Prevalence of Premarital Sex and Related Risky Practices Among Students of Ayer Tena Health Science and Business College, Addis Ababa, Ethiopia: A cross-sectional study

Background: Premarital sex may result in sexually transmitted infections (STIs) and unwanted pregnancy. Published reports on the prevalence premarital in private colleges in Ethiopia are limited. This study aimed at assessing the prevalence of premarital and risky behaviours among students of Ayer Tena Health Science and Business College, Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted among of Ayer Tena Health Science and Business College, Addis Ababa, Ethiopia. A semi-structured questionnaire was used to collect data from 390 students that were selected by systematic random sampling. Data analysis was done using SPSS version 23. Associations between variables were determined using chi-square test. Results: The study participants consisted of 81% females, 73.7% Christians, 58% business students, 56.8 % degree students, 62.1% regular students and 49.1% fresh students. We found that 23.3% of the students had exprienced premarital sex, of which 43.5% had sex in the last 12 months, 14.3% were homosexuals, and 20% started sex before 18. About 68.2% never used condom at the rst sex and 60% had history of having sex without condom. About 51.3% did not plan for the rst sex. Nearly 34% had multiple sexual partners in their life time and 15.5% had multiple current sexual partners. From 334 respondents, 14.7% said that oral contraceptive pills prevent sexually STIs. Nearly 59 % (47/80) of the study subjects did not have a practice of requesting a new sexual partner for STIs test result. Many students had a history of watching pornography (17.3%), drinking alcohol (17.3%) and taking drugs (3%). Among 65 female students, 20% had a history of pregnancy, of which 46.2% have done abortion. Among those who practiced sexual intercourse, 5.9% had history of STIs, including HIV. Premarital sex was common among males, Christians, health students, non-regular students, degree students, and among those who never attended religious services, live alone, have income, watch pornography, believe that oral contraceptive pills prevent STIs, and take alcohol. Conclusion: The prevalence of premarital is high


Background
It is well-known that human beings are borne with reproductive system that is responsible for reproduction. The primary reason for being bornewith sexual organs and for having sex is for reproduction which a means of continuation of human generations. Human beings have sex not only for the purpose of reproduction but also to derive satisfaction and happiness, and to make business. Sex between married couples is meant for reproduction and/or satisfaction, whereas sex before marriage (premarital sex) can be meant for satisfaction, business and experience sex.It might also be the result of rape. Whatever the reason is, premarital sex is unacceptable in many countries, including Ethiopia, for cultural and religious reasons [1][2][3]. However, many adolescents and youths do not care about culture or religion and they practice premarital sex [4]. This is especially true when opposite sexes get the chance to come together. One such opportunity is provided by educational institutions such as schools, colleges and universities, where students from a diverse background meet with each other. For many students, educational institutions are places where they get boy/girlfriends and start to engage in premarital sex.Although sex by itself is a natural human need, it can be dangerous when it is unsafe.Unsafe sex is a risky sexual intercourse that is performed without condom (unprotected sex), with multiple sexual partners (promiscuous sex), with commercial sex workers or at early age (early sex).
Unsafe premarital sex can usually lead to unwanted (unplanned) pregnancy and infections with any of the at least 30 sexually transmitted infections (STIs), and studies have shown that many university students have borne these consequences [5].Unintended pregnancy can be associated with di culty in delivery (even death), unplanned parenthood, and economic di culty in bringing up the child, abortion, embarrassment/shame and discontinuation of study among students. Every year, an estimated 21 million girls aged 15 to 19 years and 2 million girls aged under 15 years become pregnant in developing countries [6,7]. A national wide survey in china showed that 6.3% of unmarried youth have become pregnant [8].Abortion may bring about bad feelings due to destroying own fetus, and body injury, infection and/or death if unsafe. Globally, an estimated 3.9 million girls aged 15 to 19 undergo abortion every year [6].
STIs can lead to morbidity which may make victims incapable of performing daily activities (making them economic burden to parents and country) and damaged/nonfunctional reproductive organs (e.g., genitals), genital and other cancers, pelvic in ammatory disease, which may result in ectopic pregnancy (can cause maternal death during pregnancy) andinfertility, increased vulnerability to other STIs or other infections, all of which may result in loss of happiness and peace of mind. In the worst case, they can result inloss of own precious life, thwarting of goals and visions, making parents sad and helpless and orphaning children (which may lead to their prostitution and poverty), and divorce. STIs can also pass to the fetus, newborn, or infant through the placenta, during passage through the birth canal, or after birth through breast-feeding or close direct contact. This can lead to spontaneous abortion, stillbirth, premature rupture of membranes, low birth weight, and preterm delivery, and damage to the central nervous system, eyes, and auditory system of the child.
Pregnancy and childbirth complications are the major cause of mortality among 15 to 19 year-old girls worldwide, and 99% of global maternal deaths of women aged 15 to 49 years occurs in low and middleincome countries [9].Half of pregnancies among girls aged 15 to 19 years in developing regions are estimated to be unintended [6].The prevalence of unintended pregnancy is about 34% among college students in china [10]. Among female students of Ethiopian universities and colleges it is 6.6% [11]. Early pregnancy or marriage accounts for school dropout among an estimated 5% to 33% of girls aged 15 to 24 in some countries [12]. This is also a problem among female students in Ethiopian universities [13,14].
The rate of premarital sex among university or college students is on the rise globally and it varies from country to country. In Iranthe rate of premarital sex is 15.1% among non-medical students of a great university of Mashhad, which was more common among males than females [15].In southern Iran (in Shiraz) the rate of premarital sex among the youth is 47.5% [16]. It is 63.9% among the unmarried youth of Vientiane Capital City, with higher prevalence among males than females [17].It is 8.1% among unmarried female undergraduates in China (Wuhan) [5,18].The rate of premarital sexual intercourse was low (4.3%) among students of Dicle University in Turkey, it being more prevalent among males than females (87.7% and 44.2% respectively) [19].The prevalence of premarital sexual practice in Africa seems to be higher compared to other continents. A very recent study conducted in Nigeria showed that the prevalence of premarital sex was 45.8% among nursing students, with more frequency among male students [20]. A study published in 2014 showed a high prevalence of premarital sex (70.4%) among female undergraduates' students of Muhimbili and Dar es Salaam Universities, Tanzania [21]. It was very high in Uganda (74%) andBostwana (65.35%) as indicated by a study published in 2010and 2012, respectively. In Ethiopia the prevalence of premarital sex among university or college students ranges from about 23% to 68% [22][23][24][25][26][27][28][29][30][31][32][33][34][35].
Several studies have shown that premarital sex (having sex before the age of 18) is common in Ethiopian its prevalence varies from one university to another. It was found to be 57.6% for MizanAman College of Health Science, 37.9% for Asksum University, 47.6% for private colleges in Bahir Dar, 24.3% for Bahir Dar Universityand 23.6% for University of Gondar (23.6%) [23,29,[36][37][38]. In Ethiopia premarital sex is associated with several factors including gender, watching pornography, alcohol use, attending night clubs, khat chewing [22,25,39,40].
There are no or a few published reports on the prevalence ofpremarital unsafe sex among students of private colleges such as ATHSBC. The aim of this study was therefore to determine the prevalence of unsafe premarital sex and associated factors among students of ATHSBC.

Methods
Study area ATHSBC, located in Addis Ababa, capital of Ethiopia, was established in 2007 as a health science college and later included business departments in its academic programs. The college runs degree and level programs (level I to IV) in regular and extension modalities. During the study period, there were a total of about 2900 students in regular and extension divisions.

Study design and period
A cross-sectional survey was conducted among ATHSBC students from April to May, 2019.

Source population
The source population was all students (regular and extension) of ATHBC.

Study Subjects
Randomly selected unmarried students participated in the study.
Sampling methods and procedure Systematic random sampling was used to select 422 students from the source population of about 2900 students.

Sample size
Sample size (n) is calculated to be 380 using single population proportion formula and 50 % proportion of premarital sex from a previous study. n = z 2 p(1-p)/w 2 where, p = proportion (50%) n = sample size z = con dence interval (with 95% level of certainty) w = margin of error (5%) When 10% non-response rate is considered, the sample size became 422.

Inclusion and exclusion criteria
Unmarried students were included, whereas married students were excluded.

Study variables
The independent variables were sex, age, religion, and frequency of religious service attendance, eld of specialization, education level of parents, place of residence, cohabitant type and place of high/preparatory school completion.
Dependent variable consisted of having sex, having sex without condom, frequency of condom use, having given/received bene t for sex, knowledge of STIs of a new sexual partner, having seen pornography, having drunk alcohol, knowledge of effect of unsafe sex, and occurrence of pregnancy and abortion.

Data collection and analysis
Data was collected from study participants by using self-administered close ended questionnaire. To validate the questionnaire, a pretest survey was done among 20 students of a different private health and business college.Data was entered into Excel before export to SPSS v20 for data management and analysis. Associations between variables were determined by comparing proportions usingchi-square test or Fisher's exact test. P-value less than 0.05 was considered statistically signi cant.

Socio-demographic characteristics of the study participants
The socio-demographic characteristics of the study participants are presented in Table 1.Out of 422 single students recruited to take part in this study, 390 students lled the questionnaire, giving a response rate of 92.4%.The majority of the participantswere 18-21 years old (61%), females (81%), Christians (61.6%), business students (58.8%), degree students (56.8%), regular students (62.1%) and rst year students (49.1%). Most of them lived together with both parents (35.6%), did not have income (69%), lived in and around Addis Ababa for ve or more years (63.7%), and completed grade 10 or 12 in and around Addis Ababa (55.7%). The majority of the respondents reported that their mothers are uneducated (34.1%) or have primary education (30.7%), and that their fathers have primary (31.1%) or secondary (23.1%) education. For the majority, mothers and fathers were housewives (50.8%) and self-employed (33.6%), respectively. gave in exchange for sex. Regarding recent sexual history, 11.4 % of the participants responded that they had sex in the last 12 months.A very small proportion (3.4%) of the respondents said that they practiced homosexuality. This accounts for 14.3% (12/84) of those who had practiced premarital sex. Nine of the 12 were females. For about 61% of those who had experienced premarital sex, the rst sexual partner was a student. The most common reasons reported for starting sex before marriage was fall in love (69.3%), development of sexual desire (12%) and peer pressure (9.3%).
Chi square test revealed that premarital sex prevalence showed signi cantly increasing trend from 12.7% (16/126) in the age group 18-19 to 52.2% (12/23) in the age group 26 and higher (P = 0.000). Chi square test also showed the prevalence of premarital sex is statistically signi cantly related to sex, religion, frequency of religious service attendance, eld of study, division of study, study program, income, living habit, place grade 10 or 12 is completed, number of years lived in Addis Ababa and its surroundings, having boy-or girlfriend, seducing opposite sex, misconception about the use of contraceptive pills, watching porn, taking alcohol or other drugs (Table 2). In this regard, the current study revealed that premarital sex was more common among males, Christians, health students, degree students and nonregular students ( Table 2). It was also more frequent among study participants whohave never attend religious services and those who attend occasionally, who had income, who live alone, who completed grade 10 or 12 outside Addis Ababa or its surrounding, lived in Addis Ababa for a few years, who watch porn, who responded contraceptive pills provide protection against STIs, who take alcohol, who take drugs, who seduce opposite sex, and who have boy-or girl-friend (Table 2).

Discussion
The present study investigated the prevalence of premarital sex and risky sexual practices (behaviors) among students of a private college. It revealed the prevalence premarital sexual intercourse among the study participants, which was 23.3%, is lower than the recentlyreported gures for students of governmental higher institutions in Ethiopia, including Robe Technical and Vocational Education Training College (51.9%) [35], Aksum University (60%) [29], private colleges in Mekelle (51.9%) [33], Addis Ababa Science and Technology University (26.8%) [27], Wollega University (28.4%, 36.4%) [25,26], Jigjiga University (67.67%) [24], Debre Tabor university (25.9%) [30], Debre Markos government higher education institutions (25.%) [41] Addis Ababa University (26.8%) [27]and Debre Berhan University (54.3%) [22], and private colleges in Mekelle (51.9%) [33]. The current gure is also lower than the ones reported for nursing students from healthcare training institutions in Enugu State (45.8%) of Nigeria [20], forfemale undergraduates' students of Muhimbili and Dar es Salaam Universities(70.4%), Tanzania [21], for students of Uganda Martyrs University (74%) [42] and for students of Botswana University (65.35%) [43] as indicated by a study published in 2010 and 2012, respectively. These differences may be due to the fact that students of governmentuniversities have greater freedom to practice sexual intercourse compared to private colleges since they live in universities where parents or close relatives cannot have control over them, and where the society in which they grew up cannot see them. About 90 percent of our study participants live with parents or close relatives, and thus it might have not be easy for them to engage in sexual practice (Table 1). This could be the reason why we found that premarital sex was common among those who live alone than those who live together with parents or relatives (Table 2), and this nding is consistent with that of governmental higher institution in Debre Markos Town in Ethiopia [41].
However, it is greater than that of non-medical students of an Iranian university, called a great university of Mashhad (15.1%) [15], female undergraduates inWuhan (8.1%), China [5,18], and students of Dicle University (4.3%) in Turkey [19].This discrepancy could be explained by religious differences. In Iran and Turkey the dominant religion is Islam which does not only forbids premarital sex practice but also punishes the act. In Ethiopia, the predominant religion is Christianity, which forbids but does not punish premarital sexual practice, which may let considerably a large number of adolescents get a gap to practice premarital sexual practices. This same reason may also explain our nding that premarital sex was common among Christians than among Muslims ( Table 2), suggesting that religion and religiosity can play an important role in whether or not adolescent practice premarital sexual intercourse [2,4].
Religiositydifference may also explain our nding of higher prevalence of premarital sex among study participants who attend religious servicesdaily to one or more times per week (16.9%) compared to those who do so occasionally (43.4%) and those who never attend at all (67.7%) ( Table 2), which is consistent with a study done among students governmental higher institution in Debre Markos Town [41].
Our nding that premarital sex is more frequent in males than females is in consistent with studies conducted among students of Robe Technical and Vocational Training College, Wollega University, Haramaya University and Debre Berhan university in Ethiopia [22,25,34,35], among nursing students in Nigeria [20], among non-medical students of a great university of Mashhad in Iran [15], and among students of Dicle University in Turkey [19]. The greater frequency of premarital sex among males compared to females could be for several reasons. Males usually dare to ask females for sex, watch pornography, drink alcohol, participate in night clubs, and care much less about maintaining virginity than females do.
In this study it was found out that premarital sex is common among health students (nursing and public health) compared to business students. Since health students take courses about reproductive health and reproductive organs anatomy, class lessons about this may stimulate students to decide to get involved in more sexual practices compared to business students.
Similarly, the prevalence of premarital sex was found to be higher in degree students compared to level students. The reason for this might be age difference between level students and degree students, and the age categories at which premarital sex is more prevalent. Level students are generally younger than degree students. About 72 % of level students who participated in this study were less than 20 years of age, whereas about 76% degree student whose age was 20 and above took part in this study (p = 0.000). Premarital sex was more prevalent at and above the age of 20 ( Table 2).
The present nding that premarital sex prevailed among non-regular students compared to regular students could be due to being greater or equal to 20 years of age, both of which contribute to having premarital sex. About 80% of non-regular students who participated in this study were aged 20 or above, whilst about one-half of regular students study participant were in this age range (p = 0.000).As mention above, premarital sex was more prevalent at and above the age of 20 (Table 2).
Likewise, our study showed premarital sex was more common among students that have income compared to those who do not have. Getting involved in sexual practice might poseexpenses (travel, hotel, refreshment and other related expenses) which student who have income can afford to pay. Moreover, having income may reduce nancial stress. Therefore in the presence of income and reduced stress student may have increased interest for practicing sexual intercourse.
The nding that premarital sex was more common among those students who completed grade 12 or 10 outside Addis Ababa and its surrounding compared those who completed in and around Addis Ababa may be due that fact that most (84%) of the former group live alone, which endows them with the freedom or privacythat makes it easier for them to have sexual intercourse.In addition to freedom, living alone may reduce hotel and travel expenses that would have otherwise made sexual practice unaffordable.
Our study revealed that the prevalence of premarital sex was higher in those who seduce opposite sex than those who do not. This was expected since the purpose of seducing to stimulate opposite sex to have sex with.
Premarital sex was also found to be more frequent among those who believe that oral contraceptive pills provide protection against STIs including HIV. Because of this wrong belief they might have thought that the can avoid the two major consequences (pregnancy and contraction o STIs) of having premarital sex by taking contraceptive pills.
The nding of the current study that premarital sex was common among alcohol and drug users than non-users is consistent with a similar study conducted among Robe Technical and Vocational Training College, Wollega university, Bahir Dar university and governmental higher institution in Debre Markos in Ethiopia [23,25,35,41], it might be explained by tendencies of people to do sexual intercourse after taking these substances since they can affect decision making of a person.
Our result that premarital sex was more common among those participants who had girl/boy-fried than those who did not have suggests that the purpose establishing girl/boy fried might be to have sexual intercourse.
Our nding that premarital sex is more common among those students who watch pornography than those who do not is in agreement with a similar study conducted among students of Debre Berhan and Bahir Dar Universities [22,23]. The effect of watching pornography on premarital sexual practice is also evident among high school students in Ethiopia [39,40,44]. The most probable reason for higher frequency of premarital sex among pornography watchers is that watching pornography stimulates them to have sex.
In the present study, the majors reasons reported for having premarital sex was fall in love and ful lling sexual desire, and this is in agreement with the nding fromstudents of governmental higher institution in DebreMarkos Town , Ambo University andDebre Tabor University [14,30,41].
In this study the prevalence of early premarital sex (having sex before the age of 18) was 21%, which is lower than that of students of Mizan Aman College of Health Science (57.6%), Asksum university (37.9%), private colleges in Bahir Dar (47.6%), Bahir Dar University (24.3%) and University of Gondar (23.6%) [23,29,[36][37][38]. This might be due to differences in cultural background from which students come. Our nding that early premartital sex was found to be common among boys than girls is consistent with that of Haramaya University students [34].
In the present study 34.1% of study participants reported to have two or more sexual partners which is less than that of students of Aksum According to this study, 61.2% of those study participants who experienced sexual intercourse had ever practiced unprotected sex.This value is similar to that of students of Bahir Dar university (62%) [23], but it is higher than that of students of private colleges in Bahir Dar (38.4%) which also showed that having unprotect sex was association with alcohol intake as it is in our case [36]. In our study, 68.2 % students who practiced premarital sex reported that they did not use condom for the rst sex, and this gure is greater than that of students of Addis Ababa Science and Technology University which is 46% [27]. This difference might be explained by variation in the level of awareness.
In the present study, 17.3% had ever watched pornography. This is lower than the gure reported for students of University of Gondar (55.5%), Bahir Dar University (65.4%) and Debre Berhan University (52.6%) [22,23,38]. In line with these two studies, we also found that watching pornography was common among males than females, suggesting that male students are more interested in sex than female students.
Our study showed that 17.1% students drink alcohol is similar to that of students of Mizan Aman College of Health Science which is 17.2% [37]. This is lower than the value reported for students of DebreTabor university, Debre Berhan university and university of Gondar which was 51.6%, 50.9% and 34.6%, respectively [22,30,38].
The prevalence of self-reported STIS in this study was 1.9%, which is lower than that of students of Godar University in which 18.2% students reported to have STIs [38]. The difference might be due to difference in being careful about avoiding consequences of unprotected sex. About 96% of our study participants knew the consequences of unprotected sex.

Conclusions
The nings of this study show that the prevalence of premartital sex and risky sexual behaviors is high among students of ATHSBC. This study also indicated that many students do care about the HIV status of new sexual partners, and some students have misconception that oral contraceptive pills prevent from STIs. Therefore, effective health education must be provided to college students in order to save them from being victims of unwanted pregrancy and STIs.

Consent for publication
Not applicable.

Availability of data and materials
The datasets on which the current study is based are available from the corresponding author on reasonable request.