The Hidden Challenge: Preventive Practices of Sexually Transmitted Illness Among College Students in Western Ethiopia: The Case of Nekemte Town: A Mixed Materials and Methods Study

Objective: The study was conducted to assess the knowledge, attitude and preventive practice of college students towards Sexually Transmitted Infections (STIs) including HIV/AIDS in Nekemte town, western Ethiopia.

Result: Institutional based descriptive cross sectional study design triangulated with in-depth interview method was employed on 403 randomly selected quantitative and 12 purposively selected in-depth interview samples. Quantitative data was obtained by self-administered questionnaire. About forty percent (39.7%) of the respondents had sexual practice in their life. Females were 1.42 times more likely to be encountered in sexual intercourse in the past one year of the study period (AOR = 1.42, 95% CI: 1.3, 2.53). Sex, age, living arrangement and income level, was identified as factors initiating to sexual intercourse in college students. Qualitative evidences show that, living condition, poor access of sexual reproductive services and ever increasing urbanization, poor attention towards STI are challenging preventive practices of STI among college students.

Generally, college students have good awareness and positive attitude towards STIs. However, there was a wide gap between knowledge and practice of the students regarding STIs. Greater attention should be paid to the college students improving the living conditions and access of services.

STI: Sexually Transmitted Illnesses; MSP: Multiple Sexual Partner; FGAE: Family Guidance Association Ethiopia; OR: Odds Ratio, AOR: Adjusted Odds Ratio; SRH: Sexual and Reproductive Health

Sexually Transmitted Infections (STIs) among adolescents/youths are growing health problems worldwide with urbanization and industrialization [1]. Sexually Transmitted Infections (STIs) include; Chlamydia infection, Gonorrhea, Genital herpes, Human Papilloma Virus (HPV) infection, HIV/AIDS, and Syphilis. Globally, 70% of the four curable STIs – Chlamydia, Gonorrhea, Syphilis and Trichomoniasis are occurred among young people and about half (50%) of the new 1 million daily STI infections are youths aged 15-24 years [2,3]. STIs are mainly transmitted through sexual contacts. Untreated STIs will have acute and chronic sequel and are prevented by safe sexual practice [1,4].

Despite they are sexually active, adolescents and youths have unmet need for SRH services. Multilevel barriers related with knowledge, attitude, skill and accessibility of services are common especially in low and middle income countries. Interventions developing compressive knowledge of peers as groups may have high impact than addressing individual youths [5-8].

Studies from different public universities and towns of Ethiopia indicated, risky sexual behaviors are challenging school adolescents and youths across the country and perception of the adolescents, peer pressure, external environments were key associated factors [9-16,17].

As research evidences show, majority of adolescents and youths in school are sexually active and the age of sexual initiation is lowering averaging to 17 years. Moreover, significant (30-50%) of sexually active youths have Multiple Sexual Partners (MSP). Substance use and inconsistent use of condom worsens the situation [18-20].

According to study in west Gojjam, more than 3/4^th of the sexually active in-school youths start sex before their 18th birth day. School and community based behavioral communications are demanded in focus. Similar studies among high school and college students in northern part of Ethiopia, Kenya, Tanzania and Malaysia indicated high risk sexual practice and low knowledge of the youths to prevent STI and a need to expand public level services and educations targeting STIs linking with HIV/AIDs [21-27].

Studies in Europe and elsewhere also shows, STIs are health threats of adolescents and youths in both developed and developing country settings. The finding shows lower level of awareness on STIs except for HIV/AIDs. People who are at <25 years are at high risk to STI and less is known on the sexual behaviors of this groups [4,23,28]. On study in UK on university students, the social context of university life style, alcohol consumption, increased sexual opportunities; individual, moral, cultural, religious factors seem to affect risky sexual practice. Possibility of risk denial is also a concern [28-30].

In the study area, there is insufficient information on STIs on college students, including the private and the public colleges. Despite the alarming rate of expansion of the problems, the local system readiness and action seems fragile and nil. Most college students from rural areas join Campus in urban contexts, without adequate awareness and support systems. The study aimed to assess the knowledge, attitude and practice of college students in Nekemte Town towards STIs.

Study design, setting and population

Institutional based descriptive cross-sectional study design was conducted from May 1-19, 2017 in Nekemte town, Western Ethiopia. Nekemte town is found 331km away from Addis Ababa, the capital city of Ethiopia, to the west. The study was undertaken in colleges in Nekemte town. All college students aged between 15-24 years old were the target population and all regular class attending college students in the town were the source population who were eligible for the study.

Sample size calculation

The sample size for the study was determined using the formula for single population proportion by assuming 5% marginal error, 95% confidence interval at alpha (p = 0.05) and the population proportion (45.7%) which was knowledgeable students of Bahir Dar University towards HIV/AIDS taken from the previous study done on KAP towards HIV/AIDS [26]. After correcting for finite population and adding 10% non-response rate, the final sample size was 403.

Sampling procedure and data collection

Multistage sampling technique was used for quantitative and purposive sampling technique was used for qualitative study. The data was collected by structured self-administered questionnaire and in-depth interview mixed with closed and opened questions for quantitative and qualitative methods respectively. The questionnaire was prepared first in English language and translated back to Afaan Oromoo, the local language.

Data analysis and quality management

The collected data were cleaned and analysed using SPSS software version 24.0. Descriptive statistics was used to indicate the socio demographic status of the respondents and their sexual behavioural distribution along with the level of their knowledge, attitude and practice towards STIs/HIV/AIDS. Bivariate and multivariate logistic regressions were employed to indicate the association of the independent variables to the outcome variable. Qualitative data was analyzed by thematic analysis after coding, sorting and exploring the themes.

Socio-demographic characteristics

A total of 370 college students were included with response rate of 91.8%. Among the total, 187 (50.5%) were females and the majority were in age range 20-24 years 272 (73.5%). Majority, 351(94.9%) of the respondents were single (Table 1).

Sexual history of the college students

One hundred forty seven (39.7%) of youths had history of sexual intercourse of which 66(44.9%) of them initiated sex before age of 18 years and about a quarter had MSP. Half of the respondents, 73(49.7%) encountered their first-time sexual intercourse with their peers (Table 2).

Knowledge of the college students towards STI/HIV

Three hundred fifty eight (96.8%), 264(71.4%), 258(69.7%) of the respondents know the types of STIs as HIV/AIDS, Syphilis and Gonorrhea respectively while 201(54.3%) of them also know other types of STIs like Chlamydia, Trichomoniasis and hepatitis. Majority, 87.8% of them know that unprotected sex is one of the routes of the transmission of STIs. Nearly all, 358(96.8%) of the respondents know that STIs are preventable diseases; Respondents had known Sexual behavior promoting STIs/HIV as unprotected sex followed by having too many sexual partner, substance abuse and economic challenges representing 344(93.0%), 336(90.8%), 245(66.2%) and 204(55.1%) respectively.

Qualitatively a 22 year old female interviewee responds as, “At this time, the issue of HIV/AIDS or STIs in general is not a big problem; because, everybody knows what AIDS is and it's transmission. This is the topic which has been experienced with students since many years ago.”

A 23 year old respondent said, “We can say students have good awareness and knowledge towards HIV/AIDS; many students know the transmission, the risks and the like. Some organizations also gave us advice on the advantage of condom to prevent STI, but there is no provision of the condom. We need the service but we lack the provision at the site we need.”

Attitude of the college students towards STIs

Majority of the respondents, 360(90.8%) thought that STIs/HIV is a big threat.

Nearly all, 362(97.8%), of the respondents had a positive attitude towards importance of screening for STI/HIV before marriage and 358(96.8%) of them had strong desire for the establishment of a well functional anti-HIV/AIDS club in their colleges. The finding is also supported by in-depth interview as anti HIV AIDS club is highly important in the colleges. A 21 year old male respondent says “We hear the name, anti HIV/AIDS club, in this college. The mobilization has been started once. But it never continued. We were very interested in the club …However, we don't know the reason, it is stopped…” Another 24 year old female student from other college claimed as, “The importance of anti HIV/AIDS club is undeniable, we all agree. But there is nothing about the club in our college. Even, I myself want to be a member of the club if available. ….”

Preventive practice of the college students towards STIs

About 131(35.4%) of the respondents had sexual intercourse within the past 12 months of which 25(19.0%) had sex with MSP. Seventy two (54.9%) of had intercourse in the past 12 months, didn't use condom. Fourteen (19.4%) of the respondents didn't use condom during sexual intercourse because they were ashamed to buy it followed by 12(16.7%), 11(15.3%), 5(6.9%), 3(4.2%) and 26 (36.1%) decreases satisfaction, don't like to use, not available, don't believe the use and other causes respectively. Among the students who had used condom during sexual act, only17 (28.8%) of them had used the condom consistently.

The study revealed that 21 (5.7%) of the college students had history of STIs, from which 16 (76.2%) went to health facility, 3(14.3%) went to traditional healers and 2 (9.5%) of them didn't take any action while 18(4.9%) of them didn't know whether they are infected or not. The indepth-interview response contradict with the less number stated above as stated by a 30 year old male “The magnitude of the STIs in adolescents is obviously high, however, the great challenge is the disease is soo sensitive so that the clients always try to hide even when they are infected. The health care providers need to be critical to get the fact.”

The same respondent also claimed as “ There are challenges concerning STI prevention: Poor commitment and bad weak exampliary of teachers, night school which may reinforce for rape and unprotected sexual intercourse, low attention and linkage among different organizations regarding the issue. Eg.Wollega University, they focus only on academics.There is no regular workshop like programs for youths while it is necessary one to two times in a month. Internet is another major challenge, more than 50% of students use internet for the unintended purpose. We, as FGAE, are in dilemma whether internet is useful or harmful.”

A 48 years old male interviewee claimed as, “Amazingly, there are students who live together being opposite sex apart from the intention of their families'. … The greatest challenge I ever identified as a problem is that the living condition of the students. They live out of the compound, no dormitory at all.”

Factors associated with initiation of sexual activities among college students

Females were 1.42 times more encountered in sexual intercourse in the past one year of the study period when compared to males of their corresponding age (AOR = 1.42, 95% CI: 1.3, 2.53). Those students in age range of 20-24 years old were 1.2 times more engaged in sexual intercourse when compared to those above 25 years old.

Regarding the living condition of the students, those who live in rent, either alone or with colleagues, were about 4.53 times more engaged in sexual activities when compared with those who live with their parents (AOR = 4.53, 95% CI:1.64,12.51). Having income by themselves is considered as encouraging factor for sexual intercourse by 6.76 (AOR = 6.76, 95% CI: 3.25, 14.07) (Table 3).

The study identified that college students have adequate awareness on the STI, especially HIV/AIDs. This can be justified by the national and international mobilizations on SRH services through different media. Class room-based education and peer influences are also good sources for information on STI. However, the accessibility of service and socioeconomic and living conditions of the college students are making them exposed to risky and unprotected sexual practices. This finding is in line with previous studies [24,25-27].

The interventions and practical engagement of the actors remains low in the area. The school based and peer based behavioral change communications are not consistent and targeted. Most college students are living independently in rent houses in aggregate. Rural-urban migrations for education and seeking job make favorable condition for the unsafe sexual practice among youths and students. The students from the rural areas that are joining colleges have low life skills related with sexuality and environmental and service related barriers, and needs critical focus in Nekemte and similar contexts in the country [6,7].

Despite, the private colleges are expanding in the Towns of Ethiopia including Nekemte and many youths are joining, less attention is given to the support and reach of this sector in the study area.

Sex, age, living condition (Rent house), having source of income were factors associated with practicing sexual intercourse among college students in Nekemte town where as having information regarding STIs and having not support from their family/ relatives more than excess were factors identified as preventive for unsafe sexual practices among college students. The pattern of internet and media utilization is one of the factors raised in qualitative study. This finding is consistent with studies elsewhere [12-16].

In conclusion, even though the knowledge and attitude of the students towards STI is good, there was a poor practice regarding STIs. The students living condition while they are in college and their income level found to affect their sexual desires. Establishing and strengthening college anti AIDS clubs, provision of basic and sounding knowledge through continuous training, making condoms available through college anti AIDS Clubs, capacity building on utilization of internet and social media were some possible interventional methods highly recommended.

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