Background:  High school adolescents are assumed to be exposed to many risky sexual behaviors. However, little has been explored about the magnitude of risky behavior and its predictors’ in the context of high school adolescents in Ethiopia. Hence, we conducted this study to determine prevalence of risky sexual behavior, substance abuse and the predictors of risky sexual behavior in High school adolescents of Ethiopia.

Methods: Cross-sectional study design was employed in sampled high school students. The data was presented using frequency distribution, percentages and logistic regression to determine the predictor of risky sexual behavior.

Results: A total of 577 sampled high school students aged M(SD) 17(1.75) were involved in the study of which 53% were males. Prevalence of current alcohol use, Chat, cigarette and marijuana were respectively 11.5 % 5%, 2.8%, and 0.5%. About 24% of the study participants had ever had sexual encounter and 20% of the total study populations were involved risky sexual behavior in the previous month. Alcohol use AOR 95% CI: 12.0(5.26-27.4) and Khat chewing AOR 95% CI: 3.29(1.28-8.45) were predictors of involving in risky sexual behavior.

Conclusion: Alcohol use and Khat chewing were the predictors of risky sexual behavior in this study. We recommend the implementation of awareness campaigns, integrated interventions on sexual behavior and substance abuse prevention programmes for high school adolescents in Ethiopia to reduce risky sexual behavior.

Keywords: Risky Sexual Behavior; Substance Abuse; HIV/AIDS.   

Sub-Saharan Africa including Ethiopia has been highly affected by HIV and currently accounts for more than two thirds of recent HIV infections worldwide (UNAIDS. and WHO. 2009). The overall adult HIV prevalence in Ethiopia has remained almost similar in the Ethiopia Demography and Health Survey (EDHS) 2005 and 2011 which was 1.4% and 1.5% respectively(CSA: 2012).

 
Ministry of Education report indicates that all training institutions, colleges and universities have incorporated life-skills based HIV/AIDS education into their curricula. Preliminary work has begun to make HIV/AIDS life skills based education a stand-alone course (FMOE 2009). Educators need to move beyond imparting knowledge about modes of HIV transmission to change adolescent behavior.  However, among adolescents, sexual encounters may be unplanned and also often occur after drinking or drug use. Exploratory studies in San Francisco indicate gay men are more likely to have unprotected intercourse after alcohol and drug use (Stall, McKusick et al. 1986).
Behavioral research has focused on identification of potentially modifiable variables that may contribute to risk-taking behaviors. One factor that has been proposed as a contributor to sexual risk-taking is the use of alcohol or other drugs with sex (Stall, McKusick et al. 1986). Because alcohol and drugs are thought to interfere with judgment and decision-making, it has been suggested that their use in conjunction with sexual activity might increase the probability that risky behaviors will occur (Hingson, Strunin et al. 1989).

 
In the last few years, a number of reports have appeared suggesting a link between alcohol or drug use and sexual behavior, such as unprotected intercourse, that is known to place an individual at higher risk for HIV infection (FMOE 2009). Despite this governmental report, except very few studies, little has been explored about the pattern of risky sexual behavior and its association with substance abuse in Ethiopia high school adolescents. Thus, this study was conducted to determine the prevalence of substance abuse, and of risky sexual behavior and their association in two selected high school adolescents of Sidama zone, South nation nationalities and people region (SNNPR) for possible interventions.

A cross-sectional study design was conducted in Wondogenet and Yerigalem town high school students located in Sidama zone, South nation nationalities and people region (SNNPR). Data collection for the study was conducted from November 1 to December 30. Systematic random sampling method was used to select study population from the source population.

 
The sample size was determined using EPI-info version 3.2.2 assuming the expected prevalence of involving risky sexually behavior (P=1.4%) (Kebede, Alem et al. 2005) and found to be 530, adding the 10% non-response rate the final sample size was 583. Random sampling technique was used for selection of the participants from the source population.

Data collection was conducted using standardized pre-coded and pre-tested self-administered questionnaire. The questionnaires included socio-demographic characteristics, individual factors, attitudes towards risky sex, and beliefs about the effect of substance abuse developed using literature reviews. The questionnaire was primarily prepared in English however translated in to Amharic for data collection and back translated to English for checking consistency before data collection in double blinded way.

Substance use behaviors’ (alcohol, Khat, cigarette and others) in the last months preceding the interview and history of unprotected sexual practice were the interviewed using questionnaire. Unprotected sex was defined as sex without the use of condom during the previous year preceding the interview. Irregular use of condom was also categorized as risky sexual behavior. Logistic regression was employed to adjust for confounding in multivariate analysis. Thus, risky sexual behavior (unprotected sex) was taken as dependent variable. As independent variables, the following were included in the model: sex, age, khat, alcohol, cigarette smoking and other substance use. Current substance use is defined as the use of the substance (alcohol, khat, cigarette and marijuana) if the participants’ have used in last month preceding the interview. Life time substance use was defined as the use of the substance once or more than once in their life time. Data were checked for completeness and consistency and fed into statistitical package for social sciences (SPSS version 20) for the analysis. Frequencies’, percentages, averages with standard deviation were used to present the data, while logistic regression model was used to determine the predictor of risky sexual behavior.
Pilot study was conducted to test the relevance of data collection instruments in 5% of study population and the necessary correction was made to the tool based on the findings of pilot study.  Ethical clearance to conduct this research was obtained from institutional review board of college of medicine and health science of Hawassa University. A letter was written from the school of medicine and Permission to conduct research was obtained from the principals of the schools. Written informed consent was obtained from the respondents before data collection. Participation of respondents was strictly on voluntary basis. Privacy and confidentiality of the respondents was kept secret.

A multivariate logistic regression model examining the relationship between risky sexual behavior and different variables including (alcohol use, grade level, khat chewing, and cigarette smoking showed that alcohol use (OR; 95%CI: 12.05.26-27.4) and Khat chewing (OR; 95%CI: 3.29(1.28-8.455) were independent predictor of involving in risky sexual behavior. Alcohol use and chat chewing were predictors of involving in risky sexual behavior as indicated in Table 5

This study provides insights for association between risky sexual behavior and substance abuse and tries to elucidate the prevalence of substance use. The finding of this study was consistent with government report (FMOE 2009). However the magnitude of risky sexual behavior in this study is higher than some studies

Conducted in in-school adolescents.

Substance abuse is becoming a great concern among Ethiopian university students (Zein 1988; Deressa and Azazh 2011; Tura, Alemseged et al. 2012; Berhan, Hailu et al. 2013; Gebreslassie, Feleke et al. 2013). In all of the studies the prevalence of the life time substance abuse and current substance abuse is lower than the value from this study. This may be because of age differences and exposure difference. University students older than high school students and are more likely exposed to events that leads to substance abuse because of increased freedom.  When compared with substance abuse prevalence of other countries alcohol use in this study is much higher than that of Chinese high school students which reported: 4% as alcohol user as compared to 11,5% in this study(Li, Huang et al. 2013). Substance use prevalence in our study population is lower than that of the western countries of similar population (Shuper, Joharchi et al. 2013; Wright 2013).

This study revealed that 24% of the respondents ever had sexual intercourse. This prevalence is higher than that reported in previous national survey from Ethiopia among school youth in which 9.9% were found to have had sexual experience (FMOE 2009). The finding of this study is lower than the study conducted in 5 randomly selected high school of Jimma zones which reported 42.9% (Abebe, Tsion et al. 2013). Prevalence of substance abuse is similarly higher in Jimma zone high school students than our study participants and among Wollega University Students (Negeri 2014). This may be due co-existence of substance abuse and risky sexual behavior. Studies of other countries indicated that life time sexual intercourse in adolescents’: 48.7% in USA (Eaton and Kalichman 2009; Li, Huang et al. 2013) and 7% in Chinese (Li, Huang et al. 2013).

About 20% of the study participants had involved in risky sexual behavior. Many factors were associated with adolescents’ involvement in risky sexual behavior: age, ethnicity, gender, alcohol use, khat use, cigarette smoking, economic status and socio-cultural tradition. In this study, however, ongoing alcohol use and khat chewing are the independent predictors of adolescents’ involvement in risky sexual behavior in multivariate logistic regression. 

Only 5% of the study participants have used condom during their first sexual contact while 62.60% have used condom in their last sexual contact. This can be explained by the fact that first sexual contact is unplanned and accidental event which can have long lasting deleterious effect on individual. This can be alleviated by sexual education to the students.

Current alcohol use is a predictor of risky sexual behavior in this study. Alcohol users have 12 times more likely to involve in risky sexual behavior than non-users OR, 12.0(5.26-27.4). A study in similar population by in Jimma high school students reported alcohol use as a predictor of involving in risky sexual behavior (Abebe, Tsion et al. 2013) and a study conducted in Northwest Ethiopia out of school youths have also indicated association of alcohol use and involving in risky sexual behavior (Alemu, Mariam et al. 2007). Many similar study but in Ethiopian university students have also reported alcohol use a predictor of involving in risky sexual behavior (Deressa and Azazh 2011; Tura, Alemseged et al. 2012; Berhan, Hailu et al. 2013; Gebreslassie, Feleke et al. 2013). A possible explanation of mechanism of substance abuse association with risky sexual behavior was that the former can adversely affect judgment and thus ultimately decision making (Jesssor 1991). Studies also indicated that alcohol use promotes people to engage in unprotected sex and to select high risk partners still because of impaired judgment (Takakura and Nagayam 2007).

Study conducted Australian youth aged 16-17 years old indicated sexual related risk taking and alcohol consumption had strong independent associations (Bonomo, Coffey et al. 2001). In other studies early drinking was also found to link be associated with early sexual association (MacQueen, Nopkesorn et al. 1996; Burack 1999). From these studies we have learned that alcohol use is a universal predictor of involving in risky sexual behavior. The most frequently cited explanation for the link between alcohol use and risky sexual behavior is compromised judgment, alcohol use and risky behavior may also cluster together, sensation seeking (the need for optimal level of stimulation) (Zawacki, Norris et al. 2009). Strong association is to be expected between alcohol and risky sexual behavior because of the nature of alcohol in decreasing inhibitions, altering rational decision making (Zufferey, Michaud et al. 2007).

In the present study, khat chewing and involving in risky sexual behavior were significantly associated with OR: 95% CI: 3.29(1.28-8.45). Khat chewing was strongly associated with initiation of sexual activity with four fold increased odds in daily and weekly users in study conducted in high school and vocational schools in Ethiopia (Kebede, Alem et al. 2005). It is, therefore, safe to state; from this study and study by Kebede et al, (Kebede, Alem et al. 2005) that khat chewing practice constitutes a risk factor for the spread of the HIV epidemic. It is a serious threat to the well-being of this and future generations of Ethiopia. However, it has received very little or no attention so far. The current economic benefits gained from Kat market should be weighted with that of devastating economic loss resulted from khat chewing (Selassie and Gebre 1996).

Information on sexual behavior is important for designing and monitoring intervention programs to control the spread of HIV/AIDS. For a long times, HIV/AIDS interventions in high schools have focused on abstinence promotion by restricting sexual practice by ministry of education policy. The findings of this study provide justification for intervention targeting on key factors that promote adolescents’ risky sexual behavior. In this case substance abuse is major predictor of involving risky sexual behavior. Integrated substance abuse prevention and HIV/AIDS prevention programs may benefit further. Providing the necessary knowledge and skills for both parents and adolescents, and comprehensive substance use cessation program are among those which can be suggested for interventions.

This study is not free of limitations. First, the study used a descriptive single cross-sectional design that cannot establish trends and causality between substance use and potential risk factors. Small sample sizes, particularly among substance users, contributed to wider confidence intervals with low precision. Second, the data was collected based on self-report of the students and may be subjected to recall bias and under-reporting of substance use due to social desirability bias. Despite the limitations, these findings indicate a need to educate high school students regarding association between risky sexual behavior and substance use and its consequences.

Risky sexual behavior is relatively high in our study participant high school adolescents. We recommend concerted efforts be expended in order to address sexual and HIV/AIDS problems of high school students in Ethiopia. The interventions could include comprehensive sexual and reproductive health education on issues such as association between substance use and risky sexual behavior, sexual education, safe sex and sexually transmitted infections. Further research is also needed to develop effective interventions for this population to reduce sexual and substance use behaviors, which have a long term benefit to the control of HIV/AIDS.

Both authors have contributed equally for the finalization of this manuscript. SD have mainly involved in study design, data collection, data feeding and statistical analysis and writing of the research while AT mainly on study design, data collection and data feeding.  Both authors have reviewed and approved the final draft

We would like to acknowledge research and development directorate of Hawassa University for sponsoring this study

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