methods A cross-sectional study was conducted among 392 DM patients at Dessie Comprehensive Specialized Hospital (DCSH) from July 1 to 30, 2023. Data was collected using a structured questionnaire and chart review checklist. Systematic random sampling was employed, and the data were analyzed using EPI INFO version 7 and SPSS version 26. The outcome variable, affordability of health services, was measured by five items using a structured questionnaire. Logistic regression analysis was performed to identify significant factors associated at 95% confidence interval using odds ratio. Results Most participants were married (74.2%), and 55.9% were male. Among the DM patients, 211 (53.83%) found the health services affordable, with an interval of 48.85–58.72% at a 95% confidence interval with a p-value less than 0.05. Factors significantly associated with healthcare affordability included marital status, family size, average monthly income, and brand prescription. Conclusion The study revealed that healthcare services were affordable for approximately half of the DM patients. However, this level of affordability falls short of the ideal standard. Improving the affordability and accessibility of healthcare services for DM patients, particularly those from low-income backgrounds, is crucial to ensuring better health outcomes.

Abstract Background Community based health insurance (CBHI) is characterized by voluntary involvement, pooling of health risks and of funds occur within a community. It is becoming increasingly popular way to increase the use of healthcare services in low- and middle-income nations. Understanding the effect of CBHI on the level of health services utilization is a paramount for evidence based decision making. Hence, this study aimed to estimate the pooled effect of CBHI on health services utilization in Ethiopia. Methods Studies were searched from PubMed, Google scholar, Web of Science, Research4life, Science Direct, African Journal Online and national websites for grey literatures. We were adhered to the PRISMA guidelines. Cross sectional and quasi experimental studies were included. Studies were screened, and critically appraised for quality using Joanna Briggs Institute Critical Appraisal tools. The data were extracted using Microsoft excel and exported to STATA 17 and RevMan 5.4.1 for further analysis. Heterogeneity between studies was assessed using Cochran’s Q statistic and quantified with I2. A random-effects model was used to estimate the pooled effect size. Subgroup analysis was done to show variations of the effect sizes across study years. Result A total of 1501 studies were identified, out of which only 14 of them were included in the final meta-analysis. Health services utilization among CBHI members and non-members was 69.1% [95%CI (57.1–81.1%)] versus 50.9% [95%CI (40.6–61.3%)] respectively (difference in the effect was 18.2%). The CBHI members were nearly three folds more likely to utilize health services as compared with their counterparts [OR = 2.54, 95%CI: (1.81, 3.57). On average, CBHI users had 1.14 increased health facility visits as compared to non-insured, mean difference (MD) = 1.14 visits with 95% CI (0.65–1.63). Conclusion The CBHI has a significantly increased health service utilization in Ethiopia. Hence, it will have a great contribution to meet the health for all agenda in resource limited countries.

Abstract Introduction Obstetric fistula is a birth injury that causes the vagina to open abnormally. As a result, women may experience urinary leakage, which can lead to isolation, depression, and a lower quality of life. Due to the scarcity of evidence regarding the average recovery time for obstetric fistula in Ethiopia, Therefore, this study aimed to assess the recovery time for women with obstetric fistula in Ethiopia. Methods Between September and 8 November 2023, published studies were searched using online databases including PubMed, Hinari, Epistemonikos, and Google Scholar. The systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Study quality was assessed using Egger’s test and a visual inspection of funnel plot symmetry. Statistical analysis was performed using STATA version 17 software. A random-effects model was employed for analysis, and the Cochrane Q-test and I² statistics were used to assess heterogeneity among studies. Result A total of six studies were included in this analysis. The minimum and maximum median survival times were 2.67 and 5.19 weeks, respectively. The pooled median recovery time was 4.05 weeks (95% CI: 2.92, 5.18) based on the random effects model. Heterogeneity among the included studies assessed by the I² statistic was 97.72% (p = 0.000). The p-value for Egger’s regression test (0.017) was significant, indicating evidence of publication bias. Conclusion The findings reveal a pooled median recovery time of 4.05 weeks, with considerable heterogeneity. Although these figures provide valuable insights, the presence of publication bias was evidenced by the asymmetric funnel plot and significant Egger’s test. Efforts to address publication bias are essential to improve future meta- the reliability of the surveys has increased. Registration : The protocol for this systematic review was pre-registered on the International Prospective Register of Systematic Reviews (Registration Number: CRD42023270497).

Abstract Background Ethiopia has made strides in reducing maternal mortality, but significant discrepancies in maternal health service utilization exist across socioeconomic levels. According to studies, women from higher-income households are far more likely to use essential services such as antenatal care, delivery care, and postnatal care than poorer women. This wealth disparity is a primary contributor to persistently high maternal mortality, particularly among poor populations. The study’s goal was to assess wealth disparities in maternal health service uptake and identify contributing factors. Methods and materials We used the Ethiopian Mini Demographic Health Survey (EMDHS), conducted in 2019 on women aged 15–49 living in selected census areas, with a weighted sample size of 3,909. The Erreygers Concentration Index (ECI) was used to measure wealth inequalities in maternal health care, and the ECI decomposition was used to identify factors contributing to inequality in maternal health services. Results Maternal health service utilization was pro-rich among women in Ethiopia. The prevalence of antenatal care service (ANC), delivery, and postnatal care (PNC) service utilization showed a pro-rich distribution among Ethiopian women, with ECI = 0.115 (95% CI: 0.091–0.137), ECI = 0.223 (95% CI: 0.191–0.276), and ECI = 0.121 (95% CI: 0.041-0.200), respectively. The ECI indices were decomposed to examine the contributing factors to disparities in maternal service utilization in Ethiopia. Mother’s current age, household family size, region, birth order, and parity were contributors to maternal health service utilization. Conclusion The ANC service, delivery service and PNC service utilization showed a pro-rich distribution among Ethiopian women. Mother’s current age, household family size, region, birth order, and parity are important contributors of maternal health service inequality. To improve access and usage among low-income women, policymakers can develop programs including increasing the number of free or subsidized services and providing transportation.

IntroductionAntimicrobial resistance is a major global public health concern, especially in low-resource settings. In low- and middle-income countries, the existing evidence about antimicrobial resistance in drinking water is inconsistence and not comprehensive. Therefore, this study aimed to estimate the pooled prevalence of antimicrobial resistance profiles of Escherichia coli from drinking water in low- and middle-income countries.MethodsThis study was conducted using comprehensive literature searches using various databases such as PubMed, Scientific Direct, HINARI, and Google Scholar. Data extraction was performed using Microsoft Excel and exported to STATA 14/SE software for analysis. We used the Joanna Briggs Institute’s quality appraisal tool to ensure the quality of the included studies. A random effects model was employed to estimate the pooled prevalence. Publication bias was evaluated using funnel plots and Egger’s regression test. Subgroup and sensitivity analysis were also conducted in this study.ResultsThe study found that the pooled prevalence of Escherichia coli isolates in drinking water was 37.94% (95% CI: 26.73–49.13). The prevalence of multidrug resistance was 43.65% (95% CI: 31.15–56.15). Regarding specific antimicrobials, the pooled resistance levels of Escherichia coli were 54.65% (95% CI: 41.35–67.96) against contrimoxazole, followed by 48.64% (95% CI: −3.6–101) against amoxicillin and 48% (95% CI: −18.1–114.2) against cefuroxime.ConclusionThe findings indicated a significant prevalence of antimicrobial resistance of Escherichia coli isolated from drinking water and its multidrug resistance. To address this issue, it recommends focusing on improving basic hygiene and sanitation practices and enhancing water and wastewater treatment systems.Systematic review registrationIdentifier CRD42024533592.

IntroductionDisparities in access to basic sanitation services between rural and urban households pose significant challenges to public health and human development. Understanding the determinants contributing to this gap is vital for advancing the Sustainable Development Goals (SDGs) and improving environmental and public health through evidence-based interventions.ObjectiveThis study aims to analyze and understand the disparities in access to basic sanitation services between rural and urban households in Ethiopia.MethodsThis study analyzed a sample of 8,663 weighted households, collected using stratified sampling techniques, utilizing the data from the 2019 Ethiopian Demographic and Health Survey (EDHS). The primary outcome was basic sanitation access, defined as access to flush or pour-flush systems, septic tanks, pit latrines, or composting toilets. A multivariable decomposition analysis was conducted to identify factors contributing to rural–urban disparities. Statistically significant variables were determined at a p-value of

Abstract Introduction : Early sexual initiation has negative health, social, and economic consequences for both women and future generations. The trend of early sexual initiation is increasing globally, leading to higher rates of sexually transmitted diseases and unplanned pregnancies. Ethiopia has been challenged various disasters that makes women vulnerable and position them at heightened risk of early sexual initiation in the last four years. The spatial patterns and factors of early sexual initiation in the post-conflict-post pandemic settings is not well understood. Hence this research aimed at mapping Spatial Patterns and identifying determinant factors in the Post-COVID-Post-Conflict Settings. Methods The study was conducted on secondary data from the PMA 2021 cross-sectional survey which conducted nationally from November 2021 to January 2022 which is in the post pandemic and post-war period. Total weighted sample of 6,036 reproductive age women were included in the analysis. ArcGIS Pro and SaTScan software were used to handle spatial analysis. Multilevel logistic regression model was used to estimate the effects of independent variables on early sexual initiation at individual and community level factors. Adjusted odds ratio with the 95% confidence interval was reported to declare the strength and statistical significance of the association. Result The spatial distribution of early sexual initiation was clustered in Ethiopia with a global Moran’s I index value of 0.09 and Z-score 6.01 (p-value

Abstract Background The Family Guidance Association of Ethiopia (FGAE) operates as a non-governmental organization dedicated to offering family planning and reproductive health services to the Ethiopian population. The gap in the study regarding client satisfaction and contributing factors towards sexual and reproductive health services for youth at FGAE clinics highlights the need for a comprehensive investigation to fill this void. By conducting a mixed-method study, this research aims to provide a holistic understanding of the factors influencing client satisfaction in the delivery of sexual and reproductive health services to youth at FGAE clinics. The added value of this study lies in its potential to offer valuable insights and recommendations for improving service delivery systems and enhancing client satisfaction levels, ultimately contributing to the overall well-being and health outcomes of youth in North Ethiopia. Therefore study aimed to asses Client Satisfaction and Contributing Factors towards in sexual and reproductive health services delivery system among youth at Family Guidance Association of North Ethiopia (FGAE) Clinics, 2023. Method The study was conducted within the clinics of the Family Guidance Association of Ethiopia (FGAE), spanning Dessie, Kombolcha, and Woldia city administrations, involving a participant cohort of 416 clients. Facility-based concurrent type mixed method study design both quantitative and qualitative techniques were applied. Quantitative research employed a simple random sampling technique and conversely, the qualitative study utilized a heterogeneous type of purposive sampling strategy to recruit participants The collected data underwent a rigorous process of entry, cleaning, and coding using Epi-Data 4.6 software, followed by analysis in STATA V17. Descriptive statistics and binary logistic regression were employed to highlight the impact of independent variables on the dependent variable. A more comprehensive examination was provided through multivariable logistic regression. Crude and adjusted odds ratios, along with a 95% confidence interval, were computed, with significance set at a p-value ≤ 0.05. Result Nearly more than half of the clients 194 (47.8%) came to receive family planning services followed by maternal and child health 107 (26.4%). Sixty patients (14.8%) didn’t receive all the services they wanted or came for. Half of the participants 30 (50%) raised the unavailability of the service as a reason for not taking the service followed by not having enough time in the clinic 12 (20%). About 65.52% (60.74-70.00%) of the participants were satisfied with the Sexual and Reproductive Health services provided by the clinics of FGAE in northeast Ethiopia. Clients in the age group of 25–34 (AOR = 2.04; 95%CI: 1.11–3.72). Clients who had primary and secondary education (AOR = 2.49; 95%CI: 1.03–6.02) and (AOR = 3.05; 95%CI: 1.25–7.49) respectively. Clients who responded that physicians show respect (AOR = 5.59; 95%CI: 1.89–16.49). clients who received an explanation about the side effects of the utilized methods and follow-up dates (AOR = 4.59;95%CI:1.68–12.53) and (AOR = 2.89;95%CI:1.53–5.49) respectively. Conclusion The proportion of client satisfaction with Client Satisfaction in the Services delivery system at Family Guidance Association of Ethiopia (FGAE) Clinics was low as compared to the previous study. Age group 25–34 years, primary and secondary education, showing respect, explaining side-effects and follow-up visits were significant associated factors of client service satisfaction. Enhancing service delivery at Family Guidance Association of Ethiopia (FGAE) Clinics by targeting specific areas identified in the study. Strategies should focus on improving communication regarding side effects, ensuring respectful interactions, and prioritizing follow-up visits, particularly for clients aged 25–34 with primary and secondary education backgrounds.

Abstract Background Malaria is one of the most common causes of morbidity and mortality in developing countries including Ethiopia. Mass distribution of insecticide-treated nets and indoor residual spray for high malaria risk groups are the major prevention measures in different countries. Achievement of the malaria elimination plan is highly determined by the level of effective utilization of intervention measures. However, there is scarce information showing the national level of insecticide-treated nets utilization. Objective To estimate the pooled prevalence of insecticide-treated nets utilization in Ethiopia, 2023. Method A Systematic Review and Meta-analysis employed to assess the utilization of long-lasting insecticidal nets in Ethiopia. Published articles were searched from Google Scholar, PubMed, Web Sciences, CINAHIL, EMBASE, and Scopus. The collected articles were screened for data extraction and further analysis using preferred reporting items for systematic review and meta-analysis (PRISMA) flow chart. The quality of each study was assessed using the Jonna Briggs Institute (JBI) checklist. The data were extracted using Microsoft Excel and exported to STATA version 17.0 for analysis. The overall pooled prevalence of long-lasting insecticidal nets utilization was determined using a random effects model. Result Out of 1657 articles reviewed, only 21 of them were eligible for final analysis. All of the included studies were used to estimate the pooled prevalence of long-lasting insecticidal net utilization. The point prevalence of LLIN utilization ranged from 14.23 to 91.9%. The Meta-analysis estimated that the overall pooled prevalence of insecticidal nets utilization among all study participants in Ethiopia was 56.26% (95%CI: 44.04–68.48%). Subgroup analysis revealed that insecticidal nets utilization was relatively highest in the Amhara region [63.0, 95%CI (37.0–89.0%)] and during 2020–2023 [61, 95% CI (53.0–69.0%)]. Conclusion Long-lasting insecticidal nets utilization in Ethiopia is lower than the national target plan. Hence, it needs extra follow-up and intervention to enhance its utilization.

BackgroundIn sub-Saharan Africa, achieving universal health coverage (UHC) and protecting populations from health-related financial hardship remain challenging goals. Subsequently, community-based health insurance (CBHI) has gained interest in low and middle-income countries, such as Ethiopia. However, the rural–urban disparity in CBHI enrollment has not been properly investigated using multivariate decomposition analysis. Therefore, this study aimed to assess the rural–urban disparity of CBHI enrollment in Ethiopia using the Ethiopian Mini Demographic Health Survey 2019 (EMDHS 2019).MethodsThis study used the latest EMDHS 2019 dataset. STATA version 17.0 software was used for analyses. The chi-square test was used to assess the association between CBHI enrollment and the explanatory variables. The rural–urban disparity of CBHI enrollment was assessed using the logit-based multivariate decomposition analysis. A p-value of

IntroductionThe achievement of the minimum acceptable diet intake (MAD) stands at 14% among urban and 10% among rural under-five children in Ethiopia. Consequently, identifying the determinants of the urban–rural gap is vital for advancing Sustainable Development Goals (SDGs), fostering healthier communities, and developing evidence-driven approaches to enhance health outcomes and address disparities.ObjectiveThe objective of the study was to decompose the urban–rural disparities in minimum acceptable diet intake in Ethiopia using the Ethiopian Mini-Demographic and Health Survey 2019 data.MethodThe study was conducted using the Ethiopian Demographic and Health Survey 2019 report. A total of 1,496 weighted children aged 6–23 months were included using stratified sampling techniques. The main outcome variable minimum acceptable diet was calculated as a combined proportion of minimum dietary diversity and minimum meal frequency. A decomposition analysis was used to analyze the factors associated with the urban–rural discrepancy of minimum acceptable diet intake, and the results were presented using tables and figures.ResultThe magnitude of minimum acceptable diet among children aged 6–23 months in Ethiopia was 11.0%. There has been a significant disparity in the intake of minimum acceptable diet between urban and rural under-five children with 14 and 10%, respectively. Endowment factors were responsible for 70.2% of the discrepancy, followed by 45.1% with behavioral coefficients. Educational status of college and above was responsible for narrowing the gap between urban and rural residents by 23.9% (β = 0.1313, 95% CI: 0.0332–0.245). The number of children in the household and the age of the child between 18 and 23 months were responsible for widening the gap in minimum acceptable diet intake discrepancy between urban and rural residents by 30.7% and 3.36%, respectively (β = −0.002, 95% CI: −0.003 to −0.0011 and β = −30.7, 95% CI: −0.025 – −0.0085). From the effect coefficients, the effect of institutional delivery was responsible for 1.99% of the widening of the gap between urban and rural residents in minimum acceptable diet intake (β = −0.0862, 95% CI: −0.1711 – −0.0012).ConclusionThere is a significant variation between urban and rural residents in minimum acceptable diet. The larger portion of the discrepancy was explained by the endowment effect. Educational status of mothers with college and above, parity, age of child, and place of delivery were the significant factors contributing to the discrepancy of minimum acceptable diet intake between urban and rural residents.

BackgroundAddressing health inequity is a top priority for achieving sustainable development goals. The existing evidences in Ethiopia have shown that there are substantial inequalities in the use of health services among various socioeconomic strata. Therefore, the present study aimed to measure socioeconomic inequalities and the contributing factors in postnatal health checks for newborns in Ethiopia.MethodsWe used a secondary data from the recent 2019 Ethiopia Mini Demographic and Health Survey dataset. The study includes a weighted sample of 2,105 women who gave birth in the 2 years preceding to the survey. The study participants were selected using two stage cluster sampling techniques. The socioeconomic inequality in postnatal health checks for newborns was measured using the Erreygers Normalized Concentration Index (ECI) and illustrated by the concentration curve. A decomposition analysis was done to identify factors contributing to the socioeconomic related inequality in postnatal health checks for newborns in Ethiopia.ResultsThe concentration curve of postnatal health checks for newborns lay below the line of equality, and the Erreygers normalized concentration index was 0.133, with a standard error = 0.0333, and a p value

BackgroundExposure to pesticides is a global public health problem, especially for children. Its association with chronic respiratory disease among children has attracted considerable attention, but the existing evidence remains inconclusive and cannot be certain. Therefore, this systematic review and meta-analysis aim to determine the global pooled effect size of association with pesticide exposure and asthma, wheezing, and respiratory tract infections among children.MethodsA comprehensive search was conducted for relevant literature from electronic databases, including PubMed, Google Scholar, Hinari, Semantic Scholar, and Science Direct. Studies that provided effect size on the association between pesticide exposure and childhood asthma, wheezing, and respiratory tract infections in children were included. The articles were screened, data was extracted, and the quality of each study was assessed with four independent reviewers. Random effects models for significant heterogeneity and fixed effect models for homogeneous studies were conducted to estimate pooled effect sizes with 95% confidence intervals using Comprehensive Meta-Analysis version 3.3.070 and MetaXL version 2. Funnel plot and Higgins I2 statistics were used to determine the heterogeneity of the included studies. Subgroup analyses were computed based on the types of pesticide exposure, study design, sample size category, and outcome assessment technique.ResultA total of 38 articles with 118,303 children less than 18 years of age were included in this meta-analysis. Pesticide exposure among children increased the risk of asthma by 24%; (OR = 1.24, 95% CI: 1.14–1.35) with extreme heterogeneity (I2 = 81%, p

IntroductionExposure to indoor air pollution such as biomass fuel and particulate matter is a significant cause of adverse pregnancy outcomes. However, there is limited information about the association between indoor air pollution exposure and adverse pregnancy outcomes in low and middle-income countries. Therefore, this meta-analysis aimed to determine the association between indoor air pollution exposure and adverse pregnancy outcomes in low and middle-income countries.MethodsInternational electronic databases such as PubMed, Science Direct, Global Health, African Journals Online, HINARI, Semantic Scholar, and Google and Google Scholar were used to search for relevant articles. The study was conducted according to the updated Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A random effect model at a 95% confidence interval was used to determine the association between indoor air pollution exposure and adverse pregnancy outcomes using STATA version 14. Funnel plot and Higgs I2 statistics were used to determine the publication bias and heterogeneity of the included studies, respectively.ResultsA total of 30 articles with 2,120,228 study participants were included in this meta-analysis. The pooled association between indoor air pollution exposure and at least one adverse pregnancy outcome was 15.5% (95%CI: 12.6–18.5), with significant heterogeneity (I2 = 100%; p < 0.001). Exposure to indoor air pollution increased the risk of small for gestational age by 23.7% (95%CI: 8.2–39.3) followed by low birth weight (17.7%; 95%CI: 12.9–22.5). Exposure to biomass fuel (OR = 1.16; 95%CI: 1.12–1.2), particulate matter (OR = 1.28; 95%CI: 1.25–1.31), and kerosene (OR = 1.38; 95%CI: 1.09–1.66) were factors associated with developing at least one adverse pregnancy outcomes.ConclusionsWe found that more than one in seven pregnant women exposed to indoor air pollution had at least one adverse pregnancy outcome. Specifically, exposure to particulate matter, biomass fuel, and kerosene were determinant factors for developing at least one adverse pregnancy outcome. Therefore, urgent comprehensive health intervention should be implemented in the area to reduce adverse pregnancy outcomes.

Abstract Background Early sexual initiation refers to engaging in sexual activity at a young age, typically before the age of 18. Even though many studies have been conducted in Ethiopia, the result is inconsistent between studies. In the study area, the pooled prevalence and associated factors of early initiation of sexual intercourse among youth were not done before. Therefore, this study aimed to determine the pooled prevalence and associated factors of early initiation of sexual intercourse among Youth in Ethiopia. Methods This study used a systematic review and meta-analysis of studies conducted from 2008 to 2022, in Ethiopia. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Cochrane Library, Hinari, and Google Scholar electronic databases were searched. The analysis was performed using STATA 17 software. Heterogeneity and publication bias were assessed using forest plots, I2 , Cochran’s Q statistics and Funnel plots, Egger test, and Begg rank tests respectively. Duval and Tweedie’s ‘trim and fill’ method was also performed to adjust the pooled estimate. Pooled analysis was conducted using the inverse-variance fixed-effects model. Results A total of 10 articles were included in this systematic review and meta-analysis. The pooled prevalence of early initiation of sexual intercourse among youth in Ethiopia was 24.7% (95%CI: 10.4, 38.9). Being female (AOR = 3.57; 95% CI: 1.387, 5.743), having poor knowledge of HIV/AIDS prevention (AOR = 3.65; 95% CI: 1.981,5.309), alcohol use (AOR = 2.05; 95% CI: 1.415, 2.679), khat chewing (AOR = 3.03; 95% CI: 1.800, 4.254), Viewed pornographic film(AOR = 4.21, 95% CI: 2.135, 6.283), Cigarette smoking (AOR = 2.74; 95% CI: 2.102, 3.370) and Poor family controls (AOR = 4.39; 95% CI: 2.572, 6.199)were associated factors of early initiation of sexual intercourse. Conclusions The pooled prevalence of early initiation of sexual intercourse among Youth in Ethiopia was high. Being female, poor knowledge of HIV/AIDS prevention, alcohol use, khat chewing, Viewing pornographic films, Cigarette smoking, and poor family controls were associated factors of early initiation of sexual intercourse. It is recommended that targeted interventions be put in place to address the high prevalence of early initiation of sexual intercourse among youth in Ethiopia. These interventions should focus on addressing the associated factors such as poor knowledge of HIV/AIDS prevention, alcohol use, khat chewing, viewing pornographic films, cigarette smoking, and poor family controls. It is important that these interventions are gender-sensitive and take into consideration the unique challenges faced by females in accessing sexual and reproductive health services.