Effect of Emergency Contraceptive Pill Use on Condom Utilization Among University Students in Nekemte Town, Western Ethiopia: A Cross-Sectional Study

Background: Emergency contraceptive pill (ECP) is a type of hormonal contraceptives which prevents unplanned pregnancy, but not sexually transmitted infections (STIs). Besides, its impact on condom utilization is not known among female university students in Nekemte town. Thus, this study was aimed to assess the awareness and attitude of university students on the use of ECP and its impact on condom utilization. Methods: An institution-based cross-sectional study was conducted on 400 female students in three private universities in Nekemte town from February 1 to 29, 2016. A simple random sampling, after proportional size allocation to respective study settings, was used to select student participants. Among the 400 randomly selected participants, 381 have completed and returned the questionnaire with 95.25% response rate. Data were collected by using self-administered questionnaire and entered into EpiData 3.1, and analyzed by using SPSS version 20. Bivariate and multivariate analysis were performed to determine the effects of ECP use on condom utilization with statistical signicance set at P-value < 0.05. Results: Nearly half (48.8%) of the students indicated that they had sexual intercourse before and heard of ECP. Moreover, 30% of the respondents reported that they used ECP. Majority (61.7%) showed willingness to use ECP. Furthermore, students who used ECP were 3 times less likely to use condoms when compared to those who never used ECP (AOR = 0.322, 95% CI 0.164, 0.632). Alternatively, students who believed ECP does not prevent STIs were 2 times more likely to use condoms when compared to those who believed ECP does prevent STIs (AOR= 2.217 95% CI 1.070, 4.593). Conclusions: our ndings identied that most students lack knowledge of ECP while having positive attitude on its use. On the other hand, ECP use imposes negative impact on condom utilization so that female students could be exposed to risky STIs.

from drug retails, which also results in its overutilization and use as regular contraceptive among young females. However, ECP does not prevent sexually transmitted infections (STIs) including HIV/AIDS [6,7].
United Nation's AIDS report showed that the HIV/AIDS epidemic has reached at crisis in a number of sub-Saharan countries, where women account for a large number among the infected [7,9]. According to the 2011 Ethiopian Demographic Health Survey, HIV prevalence has been declining in the country (estimated at 1.9% in women and 1.0% in men). The survey also showed that prevalence of HIV/AIDS is being escalated with increase in the number of lifetime sexual partners [10].
Consistent condom use is critical to prevent STIs including HIV/AIDS. But, condom use may decline as relationships and contraceptive needs change [11]. According to the UNAIDS report, the level of condom use among married or cohabiting couples remain very low, regardless of the extent of the HIV/AIDS epidemic [7]. Low level of knowledge about the transmission and prevention of HIV/AIDS among youth was also a predictor of the reduction of condom use. Nonetheless, many studies have shown that youth do not consistently use condoms [7,8,12], which is the best protection method against STIs. Hence, females who use the ECP to prevent pregnancy should also use condoms to protect against STIs. In fact, one study has reported that females who use ECP do not necessarily consider using condoms for preventing STIs [8].
Since none of the contraceptive method is the best alone, it is better to use the combination of contraceptive methods for dual protection against STIs and unintended pregnancy. This dual protection includes the use of condom with ECP and other hormonal contraceptives; and intrauterine contraceptive device (IUCD). Condoms can effectively prevent both STIs and pregnancy if used consistently. But, they are associated with relatively higher pregnancy rates than other contraceptives for most users [13]. A study showed that OTC access to ECP led to an increase in STI rate as a result of an increased willingness to engage in risky sexual behaviors [14].
Even though different modern contraceptives are available in Ethiopia, the problem of unintended pregnancy and STIs still exists, which could be due to gap in knowledge and negative attitudes towards contraception [8]. As none of contraceptive method is 100% effective, ECP should be backed up with condoms. In one of the studies conducted among 368 female college students in Ethiopia, 84.2% had ever heard of ECP, 75% had ever used EC and 32.3% had a positive attitude towards it [15]. In another study among 660 university students 6.4% had history of STIs and 67% had heard about emergency contraceptives pill and 59.2% had positive attitude towards use of ECP [8]. ECP is widely available in Ethiopian major cities and towns where often misused as regular contraceptive pills. Considering the importance of ECP in preventing unintended pregnancy and condoms for dual protection, this study aimed to assess the knowledge, attitude and practice of ECP and to elucidate the relationship between ECP use and condom utilization among female students in private universities found in Nekemte town, Western Ethiopia.

Study settings and period
This study was conducted among female students pursuing their education in three private universities found in Nekemte town: Rift Valley University (RVU), New Generation University (NGU) and Dandi Boru University (DBU) from February 1 to 29, 2016. The town is located at 320 km West of Addis Ababa, the capital of Ethiopia. The universities were teaching students in regular, evening and weekend modalities.
Most of their students come from surrounding zones of the town.

Study design
An institution-based cross sectional study was conducted among female students pursuing their education in three private universities found in Nekemte town.

Study population
The respondents were only selected from the regularly enrolled under-graduate female students in three private universities and most of them were young or less than 30 years of age. We excluded female students who were above 30 years of age or who were post-graduate students.
Sample size and sampling procedure A single proportion formula was used to calculate the sample size. In this case, we took 47% of the prevalence of ECP utilization among young females in Ethiopia [16]. Finally, we determined a minimum target sample size of approximately 400 that would yield acceptable 95% con dence intervals (CI) after taking 5% compensation for non-response rate.
Four hundred (400) female students were allocated to the three universities proportional to the size of female students they had. Accordingly, 207 students from RVU, 120 students from NGU and 73 students from DBU were randomly selected and included. A simple random sampling technique was employed to select samples by using the list of female students as a sampling frame in each university.

Data collection and management
By reviewing different literatures and similar surveys, we developed structured questionnaire in English on the socio-demographic characteristics, sexual and reproductive health characters, knowledge of contraceptive methods, attitude and use of ECP, and condoms. We translated the English version of questionnaire to Afaan Oromo, a language which is spoken by most of the students. The translated questionnaire was cross-checked by an independent language professional and it was pretested on 16 female students, but not included in the nal study. The pretested questionnaire was used solely for triangulation of the study questionnaire and information form; it was not employed for the study. To get high quality of data, we provided a focused training to data collectors for half of a day. We also carried out on site supervision to check the completeness, clarity and accuracy of information.
Data processing and analysis Initially, data were coded and entered into Epi Data version 3.1, and then exported for analysis to Statistical Package for Social Sciences (SPSS for windows version 20.0) software. Descriptive statistics was computed to analyze the socio-demographic, sexual and reproductive health behavior, knowledge and level of ECP and condoms use among the student participants. Bivariate and multivariate analysis techniques were applied to determine the effects of ECP use on condom utilization. A cut off point for signi cance was set at p-value less than 0.05.

Results
Socio-demographic characteristics of the respondents A total of 381 students completed the questionnaires making a response rate of 95.25%. Approximately half (48.5%) of the students were within 20-24 age group. The mean (± SD) age of the students was 20.49 ± 2.506. Nearly ninety percent (87.9%) of the students were Oromo in ethnicity, 59.1% of them were studying in the faculty of business and economics and more than half (57%) were followers of the protestant religion. Almost two third (65.9%) of the students were unmarried and more than half (55.9%) of them were urban dwellers (Table 1). The results revealed that almost half (48.8%) of the students have had sexual intercourse. Out of these students, more than three fourth (81.7%) had their rst sexual experience before or at the age of 20 years and 72 (38.7%) had their rst sexual intercourse with a casual friend. The mean (± SD) age of rst sexual intercourse was 17.02(± 1.53). Among those who had sex, the majority (61.3%) had sexual intercourses with two or more partners whereas 36 (9.4%) of the study participants reported history of STIs. Also, it was reported that desires to have sex 73 (39.2%) was the most common of reasons to have sexual intercourse ( Table 2).  Attitude and utilization of ECP among respondents One hundred fteen (30.2%) students had used ECP prior to this study. On the other hand, majority (61.7%) of the respondents reported willingness to use ECP whenever they need it. Among those who denied willingness to use ECP, their most mentioned reasons were religious prohibition (35.4%) and fear of rumors (28%) among others. Two hundred twenty eight (59.8%) of the respondents revealed that they will recommend ECP use to others (Table 4). Association of ECP with condom use from binary logistic regression Table 5 describes factors associated with condom use. Female students, who used ECP when compared to those who did not use, were 3 times less likely to use condoms (AOR = 0.322, 95% CI 0.164, 0.632). On the other hand, female students who believed that ECP does not prevent STIs were 2 times more likely to use condoms when compared to those who believed ECP does prevent STIs (AOR = 2.217 95% CI 1.070, 4.593) ( Table 5).

Discussion
The aim of the present study was to assess the knowledge, attitude and practice of ECP and to elucidate the associations of ECP use with condom utilization among female students pursuing their education in private universities.
The nding of the present study indicates that almost half of the students (48.8%) had heard about ECP prior to this study. This gure is lower than the reports of studies conducted in the Northwest Ethiopia 67.1% [8], Mizan-Tepi University 67.8% [17], Jima technical college 80.1% [5] and Addis Ababa University 84.2% [15]. However, it is higher than the ndings reported from studies conducted in Addis Ababa 43.5% [18] and Jima 41.9% [19]. These discrepancies might be associated with socio-cultural differences, availability and accessibility of sources of information and level of urbanization within towns where studies were conducted. However, the nding is consistent with reports of a study conducted in South Africa, which was 49.8% [3].
The nding also revealed that more than half of the students know correct time of taking ECP after unprotected sexual intercourse. This gure is higher than the ndings reported in studies from Addis Ababa, Jima and South west part of Ethiopia [5,18,19]. Also, we found that the respondents had positive attitudes toward ECP use as the majority (61.7%) showed willingness to and about 59.8% pledged to recommend to friends. Similar ndings were reported by Wassie et al., [8] and Naidoo et al., [1].
The present study indicated that almost half (48.8%) of the students have had sexual intercourse before. This gure is higher than reports of similar studies conducted in Addis Ababa 19.5% [18], Northwest part of Ethiopia 16.5% [8] and Ghana 38% [20]. This may be associated with the extent of convincing the respondents to disclose the sensitive issues. However, the result is consistent with ndings of studies conducted in Kenya and South Africa, which reported 47.7% and 53.2% among university students respectively [3,21]. Among those who ever had sex, the majority (61.3%) had sexual intercourse with ≥ 2 partners. This nding is higher than Ethiopian demographic health survey report [22] and study conducted in the Northwest part of Ethiopia [8]. This discrepancy may be due to the residence of students as they were living with large communities in the present study.
The study indicated that one hundred fteen respondents had used ECP before giving 30.2% overall prevalence of ECP use among young female students. This gure is higher than that of a study by Meskerem et al. [23] which reported 9.7% in Dire Dawa. But, higher than the study conducted by Ahmed et al. [15] in Addis Ababa University which was 75%. This discrepancy might be due to difference in the socioeconomic characteristics of study populations and the extent of town modernization and availability of ECP in the towns.
Moreover, our ndings suggested that ECP utilization has negative impact on condom use. This supports the previous ndings which showed consistent ECP users do not necessarily consider using condoms for STIs prevention [7,11,24]. On the other hand, the respondents who believed that ECP does not prevent fourth of the students believed that ECP can prevent STI. This misbelief on ECP use lead to commit unprotected sexual intercourses. In this case, the students do not consistently take the necessary precautions to protect STIs; instead they focus primarily on preventing pregnancy [8,25,26]. To contain escalating STIs including HIV/AIDS and unwanted pregnancy, dual protections (condoms with other contraceptives) should be used [5,8,14,27].

Limitations
This study is not free of limitations. First, it was conducted only in three private universities found in Nekemte town, Western Ethiopia. Thus the ndings cannot be generalized to ECP users in the country. Second, the study might not be free of bias during data collection as it involves a sensitive issue (sexual intercourse). A cross-sectional design was also limited in evaluating cause-effect relationships.
Nonetheless, this study is the rst of its kind to look at effect of ECP on condom use among female students in Western Ethiopia.

Conclusions
We conclude, based on the study ndings, that young female students in private universities in Nekemte town have moderate knowledge and positive attitudes on ECP use. While ECP is commonly practiced contraceptive method among students, our ndings suggest that ECP use has imposed negative impact on condom utilization. Further prospective studies should be conducted in order to devise policy and strategies to promote dual contraception use among young female students which in turn can diminish prevalence of STIs.