|Year : 2019 | Volume
| Issue : 1 | Page : 44-50
Exploring the association between risky sexual behaviors and substance use among Jimma university students, Ethiopia
Yonas Tesfaye, Liyew Agenagnew
Department of Psychiatry, Jimma University, Jimma, Oromia, Ethiopia
|Date of Web Publication||4-Jun-2020|
Department of Psychiatry, Jimma University, Jimma, Oromia
Source of Support: None, Conflict of Interest: None
Background: Youths in colleges have special and complex needs, with extremely high rates of sexual behaviors, mental health problems, and drug misuse. Despite this, the causal relations remain to be elucidated. Objective: The aim of this study was to assess the association between risky sexual behaviors (RSBs) and substance use among Jimma University students, Ethiopia, 2016. Materials and Methods: A quantitative cross-sectional study was conducted among 700 sampled students. Participants were drawn using a multistage stratified random sampling technique. Data were collected using a pretested, self-administered questionnaire. Alcohol use disorder identification test tool was used to assess alcohol use and for RSBs, and Khat uses questionnaires that were developed after an extensive review of the literature. Data were entered into Epi-data data management software and exported to SPSS version 20 for statistical analysis. Multivariable logistic regression was used for analysis and Variables at P < 0.05, and a 95% confidence level was used to declare statistical association. Results: The prevalence of RSB among students was found 30.2%. The odds of RSB were nearly three times higher among those who had probable alcohol use disorder than their counterpart (adjusted odds ratio [AOR] 2.9, 95% confidence interval [CI]: 1.4–6.1); similarly, the odds of RSB were nearly three times higher among those who had to chew Khat 2–4 times a month than never chewed counterpart (AOR 2.8, 95% CI: 1.1–7.7). Conclusion: The prevalence of RSB and substance use among Jimma University students was high and positively associated.
Keywords: Alcohol, Khat, risky sexual behaviors, university students
|How to cite this article:|
Tesfaye Y, Agenagnew L. Exploring the association between risky sexual behaviors and substance use among Jimma university students, Ethiopia. J Mental Health Hum Behav 2019;24:44-50
|How to cite this URL:|
Tesfaye Y, Agenagnew L. Exploring the association between risky sexual behaviors and substance use among Jimma university students, Ethiopia. J Mental Health Hum Behav [serial online] 2019 [cited 2022 Jun 28];24:44-50. Available from: https://www.jmhhb.org/text.asp?2019/24/1/44/285994
| Introduction|| |
Risk-taking among adolescents is of great concern to health professionals. Most of the morbidities among young people are related to behaviors that result in unintentional or intentional injuries, drug and alcohol misuse, tobacco use, sexual behavior, diet, and physical inactivity., Mental health problems in young people are common, with an overall prevalence of around 15%.
University life, with its greatly expanded opportunities for self-governance and independence, provides an important new context in which young people learn to manage their sexual relationships and their sexuality. High-risk sexual behavior is defined as any behavior that increases the probability of negative consequences associated with sexual contact, including AIDS or other sexually transmitted diseases and unplanned pregnancy.,
Substance abuse and problems arising from it are increasing worldwide, and currently together with HIV/AIDS epidemic, become one of the most threatening and challenging social and public health problems. University students are more vulnerable to wider sexual and reproductive health and HIVAIDS problems due to new environment with poor protection, age and the need to explore life, peer pressure, and absence of proactive programs.,
The rapid mental, social, and cultural transitions that most students are now experiencing have created a breeding ground for increased and socially disruptive use of alcohol and drugs. Given the high prevalence of HIV/AIDS in the region and the increasing number of adolescents infected with HIV, an understanding of the role substance use plays in the spread of HIV/AIDS is crucial to prevention efforts of the disease among adolescent population.
Youths in colleges have special and complex needs, with extremely high rates of sexual behaviors, mental health problems, and drug misuse., The causal relations and direction remain to be elucidated, but the coexistence of drugs, risky sex, and mental health problems remains a consistent observation in epidemiological studies.
Although the effect of alcohol and other psychoactive substances in interfering with condom use has also been studied to some extent in developed societies, this vital area of research has not been explored in Ethiopia. As both Khat and alcohol are widely consumed in these groups, description of the relationship between these substances and risky sexual behavior (RSB) would usefully guide national policy and decision-making.
Hence, the aim of this study was to assess the association between RSB and substance use among Jimma University students.
| Materials and Methods|| |
Study area and period
The study was conducted in Jimma University main campus from April 5 to 20, 2016. The main campus has four colleges with a total of 30 departments: College of Health Science includes (medicine, pharmacy, medical laboratory, anesthesia, dentistry, nursing, midwifery, health officer, and environmental health departments), College of Natural and Computational science includes (mathematics, sport, chemistry, physics, biology, statistics, and information science departments), College of Social Science and Humanities includes (geography, history, Amharic, English, Afan Oromo, sociology, music, Oromo folklore, social work, and psychology departments), and College of Law and Governance includes (law and governance departments). There were 6,155 regular undergraduate students enrolled during the academic year.
Study design, population, and sample size estimation
Institution-based quantitative cross-sectional study design employed. All regular undergraduate Jimma University main campus students were a source population and sampled regular undergraduate main campus students who were enrolled from 1st year to 5th year in the 2015/16 academic calendar was the study population. In the study, all regular undergraduate Jimma University main campus students who were enrolled in the 2015/2016 academic calendar were included, and students who had an accidental illness during the data collection period which made them incapable to participate in the study, were excluded from the study. The sample size was estimated using a single population proportion formula; n = (zα/2)2P(1-p)/d considering, n = Sample size, z = critical value 1.96, α/2 = confidence level, P= prevalence of RSB at Arbaminch University students = 31.4%, d = margin of error = 0.05 (5%). Since the total, the population was <10 thousand correction formula was used to get the desired sample size, nf = n/(1 + n/N), where nf is the final sample size, n; the calculated sample size, and N; the total population, accordingly it becomes 315. In addition, since the sampling was multistage; the design effect of 2 was taken. Finally, with the addition of a 10% nonresponse rate, the required sample size becomes 700.
Sampling technique and procedures
A multistage stratified sampling technique was used to select the study participants. All four colleges were included. Stratification has done on department and year of the study level. From the 30 departments in the 4 colleges, 11 departments were selected using a simple random sampling lottery method. Finally, after the proportionate allocation of the participants from each year of study (1st year to the 5th year), a simple random sampling technique was used to select 700 sampled students using the enrollment register as a frame.
Data collection instruments and procedures
A structured and self-administered questionnaire consisting of five different subsections was used. The questionnaire has socio-demographic, RSBs, alcohol consumption, Khat chewing/use, and depression symptoms questions sections. For RSB assessment tools, face validity test by three independent experts on the field has performed, and a reliability test was done with Cronbach's alpha result of 0.78. For alcohol use, the Alcohol use disorder identification test (AUDIT) tool was used, and the modified Beck Depression Inventory-II (BDI-II) was used to evaluate the severity of depression symptoms with good psychometric properties. For Khat use, questions were developing after review of similar studies adapting for the purpose of the study.
The questionnaire was prepared in English then translated into the local languages (Amharic and Afan Oromo) and back-translated to English by language experts, so as to ensure its consistency. Finally, the Amharic and Afan Oromo version of the questionnaires were used to collect data based on the respondent's language preference.
The data collectors were five BSc, psychiatry nurses. Data collectors and supervisors were trained for 2 days by the principal investigator on the objective, purpose of the study, and data collection procedure.
Data quality management
Regular supervision was made by the supervisor and the principal investigator to ensure that all necessary data were properly collected. Each day of data collection, the filled questioners were cheeked manually first for completeness and consistency then the collected data were processed timely and enter from a paper onto the computer twice. A pretest was conducted before the main study to identify impending problems on data collection tools.
Data processing, analysis, and interpretation
The collected data were cleaned, coded, and entered into Epi-data version 3.1 data entry software and exported to SPSS version 20 statistical software for analysis (IBM Corp, Chicago, USA). Descriptive statistics were done to summarize the dependent and independent variables. A logistic regression model was used to analyze the predictors of RSB. Bivariate logistic regression was done, and variables with P ≤ 0.25 were entered into multivariate logistic regression, then variables with P < 0.05 at 95% the confidence interval (CI) was considered as a statistically significant association with the outcome variable.
Operational and term definitions
Risky sexual behavior
RSB defined in this study as participants who were engaged in not using a condom or inconsistent use of condoms during sex or having multiple sexual partners or early initiation of sex or sex with a commercial sex worker. Participants who were engaged in at least one of the above behaviors were considered to have RSB.,
Early initiation of sex: Initiation of sex before the age of 18 years
Substance: In this study includes Alcohol and Khat.
Khat: A local stimulant drug.
Alcohol consumption was measured by the AUDIT. AUDIT score of 1–7 indicates social drinking, score of 8–15 indicates “hazardous drinking,” a score of 16–19 indicates “harmful drinking,” score of 20 or above indicates probable alcohol dependence. Participants with an AUDIT score of eight or more will be used to define probable alcohol use disorder.
Lifetime prevalence of Khat use is the proportion of students who had ever used or chewed Khat, and the current prevalence of Khat use is the proportion of students who use or chew currently and have chewed within a month of data collection.
Depression symptoms were measured by BDI-II. The scores are interpreted as 0–13 indicate no or minimal, 14–19 mild, 20–28 moderate, and 29–63 severe depression symptoms.
The proposal of this study was reviewed and approved by the Institutional Review Board of Jimma University. Written consent was obtained from participants after explaining the purpose of the study.
| Results|| |
Data were collected from 660 respondents making a response rate of 94.2%.
Sociodemographic characteristics of participants
Majority of the respondents were males (n = 422, 63.9%), unmarried (n = 568, 86.1%), and mean age of the participants was 21. 29 (SD + 1.92) years. Respondents were predominantly Orthodox Christians (n = 269, 40.8%) followed by Muslims (n = 201, 30.5%). Maximum representation was by Oromo followed by Amhara ethnic tribes (n = 352, 53.3%; n = 155, 23.5%) [Table 1].
|Table 1: Sociodemographic characteristics of Jimma University main campus students, April 2016|
Click here to view
Majority of the study participants participate in religious education 539 (81.7%), most students were from the college of health science 273 (41.4%) and from 1st year 208 (31.5%) [Table 2].
|Table 2: Sociodemographic, economic, academic and parent's characteristics of Jimma University main campus students, April 2016|
Click here to view
Prevalence of risky sexual behavior
The prevalence of RSB among Jimma University students was 30.2% (n = 199).
Alcohol consumption and Khat use
The majority of the respondents report never drink alcohol (n = 483, 73.2%), of those who have reported drinking most were social drunker (n = 117, 66.1%) followed by hazardous drinking (n = 48, 27.1%) and harmful drinking (n = 6, 3.4%). The result of the analysis also showed (n = 6, 3.4%) of the total participants had probable alcohol use disorder. Most respondents report as they have never chewed Khat (481, 72.9%). Of those who chewed (n = 24, 19.2%) chew monthly or less, followed by (n = 31, 4.6%) 2–4 times a month [Table 3].
|Table 3: Participant's level of alcohol drinking, Khat use among Jimma University main campus students, April 2016|
Click here to view
Sexual practice and risky sexual behavior
Majority of the respondents neither watch pornographic movies (n = 386, 58.5%) nor attend night clubs (n = 517, 78.3%). Three quarters of the participants report there was no peer pressure to engage in RSBs (n = 492, 74.5%), and 80.8% (n = 533) students reported it was taboo to openly discuss sexual issues with parents. From the total respondents participating in the study, 35.5% (n = 234) reported having sexual intercourse; out of this 61.1% (n = 143) had multiple sexual partners and 59.8% (n = 140) had sexual experience within the last 1 year. The majority of these sexually active participants had early initiation of Sex 44.9% (n = 105). Although the majority of sexually active participants reported the used condom (n = 164, 70.1%), only 29.9% (n = 70) had not used condoms always [Table 4].
|Table 4: Participant's sexual practices and risky sexual behavior of Jimma University main campus students, April 2016|
Click here to view
In this study, 29.1% (n = 192) respondents had depressive symptoms, among them 88 (n = 13.3%) had mild depressive symptoms, 81 (n = 12.3%) had moderate depressive symptoms, and 23 (n = 3.5%) had severe depressive symptoms.
Multivariate logistic regression analysis
Age, sex, marital status, current living condition, attending religious education, level of mother education, attending night clubs, watching pornographic movies, peer pressure to engage in RSBs, having alcohol use disorder, frequency of Khat use and having depression symptoms showed association at bivariate analysis (P ≤ 0.25) and were candidates multivariate logistic regression analysis to control the confounders.
Students who had probable alcohol use disorder were nearly three times more likely to experience RSB than the nondrinker counterparts (adjusted odds ratio [AOR] 2.9, 95% CI: 1.4–6.1). Those who chewed Khat 2–4 times a month were approximately three times more likely to experience RSB than the nonchewer counterparts (AOR: 2.8,95% CI: 1.1–7.7). Students who chewed Khat 2–3 times a week were approximately four and half times more likely to experience RSB than the nonchewer counterparts (AOR 4.3,95% CI: 1.1–17.6). Students with moderate depression were nearly two times more likely to indulge in RSB than the nondepressed students (AOR 1.9, 95% CI: 1.1–3.1). Moreover, students with severe depression were nearly two and a half times more likely to experience RSB than the nondepressed counterparts (AOR 2.6, 95% CI: 1.3–5.1) [Table 5].
|Table 5: Multivariate analysis of factors associated with risky sexual behaviors among Jimma University main campus students, April 2016|
Click here to view
| Discussion|| |
The prevalence of RSBs was found 30.2%, similar findings were reported from Arba Minch University 31.4%. However, much lower compared to the study done at Haramaya University students, where 65.8% of the participants had practiced at least one of the RSBs. In the Haramaya University study, the prevalence of RSB was calculated from only those students who were sexually active, unlike in this study, the prevalence was calculated from all the study participants. However, much higher than Humera secondary school which was 13.7%. College life gives students sense autonomy, being away from parental constraints and influenced by friends, students could go in pursuit of forbidden pleasures such as substance use and seek sexual gratification from commercial sex workers.
In this study, majority of the substance user student practice RSBs, this finding is in line with the studies were done in, in-school and out-of-school youth in Ethiopia in which substances use is significantly and independently associated with RSB, the study was done in the USA among college students, other studies were done in the USA among adolescents., Young Adulthood, among incarcerated adolescents, and new patients clinics in the United Kingdom.
Another valid finding in this study, which has been supported by other literature from Uganda, Ireland, and the USA, was the higher risk for RSBs among students with probable alcohol use disorders.,, Dependence on mind-altering substances, including alcohol alters the sound thinking and social judgment and therefore less likely to enact protective behaviors. The possible reason alcohol use increases the risk of practicing RSB in all studies maybe due to the fact that alcohol interferes with judgment and decision-making capacity which led the user to involve in various RSBs.,
The use of Khat was another risk factor in this study which exposed students to RSBs. In this study, students who chewed Khat 2–4 times a month and 2–3 times a week were at higher risk to engage in RSB than those who never chewed, which has been confirmed by studies at Universities in Arbaminch, Bahir Dar and Haramaya.,, Khat interferes with cognitive capacity and interferes with judgment and, in some cases, also increases sexual desire.
There was an increase in students having multiple sexual partners in the current study (61.1%), overtaking the results reported 6 years ago in the same University 28.3% and other research findings from Bahir Dar University 42.7%, Jigjiga University 30.1%, Mekelle University 47.4%, and a tertiary institution in Nigeria 48.2%.,,, The growing influence of social media and covert peer pressure on the campus maybe promoting sexual promiscuity.
Nearly more than one-fourth of the students (29.9%) had never used a condom, and the rest (70.1%) used condoms during casual sex. However, only a little more than half of them (59.8%) always used condoms whereas 24.4% used occasionally, and the remaining 15.8% rarely used. The study done in Bahir Dar university reported similar findings for inconsistent condom use and never use of condom 36% and 25%, respectively. This study findings are also comparable to the study conducted at Mekelle University in which among those who have used condom 50.5% were inconsistent condom users. In Madagascar University, 57.6% of the respondents used condom inconsistently. However, this study findings were higher than the study done in Kenya, Nairobi University students and Colombia University students with inconsistent condom use were reported by 27.4%, 33.7% respondents, respectively,, This disparity may be explained by the difference in the culture of using the condom between the countries
RSBs were reported by 30.2% of students. Out of 222 (33.6%) students with depression symptoms, 105 (47.3%) reported practiced RSBs. Moreover, students with severe depression symptoms were two and half times more likely to engage in RSBs than students with no depression symptoms (P = 0.003); this finding is in line with the study done among Nairobi University students, Kenya 36 and US middle and high school students. The possible explanations can come from Beck's cognitive theory of depression, which describes that negative feelings and thoughts play a central role in how people feel about themselves, which ultimately influences the behavior in which they engage.,,
| Conclusion|| |
The prevalence of RSB and substance use among Jimma University main campus students were high and RSB had statistically significant association with substance use in this study.
Limitations of the study
- The definition of RSB in this study may be different from other studies because the meaning of sexual behavior as risk may vary with regards to culture, gender, age, and the threshold
- This study is cross-sectional and not explains the cause-effect relationship between the outcome variable and explanatory variables
- The study topic by itself assesses personal and sensitive issues related to sexuality and substance use which might have caused underreporting of some behaviors, and social desirability and recall bias may be introduced.
We would like to thank Jimma University for funding this study. Our heartfelt gratitude extends to study participants, data collection supervisors, academic, and administrative staff of the sampled departments.
Financial support and sponsorship
This research work funded by Jimma University.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Morris JL, Rushwan H. Adolescent sexual and reproductive health: The global challenges. Int J Gynaecol Obstet 2015;131 Suppl 1:S40-2.
Blum RW, Nelson-Mmari K. The health of young people in a global context. J Adolesc Health 2004;35:402-18.
World Health Organization. Mental Health Atlas. Geneva, Switzerland: World Health Organization; 2017.
Cooper ML. Alcohol use and risky sexual behavior among college students and youth: Evaluating the evidence. J Stud Alcohol Suppl 2002;14:101-17.
Tesfaye G, Derese A, Hambisa MT. Substance use and associated factors among university students in Ethiopia: A cross-sectional study. J Addict 2014; 2014:1-8.
World Health Organization. Global Status Report on Alcohol and Health 2014. Geneva, Switzerland: World Health Organization; 2014.
Williams H, Davidson S. Improving adolescent sexual and reproductive health. A view from Australia: Learning from world's best practice. Sex Health 2004;1:95-105.
Hawkins JD, Catalano RF, Miller JY. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychol Bull 1992;112:64-105.
Derese A, Seme A, Misganaw C. Assessment of substance use and risky sexual behaviour among Haramaya university students, Ethiopia. Sci J Public Health 2020;2:102-10.
Grace TW. Health problems of college students. J Am Coll Health 1997;45:243-50.
Pedrelli P. HHS public access. Acad Psychiatry 2015;39:503-11.
Bennett DL, Bauman A. Adolescent mental health and risky sexual behaviour. Young people need health care that covers psychological, sexual, and social areas. BMJ 2000;321:251-2.
Kebede D, Alem A, Mitike G, Enquselassie F, Berhane F, Abebe Y, et al
. Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia. BMC Public Health 2005;5:109.
Gebremedhin AT. Khat chewing and risky sexual behavior in Sub-Saharan Africa: A systematic review protocol. JBI Database System Rev Implement Rep 2013;11:59-67. [Doi: 10.11124/jbisrir-2013-877].
Derese A, Seme A, Misganaw C. Assessment of substance use and risky sexual behaviour among Haramaya University Students, Ethiopia. Science J Public Health 2014;2:102-10. [Doi: 10.1186/s12889-017-4878-3].
Sullivan C, Martin N, White C, Newbury-Birch D. Assessing the delivery of alcohol screening and brief intervention in sexual health clinics in the north east of England. BMC Public Health 2017;17:884.
Toosi F, Rahimi C, Sajjadi S. Psychometric properties of beck depression inventory-II for high school children in Shiraz city, Iran. Int J School Health. 2017;4:1-6. [Doi: 10.5812/intjsh. 41069].
Town AM. Behavior assessment of risky sexual behaviors among Arba Minch university students. J Child Adolesc Behav 2015;3:2-7.
Dadi AF, Teklu FG. Risky sexual behavior and associated factors among grade 9-12 students in Humera secondary school, Western zone of Tigray, NW Ethiopia, 2014. Sci J Public Health 2014;2:410-6.
Tura G, Alemseged F, Dejene S. Original article risky sexual behavior and predisposing factors among students of Jimma University Ethiopia. Ethiop J Heal Sci 2012;22:170-80.
Mulu W, Yimer M, Abera B. Sexual behaviours and associated factors among students at Bahir Dar University: A cross sectional study. Reprod Health 2014;11:84.
Mavhandu-Mudzusi AH, Asgedom T. ScienceDirect the prevalence of risky sexual behaviours amongst undergraduate students in Jigjiga University, Ethiopia. Heal SA Gesondheid 2015;21:179-86.
Fantahun A, Wahdey S, Gebrekirstos K. Risky sexual behaviors and predisposing factors among Mekelle University College of business and economics students, Mekelle, Tigray, Ethiopia, 2013: Cross sectional Study, American Journal of Advanced Drug Delivery, 2015;3:052-058.
Adewuya AO, Ola BA, Aloba OO, Mapayi BM, Oginni OO. Depression amongst Nigerian university students. Prevalence and sociodemographic correlates. Soc Psychiatry Psychiatr Epidemiol 2006;41:674-8.
Rahamefy OH, Rivard M, Ravaoarinoro M, Ranaivoharisoa L. Sexual behaviour and condom use among university students in Madagascar. SAHARA J 2008;5:28-35.
Othieno CJ, Okoth R, Peltzer K, Pengpid S, Malla LO. Risky HIV sexual behaviour and depression among University of Nairobi students. Ann Gen Psychiatry 2015;14:16.
Campo-Arias A, Ceballo GA, Herazo E. Prevalence of pattern of risky behaviors for reproductive and sexual health among middle- and high-school students. Rev Lat Am Enfermagem 2010;18:170-4.
Lehrer JA, Shrier LA, Gortmaker S, Buka S. Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students. Pediatrics 2006;118:189-200.
Seth P, Patel SN, Sales JM, DiClemente RJ, Wingood GM, Rose ES. The impact of depressive symptomatology on risky sexual behavior and sexual communication among African American female adolescents. Psychol Health Med 2011;16:346-56.
Shrier LA, Harris SK, Beardslee WR. Temporal associations between depressive symptoms and self-reported sexually transmitted disease among adolescents. Arch Pediatr Adolesc Med 2002;156:599-606.
Brook JS, Adams RE, Balka EB, Whiteman M, Zhang C, Sugerman R. Illicit drug use and risky sexual behavior among African American and Puerto Rican urban adolescents: The longitudinal links. J Genet Psychol 2004;165:203-20.
Chawla N, Sarkar S. Defining “High-risk sexual behavior” in the context of substance use. J Psychosex Health 2019;1:26-31.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]