Impact of adolescent engagement in sexual and reproductive health program outcomes in Northern Ethiopia

Adolescent engagement in sexual and reproductive health (SRH) programs is mentioned both as reproductive right and a solution to reducing SRH burdens on adolescent youths in a society. However, in practice, due to gaps in monitoring, evaluation, and the reassessment of program interventions, significant policy and program gaps in sexual and reproductive health (SRH) persist. The factors for these include insufficient program evaluation and follow up measures. This study assessed the outcomes of the engagement of adolescents in SRH programs in Shewarobit town and Kewet district. The study used a mixed methods approach, a quasi-action research and case study design, and a concurrent triangulation fieldwork strategy. Data were collected using desk review of documents, survey questionnaire that was administered to 416 randomly selected respondents and from 15 key informants selected by their affiliation in the adolescent SRH program. The finding from the study indicated that the participation of adolescents in SRH program improved their SRH knowledge, attitude, behaviour and practices. The study thus concludes that improving enabling environment for adolescents in SRH program enhances their influence on the program process and outcomes, and therefore participation of beneficiaries in programs, and continuous monitoring, evaluation and follow up improves the intended program results. The study finally recommends that, from program intervention dimension, participation of the intended program beneficiaries form need assessment to tracking of results is needed. From research dimension, a future study that considers holistic assessment of programs at broader country level is required to adopt the generalization of findings.


INTRODUCTION
Adolescence (10-19 years of age) is a critical period in life where a transition from childhood to adulthood occurs with extensive biological, physical and social transitions (UNCEF, 2021).Adolescence is the time when the youth face serious sexual and reproductive health challenges such as harmful traditional practices (early marriage, unwanted and early pregnancy, sexually transmitted infections).Also, adolescents at this time lack access to health services, particularly contraception and safe abortions (UNICEF, 2021).Despite accounting for 16% of the global population and being an important age for laying the groundwork for a healthy life, this age group requires special attention, especially on adolescent SRH statistics (UNICEF 2021(UNICEF , 2022)).Due to increase in adolescents targeting SRH programs over the last two decades, there has been a decrease in new HIV infections, child marriage and unintended births.However, the improvements in the SRH of adolescents worldwide have been uneven (Cortez et al., 2020).In Sub-Saharan countries, including Ethiopia, about 20% of the adolescent population continuously face SRH problems, and those become a major public health challenge (UNICEF, 2021; Melesse et al., 2020).
In Ethiopia, the 2019 CSA Survey Report shows that there are 21 million adolescent pregnancies, 50% of which are unplanned and 55% of which result in unsafe abortion (CSA, 2021).According to the 2016 Ethiopian DHS report, 40.3% of Ethiopian adolescents marry before the age of 18 and 13% of adolescent girls give birth before they are 15 years old.
The risks of STIs, unintended pregnancies, and unsafe abortion are significant among girls as a result of early marriage and early sexual debut (CSA, 2021).A study in Jimma Hospital in Ethiopia shows that women under the age of 19 are twice as likely as women of other ages to have an abortion in the second trimester (Akwara et al., 2022;Amref Health Africa, 2020).Thus, innovative approaches are needed to solve these SRH problems, including how to make SRH services more acceptable and accessible, including ending the HIV/AIDS epidemic in adolescents (UNAIDS, 2016).For these approaches to be successful, meaningful adolescent engagement in program gap assessment, design, monitoring, evaluation and dissemination of results is critical (Simuyaba et al., 2021).Participation of adolescents in all stages of program cycle enhances opportunities for as well as reduces SRH burdens on them, and enhances their influence on program and policy processes (Chandra-Mouli et al., 2015).

LITERATURE REVIEW
Adolescents' sexual and reproductive health affects not only their physical and mental health, but also their economic well-being, future employment, and the country's social and economic development (WHO, 2018).Also, engaging adolescents in the design and delivery of programs, policies, strategies, funding mechanisms, and institutions/organizations reduce their SRH burdens (WHO, 2018).However, the practice of Hando and Egziabher 29 adolescent engagement is minimal; and such findings were supported by evidence from Ethiopia, Mali, and Kenya (Admassu, et. al., 2022;Chidwick, et. al., 2022a;Wigle, et. al., 2020).The reason behind inadequate engagement was mentioned as a result of an insufficient measurement of adolescent.Also, the existing tools and frameworks of adolescent participation in programs are not adequate, and needs revision based on the dynamics in society, cultures and norms (Melles and Ricker, 2018;International Initiative for Impact Evaluation, 2017a).The issue of youth and adolescent participation is recognized as both as a rights and privilege to getting adequate services from the government, and is thus a public health issue of counties (UN Women, 2018).Also, the UN resolutions, focusing on gender and woman rights, consider it as issue of ending violence against the youth (see the pillars of UNSCR 1325).Since adolescent SRH is a public health, and rights concern of government and development actors, their meaningful engagement is essential for achieving the outcomes of SRH programs (Catino et al., 2018;UNICEF, 2021UNICEF, , 2022)).
The types of adolescent participation are also important to note.Adolescents' engagement in program phases needs to consider the dynamic intervention, policy and social, cultural, political contexts (Catino et al., 2018).Since the demography of countries manifest pyramid, adolescent engagement needs to align with such pyramid.For instance, in countries like Ethiopia, adolescent and youths together constitute more than 45% of the population (CSA, 2021).Thus, programs need to design engagement activities based on age, ability, preferences, sex and literacy levels of the adolescent youths (Catino et al., 2018;Wong et al., 2010;UNICEF, 2022).
However, the intersectional embeddedness of age, abilities, preference, and task of the youth to opportunities of meaningful participation, the power dynamics in the society is important to consider for impactful youth empowerment (DFID, 2010).Thus, adolescent youths as beneficiaries, partners, and leaders of a program, including the SRH, is not a uniform group, and needs adequate targeting mechanism (Ramey et al., 2017).The current practices in adolescent youth engagement are not adequate in guiding the targeting, monitoring, evaluation and reporting tools that fits for the diversity of adolescent groups in societies, therefore, SRH program outcomes are not achieved as expected and designed (WHO, 2021;Melles and Ricker, 2018).In Africa in general, and in Ethiopia in particular, adolescent and youths reveal that young people are less engaged to contribute to their own wellbeing and development as a result of the inadequate government's commitment and implementation of national youth engagement strategies (Wigle et al., 2020;WHO, 2021).
In order to understand and analyse the impact of meaningful participation of adolescent youths in SRH program outcomes, three theoretical lenses were used.

Int. NGOJ.
The first theoretical lens that was employed by the study was the dynamic theory of service provision.The dynamic theory of service provision (Kurgat and Ombui, 2013) acknowledges dynamically and flexibly inclusive targeting of specific categories during interventions.This theory assumes that service provision is dynamic due to various changing and unfolding contexts (such as changes in barriers, policy needs, risk sets, etc.).The changes also require continuous need assessment, flexible and dynamic policy decisions that create both enabling environment for the participants as well as the institutions to achieve their program objectives.The flexibility is needed to address unfolding needs and tailor both targeting of service seekers and strategies of implementation.Adolescent SRH gaps continuously shape and reshape, and are dynamic, self-perceived and demand redressing the current and latent needs of the service seekers (WHO, 2021).In such context, continuous need analysis and integrated adolescent SRH mainstreaming are essential to address the SRH needs of adolescents.Also, interventions need to factor timeliness, tailored-ness, costing, and inclusive targeting modelling to interventions to cater barriers to entitlements to services and this assumption links service provision to program management, analysis and evaluation.
The second theoretical lens that was employed by the study was the program intervention theory of change.The intervention theory of change is a theoretical model developed by NGOs, Donors and philanthropiesbut now is used widely by development and service providing actors (Holzer, 2013;Siegel and Welsh, 2012;Eberechi and Stevens, 2016;Ribot and Peluso, 2003).This theory is informed by beliefs about what is needed by the target groups and what strategies would enable them to meet their needs (strategic and practical) further bonding the relationship between organizational missions, strategies and actual outcomes while also creating links between who is served, the strategies and activities that are being implemented and the desired outcomes that are achieved and the enabling environment further created.It also considers the grids of collaboration, partnerships and networking needed for fine-tuning the processes, structure and targeting arrangements on the ground, and most importantly, the participation of the target beneficiaries, in our case, adolescent engagement.In this understanding the theory of change has two broad components, as indicated by Siegel and Welsh (2012) and Eberechi and Stevens (2013).These are: 2. Building justified and clear relationships among the core components and explicitly expressing them in the way that is tracked, measured and changes observed over target group as well as inform gender analysis.
The third theoretical lens that was employed by the study was the social change continuum model.The social change continuum model is coined from scholars that studies inclusion of discriminated and underserved groups in a program, institutions and the society (Kabeer, 2016;UN Women, 2018).This theory pinpoints the measurement of changes (to target beneficiaries and the contexts around them) by interventions.This theoretical model defines changes in the continuum (observed from an individual level to broader institutional level changes) of processes leading to enabling environment and expected outcomes of the program.
The core of this model is the empowerment of target beneficiaries as individuals and groups (in our case, adolescent female and male youths).The dimensions of this model encompass cognitive (in our case, knowledge, awareness and information on SRH), psychological (social beliefs and behaviours perpetuating their SRH attitudes, behaviours and practices), and institutional (ability to influence the intervening institutions to create an enabling environment, engage them in the program and benefits).The theory further assumes that addressing these dimensions manifests holistic changes in the intervention process as part of knowledge-making, attitude and behaviour change, and inculcation of the SRH practices, leading to the upholding of their rights to and solutions to the SRH gaps in the specific cultural and policy/program context (Nussbaum, 2011;Kabeer, 2016;UN Women, 2018).
Progressive scholars of social inclusion in program intervention context argue that reference to informed intervention and outcome (impact) requires documentation and flexible and dynamic gaps analysis continuously and progressively.
Such analysis and intervention practice aims at revisiting exclusion as a continuous but also a neverending change continuum that ultimately leads to a fit in the dynamics of unpredictable and unfolding social changes, in which adolescents grew and transform.In this respect, interventions need to involve a participatory, stakeholders' ownership building, change aware and context fitting solutions.The progressively changing demands of adolescents, in our case, need a continuous revision and reformulation of SRH program activities.In a broader stance, this model sets platforms, agenda, in line with the micro and macro-level changes and the tracking of the overall enabling context.This study thus assessed the impact of adolescents' participation in sexual and reproductive health program outcomes in Northern Ethiopia.The findings of this study will serve as an input for adolescent focused programming as well as adolescents' participation in SRH programs thereby to influence policy makers, and their cultural/ social contexts.The analytical gaps and the framework in the subsequent sections were based on the understanding of the three theories reviewed above.These theories were also used as a lens to design the methodology, the analysis and interpretation of the data results.Thus, the analytical framework of the study was as follows, as in Figure 1 above.
The framework design first considered the analysis of the enabling environment for adolescent engagement in the program, the policy measures/practices and the outcomes in terms of changes in SRH knowledge, attitudes, behaviours, and practices.The grids of analysis in the framework components focused on whether the measures the improvements in the SRP practices by adolescents are associated with their engagement in the program from its gap assessment, design, launching, implementation, monitoring and evaluation.In regard to sustainability of the improvements in the SRH outcomes identified above, changes in parent, community and institutional contexts were also considered in the analysis.The whole intervention and outcomes of the program was analysed in the framework of dynamic service provision (policy practice), program theory of change (need assessment to monitoring and evaluation) and the social continuum modelling (the program's alignment to changes in social, policy, institutional, community. The framework design set the key gaps for this study from literature and designed key inquiries (questions).The gender lens considered the gender gaps in the frameworks of understanding (knowledge), thinking (attitudes), decisions and actions (behaviour and practices including intervention policy response/practice) and continuous awareness and creation of enabling environment (SRH information and actions).In considering this analytical framework, the study assessed the intended outcomes of the intervention, focusing on whether the program engaged adolescents, and whether in the intervening institutions created an enabling environment for their engagement, which is intended to contribute to the improvement of the SRH knowledge, attitude, behaviours and practices of the adolescent that are beneficiaries of the program.In doing so, also, the analytical focus considered the dynamic and changing nature of SRH demands of adolescents, and the continuous changes of societal, community, organizational, parental and program demands in the specific context of the study.

MATERIALS AND METHODS
A mixed study approach and concurrent triangulation study design was used to assess the outcome of adolescents' engagement in SRH programs because it allows for the confirmation, cross validation, and corroboration of findings for a better result.Initially, desk review was used to analyze and substantiate evidence of how adolescent engagement in SRH programs improves program outcomes, which then were used to best describe the results obtained from both quantitative and qualitative data.Both quantitative and qualitative data was collected separately in the field at the same time, then triangulated after analyzing both data sets and interpreting the data by pinning the similarities and incongruences between the two data sets, comparing and contrasting results and if there also complementarity.
(1.3).Improved adolescent health service utilization and perception.Considering the theoretical tenets reviewed in chapter 2 (2.6), the data analysis followed a program theory of change within the framework of dynamic service deliver and social change continuum modeling following.
The study, as indicated in Figure 2, employed a mixed methods approach.In terms of design, it employed a case study-driven quasi action research.The field work strategy (application of the approach and the design in the field) employed by the study was a concurrent triangulation strategy including a parent and youth transformation aspects).
This study used both secondary and primary data, with secondary data obtained from a desk review of various reports and studies focusing on evaluating programs that work by engaging adolescents to determine how involving adolescents in SRH programs improves program outcomes.Using a prepared questionnaire for adolescent engagement in SRH programs as well as other key stakeholders, including program administrators, the primary data were used to assess adolescent engagement in SRH programs and the status of the enabling environment in the study area as well as in the analysis of engagement outcomes.
All of the adolescents and programmers that live in the study area and are in clubs related to sexual and reproductive health make up the source population.Adolescents between the ages of 15 and 19 who enrolled in chosen wored as in the academic year 2022-2023 as well as all in-school and out-of-school adolescents between the ages of 15 and 19 who was participating in youth clubs, power to youth program and engagement of adolescents in sexual and reproductive health project living in the selected areas of the program make up the study population.For the qualitative study selected adolescents who participated in the quantitative study, youth club leaders and programmers were study population.Any participant who has any hearing and visual impairment and cannot engage or communicate was excluded from the study.
The sampling techniques that were used for sampling were both probability and non-probability sampling method where multi-stage sampling and intensity purposive sampling technique was used respectively.A total of 396 sample size was estimated based on Slovin (1960) formula of assumption Based on the SRH program that was being implemented and due to the political instability, Shewarobit town and Kewet district was selected for this study.Both the town and the district were supported by the Power to youth project, are diverse in sociocultural characteristics including urban (Shewarobit town), rural (Yelen kebele) and pastoral features Abiy Atir kebele.Amref Health Africa led the project in Tere Kebele in Kewet district and all Kebeles in Shewarobit town.Whereas, Fana Addis Tiwulid Ethiopia implementing in two primary schools in Kewet woreda (Sefiberet and Yelen primary schools).Then simple random sampling was used to select required number of samples in each selected schools and youth clubs after proportional allocation and equal allocation of study population for each selected woreda youth clubs and schools.
For the qualitative study intensity purposive sampling method were used with in depth and key informant interview until the information gets saturated.With the assumption of rule of thumb, 15 key informant interviews were conducted.Total of 8 youth club leaders and adolescents was selected to evaluate their engagement in the programs with supportive explanations from the youth leaders, and 7 interviews was conducted with youth club officials and programmers since there were key stakeholders and runners of the program and where the power of youth project is working.A single population proportion formula was used to determine the sample size.The percentage of engagement of adolescents was taken as 50% in Ethiopia since the researcher couldn't find other researches done on this area, 95% CI and 5% degree of precision.The percentage of engaged adolescents are assumed 50%.

n= (1)
Where; n the minimum sample size required; Z a/2 the critical value for a given confidence interval; P, proportion value; d margin of error.So, our-Z a/2 will be 1.96 if we take 5% or confidence interval of 95%: n = (1.96)2x 0.5(1-0.5)/(0.05)2 (2) = 3.8416 x 100 = 384 The non-response rate=10% which will be 38.Then by adding none-response rate, the final sample size will be:

384+38=422
(3) The dependent variable is adolescent engagement that results in improved SRH knowledge, attitude, behaviour, relationship, and SRH practices.In detail the dependent variables as associated with independent variables as follows.
The secondary data was collected from review of program documents and reports as well as empirical and policy literature.The quantitative primary data was collected by trained enumerators using structured questionnaires.To ensure the consistency of the tools, the questionnaire was written in English, translated into Amharic, and also pre-test was conducted on 5% (20 participants) of the samples.
The pre-test, the use of experienced and trained enumerators reduced potential biases during data collection and ensured data quality.To preserve data completeness, clarity, and consistency, the completeness of the questionnaires and data collected were reviewed daily.The following day, before starting data collection, any errors relating to clarity, ambiguity, incompleteness, or misunderstanding were corrected.For the qualitative study the researcher stayed in the field for long, data collected were checked and peer briefings were done after the analysis.
A descriptive method was used for the quantitative and a thematic analysis was used for the qualitative data analysis.The quantitative data was cleaned, and entered into an excel sheet, and then imported to STATA Version 26.The demographic and other characteristics of the participants were analysed using frequencies, percentages, means, and standard deviations.Furthermore, the dependent variable which is adolescent engagement and independent variables such as knowledge, behaviour was analysed using descriptive statistical method.Furthermore, a chi-square test was used to study the association between the dependent variable and independent variable.
For the qualitative study, data were transcribed and translated which lead to anonymization of the data simultaneously code book were developed, and the data re-read then coded using Atlas Ti software, which reduces the data.Thematic analyses were used to analyse the data and give meaning to it.Coded data categorized and themes formed which emerge from the data analysed.
Ethical clearance and approval were obtained from Skill mart international college ethical committee and form power to youth project where the evaluation took take place.Both oral and written informed consent and assent was obtained from each study participant including adolescents who are under 18 years in which both parental and participant informed consent was obtained, and all participants were informed about the purpose of the study, the benefits they would gain, possible harms that would cause and their right for a decision on participating in the study.All the information collected from the study participant was kept confidential.

DATA RESULTS
The thesis was aim to assess the outcomes of adolescents' engagement in SRH program, and analysing and substantiating evidence on whether adequate adolescent engagement in the SRH program is associated with improved knowledge, attitude, and behaviour of the adolescents in Shewarobit town and Kewet district of Northern Ethiopia.
The study identified the gaps of the program implementation in terms of adolescent engagement and discerned actionable areas for the improvement of the SRH program under implementation; specially, by creating enabling environment for adolescent engagement in the program and improve program outcomes.The study thus inquired the status and creation of enabling environment of adolescent engagement, and the contributions of creating enabling environment and youth Hando and Egziabher 33 engagement for the improvement of the outcomes of the SRH program under implementation in the study site.
The study employed a self-administered survey questionnaire for 422 sample respondents and conducted a key informant interview with 15 participants.Out of the 422 sample respondents, 416 filled the questionnaire, while four of them declined their response, and two of them were excluded because of incomplete data.Thus, the response rate was 98.6% (416 adolescents participated and completed the survey questionnaire).The attrition rate was thus 1.4% (6 adolescents were excluded).Similarly, out of 15 key informant participants (youth club leaders, youth health officials and programmers), 100% (all 15 participants) participated in the key informant interview.
In the following sections of this chapter, we present the data results obtained from the field.These results cover various aspects, including adolescent socio-demographic characteristics and family background of the respondents, the status of adolescent engagement in the SRH program, the creation of an enabling environment for adolescent participation, and the outcomes of the program.Specifically, we explore how the participation of adolescents and the establishment of an enabling environment have influenced improved adolescent SRH knowledge and changes in SRH behaviours and attitudes in the study area.
After substantiating evidence on these domains, the study analysed the contribution of the SRH program implemented in Shewarobit Town and Kewet District in the improved SRH knowledge, behaviours and attitudes.

Socio-demographic Profiles of adolescents
In the first domain of socio-demographic characteristics of adolescent SRH program beneficiaries, sex, age, education level, marital status and religious affiliation were assessed.As the data results in Table 1 show, the first characteristic assessed was age.The variations of the age of the respondents were analysed using standard deviation and mean.
Thus, the age of respondents ranged from 15 to 19 years with mean age of 16.71 ± (1.297 SD) and median age of 17.The second variable assessed, as indicated in Table 1, was the sex of respondents.To present the outcomes of the program and analyze the enabling environment and adolescent engagement in terms of gender characteristics, an equal number of male and female adolescent participants participated and completed the survey questionnaire.Consequently, the ratio of male to female participants in the study was 1:1, meaning that 50% of the participants were male, and 50% were female adolescents.
The third, fourth, and fifth socio-demographic variables assessed were the participants' education status, marital (civil) status, and religious affiliation.Among the total participants, nearly nine out of ten had received formal education.The majority of adolescents (93.9%) were attending secondary school, while a smaller percentage (3.36%)were attending primary school.Regarding marital status, the majority (92.5%) were not married, with the remaining 4.8% being married, all of whom were adolescent females.In terms of religious affiliation, more than half of the participants were Christian (50.0%), while 15.2% were Muslim.
The study made certain assumptions, including that an adolescent's schooling status, such as being enrolled in formal education, is associated with factors like family educational background (having educated parents) and residential location (urban or rural).Drawing from existing research on gender and education, the study assumed that adolescent females who are out of school may be more likely to engage in paid or unpaid work to support their households.Additionally, the study hypothesized that adolescents in urban areas are more likely to be enrolled in school compared to those in rural areas.These assumptions are expected to influence various program outcomes, including the creation of an enabling environment, changes in SRH attitudes and behaviours, and knowledge of SRH.In the first domain of sociodemographic characteristics of adolescent SRH program beneficiaries, status of beneficiaries in schools versus employment, residence (urban or rural), education status of mother and father of the adolescent beneficiaries of the SRH program were assessed.From the data results in Table 2, the majority of the respondents 80.80% were students (are in school) while the rest 19.2% were out of school.From those out of school, 12.1% were unemployed (engaged in unpaid work) while the rest 4.3% of them were employed (engaged in paid work).
Regarding the educational status (level) of parents (mothers and/or fathers), as indicated in Table 2, most of the parents of adolescents, 34.8% of fathers, and 35.5% of mothers cannot read and write.At the same time, more than two-thirds of the adolescents, 80.8% have parents (mother and/or father).Out of the adolescent participated in the study, 35.6% currently live either with a mother or a father, while the rest 64.4% currently live with both of their parents.From other studies on the difference between parents' education based on Sex which determines the engagement status of adolescents, the study assess the difference in terms of sex of adolescents and their parents' educational status where there was no significant difference seen in terms of sex.

Socio-demographic characteristics of key informants
A total of 15 key informant interviews were conducted with SRH program experts, adolescent club leaders, students and teachers, related to SRH program beneficiary adolescents.In order to capture diverse views and perspectives, the key informants were identified based on sex, age, education level, occupational status and participation in the leadership of activities related to the SRH program in the study location.
The selection criteria were identified based on the assumption of their level of involvement on adolescent engagement in SRH programs, their perspectives on the outcomes of the program, the status of enabling environment and the improvements in adolescent SRH knowledge, behaviour and attitudes.Out of the 15 key   education, occupation and involvement in the program by key informants were assessed.From the data results, the age of the key informants ranged from 18-39 years with a median age of 30 years.Almost one third of the participants were adult and in the youth category.Out of the key informants interviewed, 40% were females while the rest 60% were males.
Regarding education level of key informants, 33.3% attend in secondary education.53.3% were BA/BSc holders and the rest 13.3% were MA/MSc holders.
In terms of occupational status of key informants, 40% were students, 33.3% were teachers and 26.7% were SRH program experts, regarding the role of the key informants in the SRH program, 40% were youth student club leaders, 33.3% were SRH sensitization/awareness creation teachers and the rest 26.7% were SRH program coordinators (facilitators).The youth are SRH student club leaders, the teachers are facilitator and leaders of the school clubs related to sexual and reproductive health, and the programmers are from the non-governmental organizations working on SRH programs as a facilitator of the programs that work on SRH with schools in the study location.

Adolescent engagement in SRH programs in the study area
The engagement of adolescents in the SRH program was assessed during the fieldwork.From the data results, in Figure 3, 271 (65.4%) of the students have never been engaged in any sexual and reproductive health programs (Figure 3) and never heard of any SRH programs.
The results presented in Figure 3 were further supported by the interview narrative reports.The interviewees, who were youth club leaders, indicated that most adolescents were actively involved in the implementation and monitoring and evaluation stages, but not as much in the design stage.For instance, a 19year-old youth club leader from Yellen corroborated the findings presented in Table 4 and Figure 1 with the following statement:

"…we usually create awareness in the community through our club by preparing dramas, poetries and other art related works otherwise we have never been consulted or participate in such kind of program planning session…"
The study also assessed the engagement of adolescents in program design, implementation, monitoring and evaluation stages.Regarding their participation in program design stage, as indicated in Table 4, from the total participants, the majority 334 (80.28 %) of them reported that they have never been consulted or participated in the design of SRH program, while only 94 (22.5%) of them participated in the design of SRH program.
The participation in project implementation stage, according to the results in Table 4, is relatively higher than the participation of the adolescents in program design stage.Out of the respondents, 151 (36.29 %) mentioned that they have been engaging in the SRH program implementation, while 277 (66.5%) of them have never been engaging in this stage.Out of the respondents, as indicated in Table 4, 77.8%% were mentioning that they have never been engaging in the SRH monitoring and evaluation stage while the rest 22,11% participated in this stage.
The study analysed gender variation in the participation of the adolescents in the SRH program.Out of the respondents, 34.8% of adolescents were engaging in SRH programs.In terms gender variation, most of the participants were male which constitute 86 out of the 145, which is 59.3% of those participating.Similarly, male adolescents showed relatively higher levels of engagement in the design (63.41%), implementation (56.95%), and monitoring and evaluation (61.95%) stages compared to female adolescents.However, a higher level of engagement was observed in the implementation stage of the SRH program for both genders.Interestingly, these findings contradict the data from the qualitative study in which teachers reported that female adolescents were more engaged than male adolescents in the school clubs due to current empowerment practices and the enabling environment created for female students.For instance, a 32-year-old male teacher stated: "….we encourages female students to participate in the school clubs since they are more vulnerable to SRH problems.As a result, more female students participate in the clubs than males…it is also because of clubs are formed usually targeting females thus the program created an enabling environment for them…" This result confirms the findings of existing studies regarding failures in parity in targeting and tracking or progress (program results), which UN Women Study Report (2021) terms as a reporting fallacy and a gap between practice and rhetoric regarding gender parity.The variation in engagement of adolescents in SRH program in terms of marital status, educational status, religion, residential location and employment status were assessed in the study based on other findings.Thus, the difference was observed to be significant, as in Table 5, in which all female adolescents who are married 29 (6.97%) don't engage or have never been engaged in any SRH programs.It is supported by a finding from programmers and youth clubs that adolescents would leave the club or won't be engaged at all if they get married because of their ability to make decision by their own for their engagement.In a similar way, adolescents who are in primary school are less engaged 5 (1.2 %) than that of secondary school adolescents 148 (35.5%), this is also shown by the qualitative study where adolescents who are in primary school have less possible engagement areas which is school club than that of secondary school where they can be engaged in both youth clubs (out-side the school), school clubs as well as in programs of NGOs.The variation related to socio-economic and sociodemographic variables was also seen in adolescents who are students (In-school) 118 (28.36%) as well as outschool (employed or unemployed) 30 (7.21%).
"…In here most of them are early aged (<14) Children, who don't reach the age for SRH…even organizations who work on SRH want those who are old and request…" (24 years old, Male from Yellen) In a similar case, it was mentioned that the youth clubs, which are potential engagement spaces for adolescents outside of school, are primarily formed for artistic purposes where adolescents participate in various artrelated activities alongside SRH activities.However, due to these artistic activities, some religious groups prefer not to engage in such clubs.This statement was supported by a 36-year-old Health officer from Shewarobit town: "…The club is formed by culture and heritage with the main purpose of preventing adolescents from spending their time in bad places with Art based activities, but later on the idea of SRH came into this clubs with NGOs, and they started to have SRH sessions alongside the ART, so other religion adolescents are less likely to join...Even their parents won't let them."

Outcomes of adolescent participation in SRH programs
The study assessed the improvements of the SRH knowledge, behaviour, attitudes, and practices and also analysed whether the improvements are linked with their engagement in the SRH program implemented in the area.From the total participants, 221 (59.7%) of the adolescents have knowledge on SRH (Figure 4).The majority 315 (73.4%) of them reported having negative attitude toward SRH, while 108 (25.3%) have positive attitude toward SRH.For 236 (55.0%) and 180 (45.9%) of adolescents, their risky sexual as well as abusive behaviour and with no risky behaviours were the major findings in the outcome of SRH, respectively.This finding supported by the qualitative finding where, Key informants consistently mentioned that adolescents lack the knowledge on SRH as well as their rights in SRH, where they are more likely to be vulnerable to risky sexual behaviours.
As indicated in Table 6, whether the participation of adolescents in the SRH program contributed to the improvement(changes) in their SRH knowledge, attitudes and practices were assessed, and the contribution analysis was conducted.
The data sets in Table 5 show that the participation of  The results of the chi-square test of association revealed that sex of the adolescents, educational status, marital status, and area of living, knowledge of adolescents on SRH, Attitude and Behaviour of adolescents have statistically significant association with, adolescents' engagement in SRH program as summarized in Table 7.The schooling status and religion of adolescents had no statistically significant relationship.

Enabling environments of the participation of adolescents
It was mentioned by other study findings that adolescents should get an enabling environment to be engaged in their SRH programs which was assessed in this study.In SRH program adolescents were engaged mostly in implementation stage of a program where the program designed to engage adolescents in lobbying, advocacy such as preventing SGBV, eliminating child marriage and FGM, recognition for sexual right as well as in decision making at youth club levels.In addition to this the program provide peer to peer education and Trainings so as to capacitate and enable adolescents to identify their own SRH problems such as HTPs and draw a solution with having enough awareness about engagement.For this case, studies conducted in Bahir Dar, Ensaro and Afar revealed that respondents who were engaged in CSOs felt that their engagement was meaningful.
During the program's implementation, adolescents faced challenges in their engagement due to various factors.These challenges included issues related to adult-adolescent relations, where it was reported that adults often listened to adolescents but did not always consider their input, leading exercises or making decisions without consulting the adolescents who were the direct beneficiaries.Additionally, district gender norms and social norms played a role, as the community sometimes viewed females as lacking the ability to perform in the same way as men.As revealed in the interviews, the local community often holds the belief that women lack the capacity to instigate positive changes within the community.Unfortunately, girls are not granted the opportunity to engage with their parents and the community.As they are unable to speak publicly about their rights, they continue to be the primary victims of harmful traditional practices.
The mid-term evaluation report of the program refines that the community in the area (adults) as such that adolescent's discussion with parents on these topics were less common, but took place.Parents were the main decision makers though adolescents tended to push their voice on topics that affected them.The qualitative findings of other studies also show that youth-led organizations had little involvement in policymaking.And in addition, government departments were not willing to involve youth-led associations.Organizations initiated and led by youth received less attention than governmentinitiated youth associations such as youth federations and leagues.In this case a 35 years old programmer told: "….adolescents are more open to discuss with their peers they usually don't get along with the community in same way adults doesn't count them in serious terms to involve them in leadership or decision-making areas…" The limited experience of adolescents in decision-making and the need to enhance these skills, as well as the attitudes of some adults towards adolescents' contributions, were the main areas expected to be addressed by the program.In response, a parents-youth forum was established to empower adolescents to voice their concerns within the community, and awareness campaigns targeting adults, particularly parents of adolescents, led to increased adolescent engagement in community youth clubs to address SRH issues.Additionally, as part of the program, a societal committee was formed, which includes adolescents and youths as committee members, allowing them to voice their concerns and participate in decision-making activities aimed at addressing SRH-related issues in the community.
In similar way, on this study 87(19.6%) of them have mutual agenda with that of adolescents which is including same set of objectives to work on in a program which should be improved through other programs, that are working on the area for the improvement of adolescents' knowledge on SRH.In addition, the youth clubs under the SRH program have been performing in direct way of improving knowledge, attitudes and behaviours of adolescents towards sexual and reproductive health were showed by the study where adolescents who engaged in SRH programs with appropriate enabling environments from family, community and government levels have improved set of knowledge, attitude and behaviour than adolescents who are not engaged.There for in order to enable adolescents engage in such program's parentsyouth forums should be conducted as woreda or zonal level with adequate attention and resource also in similar case parents' awareness should be raised to allow their Children's engage.Furthermore, awareness should be created in the community to resolve the gender variation, considering empowerments of female adolescents in place.In general, the sustainability of adolescents SRH information should be set as a priority because of sustainability issue which means most SRH programs as well as engagement of adolescents are being included mostly at CSO level which make the programs as well as projects time-bounded and conducted with limited aspect and budget which could in turn affect adolescents' knowledge, attitude and practice in time sequence unless adequate attention and concern is given from the government.

DISCUSSION
This study is one of the first mixed studies to assess the outcomes of adolescents' engagement in sexual and reproductive health programs.It extends the evidence base by illustrating knowledge, attitude and behavior which are the outcomes of adolescents' engagement in sexual and reproductive health programs.The outcomes were improved in knowledge, attitude and behavior in SRH (Figure 5).Adolescents who were engaged in the program were found to have better knowledge in SRH than those adolescents who were not engaged.In a similar way adolescent who were engaged in the program were seen to have positive attitude and improved behavior.In relation to this, in the finding of the study, males, unmarried, secondary school adolescents as well as adolescents who live in urban areas were found to be more engaged in SRH program.The hypothetical relationships in Figure 5 depicted based on the findings from this study.
Out of 416 selected adolescents who enrolled in the study, 271 (65.4%) reported having no engagement in SRH programs, 34.8% were engaged and this was higher than baseline study conducted in Bahir Dar, Asayita, Ensaro and Semera which was 16%, but it is relatively the same with particular study in Bahir Dar (36%).Also, in terms of gender variation in this study most of the participants were males 86/145 (59.3%), this finding also agrees with same baseline study conducted in Bahir Dar as well as a qualitative study conducted in Malawi on Youth participation in sexual and reproductive health: policy, practice, and progress but this it contradicts with the study finding of the qualitative section of the study which state females are being empowered and encouraged to engage in SRH programs than male (Amref Health Africa, 2020; Wigle et al., 2020).As a result, the difference could be due to the perceptions of the key informants taken including the programmers and Health officials.
In this study, around 36.29% of adolescents engage in implementation levels of programs than in design and monitoring and evaluation level which is supported by a study conducted in Kenya on assessing the roles of adolescents' engagement in SRH programs stated as adolescents are being engaged as health promotion/peer education playing supportive role in a program instead of their engagement in leadership, consultation, and decision-making roles (Bulc et al., 2019).All adolescents 29(6.97%)who are married have never been engaged in SRH programs and this is in line with studies conducted in Kenya, Rwanda, Tanzania and Uganda on exploring engagement of adolescents in health research.In addition to these adolescents with limited formal education and those living in rural areas are not getting equal access for engaging in SRH programs which is similar with previous study (Chidwick et al., 2022b).
In the study, it was observed that adolescents engaged in SRH programs exhibited greater knowledge, more positive attitudes, and improved practices related to SRH.This observation was supported by the chi-square results, indicating an association between engagement and knowledge, attitude, and practice, which aligns with the findings of a systematic review by Liebenberg et al. (2017) involving 32 empirical studies.The review showed moderate effects of student participation, including increased self-esteem, social status, and life skills.Additionally, a study on adolescent engagement, conducted as an environmental scan in 2022, found that adolescents engaged as decision-makers, leaders, and implementers in SRH programs demonstrated better outcomes in terms of knowledge, as reported by Int.NGOJ.Peterson et al. (2020).Similarly, reports from the Center of Excellence, based on various reviews of youth engagement and health outcomes, have found that adolescents who engage in sexual health programs are more likely to avoid risky sexual behaviours, as noted by the World Health Organization (WHO, 2018) and UNICEF (2022).

Conclusion
The findings of this study demonstrated that adolescent engagement in SRH programs led to improved knowledge, attitudes, and practices in sexual and reproductive health.Out of the total 416 participants, 116 were engaged in SRH programs and possessed knowledge about SRH.Among the participants who were not engaged in SRH programs, over half (268 out of 416) had a negative attitude, whereas 189 had no knowledge of SRH.Additionally, 121 participants who were engaged in SRH programs had a positive attitude, and 105 demonstrated better practices in terms of sexual behaviors and SRH programs.
It was observed that male adolescents, those living in urban areas, and those attending secondary school were more likely to be engaged in SRH programs and had better knowledge and practices.The majority of adolescents had little to no knowledge about SRH, which posed a significant barrier to their engagement in SRH programs due to the lack of an enabling environment.Therefore, it is essential to prioritize the creation of an enabling environment to promote adolescent engagement.

RECOMMENDATIONS
The recommendation of the study is presented in three key domains of the study.The first recommendation related to the engagement of the adolescent youths in the SRH program.The second recommendation related to inclusion and social diversity of the program beneficiaries in the study context.And, the third recommendation relates to social and institutional dimensions of the SRH program in the study area.Thurs; 1.The study findings shows that most of adolescents who doesn't engage in SRH program had no knowledge, negative attitude, and are more likely to practice risky SRH behaviors.Therefore, all organizations and partners that work on adolescent focused SRH programs/projects must put in much more effort in engaging adolescents in designing, implementing and monitoring and evaluation of such programs.2. The study findings show that there is considerable difference in the program outcomes for male and female adolescents, and also participation in schooling, leadership of the program teams and activities in the study area.Thus, all organizations and partners that work on adolescent focused SRH programs/projects must practice an appropriate recruitment strategy should be implemented to assure all groups including females, early adolescents (primary school) to be included in engagement of SRH program, and target adequately in the components of the programs/projects.3. The study findings show that early marriage and low power in decision-making roles by female adolescents, regarding their future, affected their participation in the regarding their future, affected their participation in the program and benefits from the outcomes.Thus, all organizations and partners that work on adolescent focused SRH programs/projects should give adequate attention gender inequality concerns of female adolescents.4. The study findings show that creating an enabling environment, and collaboration among stakeholders and partners is important, yet is weak in the context of this program.Therefore, all organizations and partners that work on adolescent focused SRH programs/projects should work together to improve the engagement status of adolescents in order for them to meet their needs and for the program to achieve its intended outcomes.
The study focused on the case of one town and one district.Also, the study focused on the assessment of outcomes of the programs on beneficiaries (adolescents) in these specific locations.The study is thus limited by its objectives and the time limitations.Therefore, for broader generalizability, future studies should select adequate sample at country level at one hand and assess the cases of adequate number of SRH programs at country level.

1.
Conceptualizing and operationalizing the three core frames of the theory: a. Groups served; b.Strategies (what strategies can accomplish the desired outcomes); c.Outcomes (what accomplishment is intended to change the gap assessed as a constraint;

Table 1 .
Residential and family background of survey respondents (2023).
Source: Own Field Survey Result (2023).informantinterviews conducted, six interviews involved SRH youth student club leaders, four involved SRH program experts and five involved teachers.As the data results in Table 3 demonstrate, sex, age,

Table 4 .
Adolescents engagement in SRH program in North Shoa by Sex (2023).

Table 5 .
Adolescents' Socio-demography and Participation in SRH programs.

Table 2 .
Changes in Adolescents' SRH Knowledge, Attitude and Practices.

Table 7 .
Contribution of adolescent engagement to SRH program outcomes.