Assessment of the factors affecting practice towards HIV/AIDS among in-School Youth in the West Guji Zone, South Ethiopia, 2021

Back Ground: Human immune deciency virus was a worldwide pandemic, yet there is no proven medicine and vaccine to cure or prevent it. Prevention is only the mainstay solution to control the spread of the virus among high-risk young populations. Young peoples were at the greatest risk of HIV because of several inuencing factors like: maturity-related physiological, emotional changes, sexuality, peer pressure, economical problem, and knowledge gaps concerning HIV. Therefore, continuously assessing prevention practice towards HIV among vulnerable young populations is relevant to yield necessary intervention. Methods and materials: Health care facility-based cross-sectional study design took place from December 01/2020 To January 01/2021. The multistage sampling technique was used in this study and a total of 615 participants were enrolled in the study. A self-administered questionnaire technique was employed to collect the data. The data was cross-checked before entered into Epi-Data version 4.4.3.1 and exported to SPSS Statistics Version 25 for analysis. Descriptive and inferential statistics were needed in the study. Bivariate logistic regression was done to check the association between dependent and independent variables. Variables that had association at p< 0.25 were entered into a multivariate logistic regression model to obtain an adjusted odds ratio. Statically signicance cut point settled at p < 0.05 with 95% condence intervals. Results: Out of the 615 students, 586 were completed the questionnaires in which 95.3% of respondents rate. The overall scores of poor knowledge, unfavorable attitude, and unsafe practice concerning HIV in the current study were 25.1%, 27.5%, and 24.2%. Of all study subjects; 38.7% were undifferentiated HIV from AIDS and 20.1% of them were wrongly reported as HIV/AIDS was a curable disease. Slightly more than half 51.5%, 28.2%, and 19.3% of the respondents were misbelieved that HIV transmitted by mosquito bit, eating food cooked by HIV positive person, and handshaking respectively. Voluntarily counseling and testing service was not utilized by (34.8%) respondents and 139(23.7%) were sexually active. Early initiation of sex at age < 15 years old was reported by


Introduction
The human immunode ciency virus (HIV) is the causative agent for an advanced deadly disease called Acquired immunode ciency syndrome (AIDS) by impairing and destroying the human immune system that defends the body against foreign antigens [1,2]. The young people, who account for 42% of the global population who were seriously attached by the HIV/ AIDS pandemic than any other segment of the society. Sab-Saharan Africa stayed the most affected region by HIV that 36. 7 million people were positive to HIV currently shared 70% of HIV infected people from the globe [3,4]. The lives of young people are catastrophically attacked by the human immune de ciency virus. There were about 4 million youth living with the virus nowadays. On average, 1600 young people are infected by HIV per day. Every ten minutes, the life of a young person passed away due to HIV and its related complications [4,5].
In Ethiopia, the challenges from HIVAIDS becoming a dominant public health issue which more than one million people were living with HIV. The prevalence of HIV varies across the different regions of the country. Amara region shared 30% of PLHIV followed by Oromia regional state which 26% of people were saro positive. The overall HIV prevalence rate in our country among youth (15-24) was 2.9 urban versus 0.4 in rural [6,7] There are many factors that attributable to an elevated risk of HIV among young people. These factors include maturity-related physiological and emotional changes, peer pressure, gender norms, sexualityrelated factors, economic problem, attitude, and knowledge gaps, socio-demographic and personalrelated factors [8,9]. According to the Ethiopian Demographic Health Survey (EDHS) of 2016 and United Nations (UN) reports indicates; only one-third of youth in Ethiopia had adequate knowledge and safe practices towards HIV. The knowledge level varies between the gender that female youth were scored less level of knowledge which was 24-30.5% [10,11]. Young people have the right to get access to information about HIV/AIDS and voluntary counseling and testing services to protect themselves from the virus. Responsibly bodies also play a crucial role in delivering appropriate, acceptable and accessible youthfriendly health services to young people [12,13]. Continues assessment of misconception, level of awareness, and prevention behaviors concerning HIV/AIDS was an essential step to provide necessary intervention. The extensive intervention that focused on the nature of HIV/AIDS, ways of its transmission, and how to tackle its spread must be given to assure Sustainable Development Goal (SDG3) an end of HIV epidemic by 2030 G.C [3,11,13].
There was no proven medicine to cure HIV/AIDS and vaccines against it. So that, prevention was the mainstay measure to combat the spread of HIV. This can be achieved through multilayered efforts of all concerned stakeholders to correct misconceptions around HIV, raise awareness and preventive skills among young people. Furthermore, the intervention involves; sex education targeted on ABC approach which means (A: abstinence, B: be Faithfull and C: use of a condom) and use of pre-exposure (PrEP) and post-exposure prophylaxis (PEP) [2,8,[14][15][16].
Therefore, this study stressed on the assessment of misconception, level awareness, and preventive practices among in-school youth in the west guji zone, south Ethiopia.

Methods And Materials
Study area and period The study was done at selected High Schools in the West guji zone in south Oromia, Ethiopia. The zone elevation between 500-2200 meters above sea level. The highest percentage of the climatic condition of the zone is relatively hot. The zone has ten districts (woreda). According to the 2007 census conducted by the Central Statistical Agency of Ethiopia (CSA), there were 1,300,000 million populations live in the West Guji Zone of which 50.4% males and 49.6% were females. There were thirty-eight (38) high schools and 37,128 students currently learned in the West guji zone. Study design: Institutional-based cross-sectional study design was carried out from December 01/2020 to January 01/2021 G.C.
Study population: The study populations for this study were grade nine and grade ten students of selected high schools in the West guji zone whose ages between fteen to twenty-four (15)(16)(17)(18)(19)(20)(21)(22)(23)(24). All regular students of selected high schools were included in the study. Students age less than fteen (<15) and greater than twenty-four (>24) years old were excluded from this study because of this study was conducted among the in-school youth.
Sample Size Determination: The sample of this study was determined based on the objective of the study.
For the rst Objective, The sample size was determined using the standard formula for single population proportion based on the following assumptions for objective one.
However, the sample from the formula of the second objective was less than that of objective one which was = 615 Sampling Technique: Multi-stage sampling technique was used in this study. Firstly out of thirty-eight high schools found in the zone, eight high schools were selected by simple random sampling method. Then grade nine and grade ten students of selected high schools were enrolled in the study by systematic sampling technique.

Measurement
In questionnaires to assess the level of prevention practice from HIV, ten questions were used. The correct answer was assigned 1 point and the incorrect was assigned 0 points. Then the mean score of practice was calculated. The students who scored more than the mean considered as had good prevention practice and those who score less than the mean score categorized as poor prevention practice.
The level of knowledge was assessed by twenty questions in this study. The correct answer was assigned 1 point and incorrect was assigned 0 points. The mean score was taken as a cut point for the good and poor level of knowledge. Students scored greater than mean were considered as having good knowledge and those who scored less than the mean score were categorized as poor knowledge regarding HIV.
The level of attitude of the students towards people living with HIV was assessed by fteen questions. Likert scale was applied to calculate attitude score. The correct answers were assigned 1 point and incorrect answers were assigned 0 points. Then the mean attitude score was calculated. The students, those were scored greater than the mean attitude score considered as had favorable attitude and those who scored less than the mean score was categorized as unfavorable attitude towards HIV.

Operational De nition
Knowledge: In this research paper, those who respond correctly less than or equal to10 questions out of knowledge assessing questions were rated as had poor knowledge while those who answered correctly 11 questions was categorized as had good knowledge. Attitude: A tendency of mind or a relatively constant feeling of the respondent towards HIV prevention method. In this research paper those who responded correctly 8 questions out of the 15 attitude assessing questions were recognized as have a positive attitude.
Practice: Is de ned as a health behavior that prevents disease or the opposite, what the individual has been doing regarding the HIV prevention. In this paper, study subjects who answered correctly 6 questions out of 10 practice assessing questions considered as they had good prevention practice from HIV. Youth: The person whose age found between ranges 15 -24 years old. In this study youth is high school students whose age between 15-24 years old [9].

Data Collection Tools and Technique
The data collection instrument was adapted by reviewing different relevant articles to gather the required information from respondents [9,19,20,21,23]. The questionnaires were pretested before administers to the participants. The questionnaire has ve parts: Part I: Socio-demographic characters, Part II: Knowledge of students regarding HIV/AIDS, Part III: Attitude of Students towards HIV, Part IV: Personal related factors, and Part V: Prevention Practice from HIV/AIDS. Questions were prepared in English language and translated to Afaan Oromo and back-translated to English to ensure consistency. Eight diploma nurses for data collection and two BSc nurses for supervision of the data collection were recruited in this study. The study assistants were trained for two days concerning the study tools, data gathering procedures, objective of the study, and con dentiality of the collected data. Before data collection, all study participants were well instructed about the objective of the study, the bene t of the study, the risk to participating in the study, and con dentiality of their information.
During data collection, each respondent was invited voluntarily to participate in the study and the right to refuse or withdraw from participation was maintained. Self-administered questionnaires technique was used in this study. The supervisors have checked the questionnaires for completeness every day.
Quality Control Measures: The quality of the data was secured by using standard, pre-tested questionnaires, and proper data collection procedures. Two weeks before the actual data collection, pretesting was done on 5% of the total study subjects in the Yabelo High school students. Based on the ndings from the pre-test, necessary amendments were made regarding internal consistency, clarity and logical organizations of tools, and time to be taken completed questionnaires. Close supervision was carried out during data collection by the supervisors to assure the correct data collection procedures were implemented. Moreover, the data was carefully cross-checked before entering and beginning of the analysis.

Data Processing and Analysis
The data was coded and entered into Epi-Data version 4.4.3.1 and exported to SPSS Statistics Version 25 for analysis. Descriptive statistics and inferential statistics were applied in this study. Bivariate logistic regression and multivariate logistic model used to clerk association between the dependent variable and independent variables. The variables that had associations at p< 0.25 were entered into multivariate logistic regression model to control cofounding variables and obtain adjusted odds ratio at a strong level of association. The signi cance level for multivariable logistic regression was adjusted at p < 0.05 and 95% con dence interval.
Ethical Approval: Bule Hora University College of Health and medical science, Institutional Review Board (IRB) approved for this study before the commencement. Permission letter was given to the high schools administration o ce. For study participants aged less than eighteen (< 18) assent was taken from each participant in addition to consent taken from their guardian. This study was harmless to the participants that required the only collection of the information related to knowledge about HIV transmissions, attitude toward people living with HIV, and prevention practice concerning HIV. After the aim of the study, bene ts and risks related to the study explained verbal informed consent was obtained from each participant. The collected data were kept in a safe place and data used only for the purpose of the study to maintain the con dentiality of the collected data. Overall, concerning ethical issues since this was done on human beings, each traveled steps lined with the declaration of Helsinki.

Results
Out of 615 students who participated in this study, 586 of them completed the question that response of this study was 95.3%. Males were slightly greater participants of this study 56.7% as compared to females. The average age of study subjects was 16.88 + 2.98 and the median age was 17. Oromo was the dominant Ethnic group followed by Amara. The protestant and Orthodox were religions with a larger number of followers 64.2% and 14.3% respectively. The majority (59.2%) of the study participants were from the rural areas (See Table 1).  Table 2). same home with the HIV-infected persons. The number of high school youth who were not correctly identi ed means of HIV transmission, risk group to HIV, and how to use a condom were not minimal (See Table 3). Regarding the substance history of the study participants, 50(8.5%) of students had a history of drinking alcohol, and of them were 22(3.8%) chat chewer. 54(9.2%) of youth were visited pornography (See Figure  2).

Preventive Practice of High school youth towards HIV/AIDS
About three-fourths 444(75.8) of study subjects had a good level of practices towards HIV and 142(24.2%) had a poor level of preventive practice. Out of all participants, 382(65.2%) received VCT service and 554(94.5%) of them never shared sharp materials with their friends. Of all study subjects, 139(23.7%) and 70(50.4%) participants started sexual intercourse before 15 years old and the median age for rst sex was 15. Of those who experienced sexual activities, two-third (71.9%) of them with their permanent friends. 65.5% sexually active students used condoms and few of them utilized persistently.
One-thirds of sexual engaged participants practice sexual intercourse with multiple sexual partners and 46% of them had a sexual experience with the past 12months. The mean age of the rst sex was (15.68 + 2.13SD) (See Table 4).

Factors Associated With Prevention Practices towards HIV among High School Students
To identify factors associated with preventive practice toward HIV, binary and multivariable logistic regressions were done. Variables signi cant at a P-value of less than 0.25 were considered as a candidate to multivariable logistic regression. The statistical signi cance was adjusted for multivariable logistic regression at P value less than 0.05.
Accordingly, the independent variable that had an association with the preventive practice of HIV was: gender, females were 71.6% time more likely to protect themselves from HIV AOR=0.284, 95% CI (0.18-0.43) than males. Study participants age group 15-19 were ve times more likely to practice good prevention towards HIV AOR=4.69, 95%CI (2.33-9.42) than the counter-part. Concerning marital status, singles were seven times more likely to exercising a good prevention mechanism AOR= 7.03, 95%CI (3.19-15.52) than married. Visiting pornography lm AOR= 0.202, 95CI (0.11-0.38) and sharing sharp materials AOR= 0.089, 95%CI (0.04-1.21) were factors that contributes to poor preventive practices among the high school students in this study. Furthermore; unprotected sexual activity, sharing toothbrush, traditional circumcision, and alcohol drinking were risk factors for poor preventive practices (See Table 5). 0.001** Key: COR-crude odds ratio, AOR-adjusted odds ratio, * significant at P-value < 0.25, ** significant at P-value <0.05

Discussion
This quantitative study approach was carried out among high school youth to identify their level of preventive practice and associated factors. Misconceptions concerning the ways of HIV transmission were out of nding from this study. Of study participants; 302(51.5%), 165(28.2%), and 113(19.3%) were reported as HIV transmitted by mosquito bit, eating food cooked by HIV infected person, and hugging, kissing and handshaking respectively. These results were in agreement with existing literature [17][18][19][20][21]. This can be explained in terms of less knowledge of the high school youth regard ways of HIV transmission that indicates the needs training.
The majority of the students got information about HIV from a reliable source, health care workers, and mass media. This nding coincided with several studies conducted in Iran, Lao People's Democratic Republic, Nigeria, and Uganda [17,19,21,22]. This may be due to the government and non-governmental organizations concern about HIV which involves multiple stakeholders in information dissemination including health care institutions and media.
The current study denotes two-third of in-school youths had good knowledge about HIV. This is compatible with the study done in southern Ethiopia, Arba Minch town that 70% of study participants had adequate knowledge of HIV [23]. This might be happened due to a similar geographical location which was far from the center and slightly similar population size. The nding was lower than the studies carried out in South Africa 95.5% [24]. However, the result higher than the studies conducted in northern Ethiopia, Gondar town 45% [25] and in West Africa Ghana 61.6% [26]. The observed difference can be explained in terms of the study population and population size, that the study population in the previous studies included preparatory students and the less population size in former studies.
Nearly, two-thirds (67.4%) of study participants agreed on healthy-looking persons may have Human Immuno Virus in their blood. This nding was lower than studies carried out in the South West Region of Cameroon 98.8% [18]and North West Region of Cameroon 81.45% [27]. The variation can explain by a difference in the study setting, study population and methodology used that were in previous studies nonprobability sampling technique was applied, the cut point for a mean score also different and wide coverage area. On the other hand, the nding of the present study was higher than the survey done in Osun state of Nigeria (52.2%) [21]. Study time gap and study setting difference can be possible factors to the difference.
In the present study, more than half (62.6%) of study subjects have neglected the misconception, HIV was panishment for bad act. This result was supported by the survey conducted in Iran that (57%) of the participants were considered, HIV was not punishment for sin [17]. However, misconceptions around HIV still needs greater attention from stakeholders to brings a change in perception and believes among the young high-risk populations. The overall positive attitude score in this study was (72.5%). This result higher in comparison with the study carried out in South Africa (63.1%) [24]and in Ghana (58.5%) [26].
However, lower than the survey conducted in Uganda 80.5% [22]. The difference might be due to the study time gap and population size which was less population participated in previous studies. Of all 586 study subjects, 139(23.7%) had the previous history of sexual intercourse. The result was inconsistent with the studies done in Iran, southeastern Ethiopia, Bale zone, and south Ethiopia, Arba Minch town [17,20,23]. In contrast, the nding was lower than studies carried out in Cameroon, Lao People's Democratic Republic, Uganda, and Eastern Ethiopia, Dire Dawa City [18,19,22,28]. This variability was due to methodological difference, study population, and study time gap that in the former study quota sampling technique was used.
The present study reveals early initiation of sexual intercourse was a remarkable concern that among those who had a history of sexual debt, half (50.4%) of them started age less than fteen years old. The mean age of sexual initiation in this study was (15.68 + 2.13SD). This nding was well-matched with the studies done Lao People's Democratic Republic (16.1 + 1.1SD) and southern Ethiopia, Arba Minch town (16 + 1,18SD) [19,23]. This can be due to physiological maturity, secondary sexual characteristics, and visiting sexually related videos.
According to the current study, the magnitude of condom utilization among those who were sexually active was 65.5%. This result was comparable with studies conducted in Lao People's Democratic Republic (70.2%) and East Ethiopia, Dire Dawa town (62,2%) [19,28]. This is because the existed misconceptions regarding condom utilization were still a barrier for users. On the other hand, this nding was higher than existing literature [17,18,20,22,25,29]. This difference might be due to variation in the study population, population size, and study setting coverage, and cut point for operational de nition. Which were the previous studies used nonprobability sampling methods, smaller population size, preparatory and college students were enrolled in the study.
Of all the study subjects, more than two-thirds (75.8%) were safely practiced concerning HIV. the nding was higher than as compared to the study carried out in the Lao People's Democratic Republic (56.4%) [19]. This can be happened due to the difference in the study population, in former study unmarried male participants those were age between 16 to 19 years old participated in the study, and the population size also less than were 300 males involved in the previous study. The result was similar to a cross-sectional survey conducted in southern Ethiopia, Arba Minch town (77.6%) [23]. this may be due to a similar study setting and study population.
In this study, several factors are associated with students` practices towards HIV. Those factors were tested at two levels of the regression analysis model. The rst one was at binary logistic regression and the next at multiple logistic regression level to identify candidate variables and to check the strength of association. Therefore, variables such as; gender, age, the practice of sharing sharp materials, traditional circumcision, drinking Alcohol and visiting sexually related lm were factors shows a statistically signi cant association. Female participants were 71.6% time more likely protected from HIV than a counterpart in the current study. This nding was supported by a study done in eastern Ethiopia, Dire Dawa town that male participants were thirteen times more likely to exhibit risk practice towards HIV [28].
This might be explained in terms of socio-cultural norms regarding gender-based restriction sexual behavior.
Study subjects, age group between15-19 were ve times more likely protected from HIV than age group between 20-24 years old. This result was in contrast with a study conducted in North Ethiopia, Gondar town that participants with an age range between15-19 were 1.72 times more likely exposed to HIV [25]. The difference may be due to the population which was a larger sample size in the present study and study area. Visiting sexually related videos and drinking alcohol were risk factors for poor preventive practice towards HIV in this study. These ndings were a rmed with the studies carried out in south Ethiopia, Arba Minch town, and North Ethiopia, Gondar town [23,25]. This can be due to the fact that visiting porn graph stimulates the youth to the risk practices and alcohol was central nervous system depressant which contributes to less protection from HIV.

Limitation of the study
This study was done during the COVID-19 pandemic, which was a global burning issue. So that, less focus was given to other diseases including HIV.
The study was conducted among sample students from eight high schools in the west guji zone. This can be lead to the di cult generalization of the nding.
In this study, the self-administration questionnaire technique was used for data collection. Thus, there may be the possibility of responder desirability bias.

Conclusion
In the present study; misconception on ways of HIV transmission; misbelieves regarding people living with HIV, and overall, prevention practice gaps were identi ed. Misconception like HIV/AIDS was a curable disease, the transmission of HIV by mosquito bite, sharing sharp material and traditional circumcision were considered as correct responses by the many participants.
Gathering information from an unreliable source such as friends and traditional healers were another nding from this study. Misbelief towards people living with HIV was addressed in this survey. The HIV risk behaviors including alcohol drinking, improper use of sharp materials, and pornography visiting were identi ed.
The overall poor knowledge, unfavorable attitude, and unsafe practice regarding HIV in the current study were 25.1%, 27.5%, and 24.2% respectively. These results indicated, nearly one-third of study participants needed consideration for training on HIV. Voluntarily counseling and testing service was not utilized by (34.8%) of the in-school youth. Out of all study subjects, 139(23.7%) were sexually active. Early initiation of sexual intercourse age less than fteen years old was reported by (50.4%) of sexually active participants and the mean of the rst sex was (15.68 + 2.13SD). Having multiple sexual partners, none, and inconstant use of condoms were the risk behaviors to HIV by sexually active young people's found in this study.
In this study, gender, age, visiting sexually related videos, drinking alcohol and improper use of sharp materials were factors signi cantly associated with practice towards HIV.

Recommendation
Based on the ndings, the following recommendation forwarded; Local governmental health care institutions and non-governmental organizations provide; a continuous and age-appropriate youth-friendly health service that enables the students to reduce HIV risk behaviors and delay early initiation of sexual intercourse.
The training focused on HIV, ways of transmission, and how to prevent it must be given to in-school youth to step up the students' knowledge, attitude and practice.
HIV/AIDS was a deadly disease. Therefore, all stakeholders including health care institutions, education institutions, and mass-medias give strong concern to the disease to alleviate misconceptions around HIV/AIDS particularly in this time of the COVID-19 pandemic.

Declarations
Data Availability Author of this study declare that all data needed in this study can be available upon request by the side of corresponding author.

Con icts of Interest
Author of this study a rm that there was no con ict of interest (both nancial and non-nancial competing of interests).

Figure 1
Sources of Information about HIV among High school students at West guji zone , 2021 HIV risk factors practiced by in-school youth, study at West guji zone, 2021