Assessment of Level of HIV/AIDS Preventive Self-Ecacy and Associated Factors Among Regular Undergraduate Students of Madda Walabu University, Southeast Ethiopia, 2020. A Cross-Sectional Study

Background: Self-ecacy for HIV prevention is described as a person’s belief in his/her capacity to carry out necessary actions to perform a specic behavior for HIV prevention. This study aimed to assess level of HIV/AIDS preventive self-ecacy and associated factors among regular undergraduate students of Madda Walabu University, Southeast Ethiopia, 2020. Methods: Cross-sectional study was conducted from February 15 to 20, 2020. Four hundred forty-two study participants were selected using simple random sampling technique. Data was entered to Epi Data version 4.6.0.2 and analyzed using SPSS version 26 software. Bivariate and multivariable logistic regression model was tted to identify factors associated with HIV/AIDS preventive self-ecacy. Odds ratio with 95% condence interval was computed and p value less than 0.05 was used to determine the level of signicance. Result: The mean level of HIV/AIDS preventive self-ecacy among regular undergraduate students of Madda Walabu University was found to be 74.58+19.98. Being female [AOR=1.76(1.04-2.81)], in eld of health science [AOR= 1.92(1.10-3.36)], second year of study [AOR=2.77(1.55-4.94)] and drinking alcohol [AOR=2.9(1.61- 5.23)] were found to be factors associated with higher HIV/AIDS preventive self-ecacy. Whereas, exposed to pornography [AOR=0.53(0.33-0.85)] was found to be factor associated with lower HIV/AIDS preventive self-ecacy. Conclusion: The mean HIV /AIDS preventive self-ecacy of the participants in study area were found to be low. Sex, eld and year of study, and ever watched were factors signicantly

Self-e cacy concept derived from Bandura's social-cognitive theory, considers individual's insights of their own capabilities to play a key role in changing their behaviors, motivations and experiences (1) . It is one of the crucial components in learning effective behavior for dealing with AIDS crisis since many students engage in high risk sexual behavior even if they are aware of the risks. Enhancing self-e cacy for reducing HIV/AIDS-related risk behaviors is a critical element for HIV preventive programs among adolescence (2) . Therefore, self-e cacy for HIV prevention is described as a person's belief in his/her capacity to carry out necessary actions to perform a speci c behavior for HIV prevention. It is being strongest predictors for HIV prevention (3) .
In 2018, 510,000 adolescents below the age of 24 were newly infected with HIV worldwide and projected to rise from 250,000 in 2015 to nearly 400,000 annually by 2030 if progress in reaching adolescents stalls (4) . In Sub-Saharan Africa these case seems serious which 89% of HIV cases were adolescents and girls being newly infected at four times the rate of adolescent boys (5) . In Ethiopia 30% of university students, both male and female, were sexually active and they were at risk of complications related to unsafe sex such us STI including HIV and abortion (6) .
University students are very mobile group, and if not protected and preserved from the scourge of HIV and AIDS, they can become dispersal agents for the spread of HIV in society (7) . They are at higher risk of engaging in risky sexual behavior, especially if they are under the in uence of alcohol or drugs and lack the necessary maturity in handling negative peer pressure (8) .
Students with lower self-e cacy have less control over their lives and are more likely to be subjected to highrisk behaviors. In sum, low self-e cacy of the students can destroy their motivation, interfere with cognitive abilities and increase the possibility of high-risk behaviors and vulnerability for HIV infection (9) . For instance the study found students with low condom e cacy had a higher risk of inconsistent condom use with a new sex partner (10) .
According to study conducted on Mexican adolescence the level of HIV/AIDS preventive self-e cacy was found to be 95.14(SD ± 25.80) (11) . Other study conducted on Turkey university students showed that the mean level of HIV/AIDS preventive self-e cacy was 87.66 (SD ± 23.94) (12) and further study conducted on Tawenness adolescence reported the mean level of 74.45(SD ± 17.05) (13) .
In Ethiopian universities, students were reported to be engaged in different risk activities which facilitate the infection to increase. For instance in Debre Berhan University, (25.13%) students have at least one risky sexual behavior in their lifetime in which cigarette smoking and pornography exposure shows signi cant association with risky sexual behavior (14) and in Bahir Dar University, having sex after alcohol drinking and khat chewing ,watching pornography and inconsistent use of condom were the risk factors for HIV infection (15) . In addition, a qualitative study carried out in higher educational institution of Ethiopia revealed that substance abuse and addictions, early initiation of sex, and exposure to pornography were reported as a problem for the increase HIV infection (16) . Furthermore, other study found that characteristics of university students like; their age, ambition, experience of new events (17) , and other contextual driving factors, increase their exposure to HIV/ AIDS (18) .
Hence, keeping in mind high-risk behaviors of university students and their potential risk for all society, assessing their preventive self-e cacy regarding HIV/AIDS may be helpful in identifying their potential ability to engage in risk reduction behaviors. However, no study was found on HIV/AIDS preventive self-e cacy in Ethiopia in general and in the study area particularly. Thus, this study was aimed to assess level of HIV preventive self -e cacy and associated factors among undergraduate regular students at the study area.

Study settings
An institutional cross-sectional study design was conducted among undergraduate regular students of Madda Walabu University from February 15 to 20, 2020. The university was established in 2006. According to the data obtained from the registrar record o ce in 2020, the university had three campuses namely Robe, Goba and Shashamane. In 2020, the university had a total number of 9253 regular undergraduate students with 50 undergraduate programs, eight schools, one institute and two colleges of health sciences (19) . All regular undergraduate students at Madda Walabu University were source population, whereas randomly selected voluntary students who attended class at data collection period were study population.
Sample size determination and Sampling procedure Sample size was calculated using sample size for single population proportion formula. After exhaustive searching, the principal investigator was not found study done previously on university students regarding HIV preventive self-e cacy either in Ethiopia or study area. Therefore, the assumption of, 50% proportion, 95% CI and 5% degree of precision was used to calculate the sample size. After adding 15% non-response rate, the nal sample size was found to be 442. From the total eight schools in Robe campus, six schools were selected randomly and Goba and Shashamane Collage of Health Sciences were included. Sample size was allocated proportionally for each schools and colleges. The total number of students under selected schools and collages were 5680. The students were strati ed for selected schools in Robe Campus and both collages of health sciences. Then students were further strati ed in class years. Finally, simple random sampling was implemented using students list obtained from registrar as sampling frame.

Data Collection Procedure and Instrument
Data was collected through self administered questionnaire prepared in English language, since language of instruction in Ethiopian higher inistitutions is Eglish. Four diploma nurses were asigned as data collectors and three Bsc instructors with previouse research experience were assigned as supervisors.
To examine HIV preventive self-e cacy among students, the Self-E cacy scale for AIDS (SEA-27) AIDS-Prevention Self-e cacy scale was used. The scale has 27 ve-point Likert scale consisting, 1 = "not at all sure", 2 = "a little sure", 3 = "somewhat sure", 4 = "pretty sure" and 5 = "Very sure". It evaluates self-e cacy with the Bandura's socio-cognitive theory, in three aspects of sex-related behavior: ability to say no to sexual intercourse under different circumstances, ability to ask partner about previous sexual relations and other risk behaviors such as drug use and perceived ability to acquire and correctly use condoms (12) .
Initially Kasen, Vaughan & Walter developed scale with 22 items as measuring HIV/AIDS preventive selfe cacy among adolescents between ages 15 and 19; in that study the internal consistency of this scale was high (α = .91) (20) . The scale was tested again on a large sample group of high school students and some items of the scale were modi ed, and the number of items was increased from 22 to 27. Internal consistency of the 27-item self-e cacy scale was found to be 0.89 in study done on Mexican Youth (11) . In this study, the last version of the Self-E cacy scale for AIDS (SEA-27) tested on Turkey University Students and reported with internal consistency of 0.93 was used (12) . Yet; one question which asks about homosexual was excluded in Ethiopian context. Students who has scored above mean value will be considered as having good preventive self-e cacy.
Believes assessment tool was developed from literatures pertinent to the topics (21) (22) . In addition, the tool for assessing risk behavior was adopted from literature reviewed pertinent to the topic (23) (17) and from standard questionnaires designed by Family Health International for Behavioral Surveillance Survey(BSS) on high-risk behavior for HIV-1 (24) . Level of HIV/AIDS knowledge was assessed using HIV Knowledge Questionnaire (HIV-KQ) with internal consistency reliability analysis of HIV-KQ (N = 1033) (α = .91) (25) and internal consistency reliability as measured by Kuder-Richardson formula(KR-20) (α = 0.58) (n = 483) and test-retest 0.59(n = 39) (26) .
Students who scored above mean score will be considered as having good knowledge.

Data quality assurance
Pretest was done in 5% of the sample size in non-selected department of Madda Walabu University, in order to check the clarity of the tool and allocate time needed for lling the questionnaires. Training was provided for data collectors and supervisors. Through the course of data collection, the data collectors were supervised and there was regular phone contact between principal investigator and data collectors to know the data collection progress. Incomplete data were discarded and considered as non-response. The data was said to be incomplete when half of the items in each section were not lled. Therefore, twelve questionnaires were discarded based on this criterion. Finally, the collected data was reviewed and checked for full completeness before data entry.

Data processing and Analysis
The data was coded and entered to Epi Data 4.6.0.2. Then exported to SPSS version 26 and cleaned before analysis. Descriptive statistics was calculated for the variables. Statistical signi cance and strength of the association between independent variables and outcome variables was measured by using logistics regression model. A variable P value less than 0.2 and important variable was transferred to multivariable logistics regression model to adjust confounder's effects. A p value less than 0.05 were considered as signi cantly associated. Crude and adjusted odds ratios with their 95% con dences intervals was calculated. Finally, the result of the study was presented using tables, graph, chart and texts based on the data obtained.

Result
In this study, 442 students were approached and a total 430 responded fully yielding response rate of 97.3% whereas the remaining 2.7% non-responses were due to incomplete data.
Of 160(37.2%) sexually active participants, only 30(7%) of them used condom in their rst sexual contact. The mean ages at rst sexual intercourse of the participants were 18.21 (SD 2.113), in which it was 18.55 (SD 2.11) for males and 17.28 (SD 1.89) for females. Regarding sexual partners, 42(9.8%) participants ever had more than two sexual partners in their lifetime's and 11(2.6%) had more than two current sexual partners. Among participants ever had sexual intercourse, 23(5.3%) reported having sex while drinking alcohol and 13(3.0%) had sex while using psychoactive drugs (Table 4).     Fig. 3 shows, after computing the variables and categorized the level of prevention, more than half 220(51%) of the participants found to had good level of HIV/AIDS preventive self-e cacy which scored greater or equal to mean value and 210(49%) participants were found to had poor level of HIV/AIDS preventive self-e cacy ( Fig. 3).
Factors associated with preventive self-e cacy   (13 ), however the nding was lower than the study conducted in Turkey on 507 University students 87.66(SD ± 23.94) (12) and study conducted on 962 Mexican adolescents from 60 public health centers 95.14(SD ± 25.80) (11) .
The possible reason for the discrepancies in HIV/AIDS preventive self-e cacy may be due to difference in the study place. Further reason may be data about adolescents collected from high school students and public This study reported (51.4%) of respondents were knowledgeable about HIV/AIDS. This nding was higher than study conducted on Bahir Dar university(45.7%) (21) and study conducted on Maddawalabu University(49.37%) (27) . However, it was lower than study conducted on undergraduate students of Addis Ababa University (66%) (28) . The difference in the nding may be due to difference in sample size and study period.
Of total respondents in the study area, 160(37.2%) participants were found to be sexually active. This nding was lower than study conducted in Turkey University (52.7%) (12) and Wollega University, Ethiopia(49.1%) (17) .
The mean age of sexual debut of the participants in the study area was 18.21 ± 2.11 in which it was higher for males (18.55 ± 2.11) than for females (17.28 ± 1.89). The nding was higher than study conducted in Turkey University (17.8 ± 1.98 ) in which it was 17.6 ± 2.00 years for males and 19.0 ± 1.35 years for females (12) and related study conducted in Wollega University (17.2 ± 2.15) in which it was 17.5(± 2.21) and 16.9(± 3.10) years for males and females respectively (17) and students of Addis Ababa university 17.4 years (28) . The discrepancies may be due to difference in study place and period. The other reason may be difference in sociocharacteristics and behavior of the students in this different campus.
Among socio-demographic characteristics sex was found to be signi cantly associated with HIV/AIDS Preventive self-e cacy. According to this study, females were 1.76 more likely to had higher HIV/AIDS preventive self-e cacy when compared to males. In this study the mean HIV/AIDS Preventive self-e cacy was 71. 38 ± 18.01 and 81.21 ± 22.18 for males and females respectively. This is consistent with the study conducted in Turkey University (12) and among Taiwanese adolescents (13) . The reason may be due to female's precaution on sexual intercourse and fearing of suffer from the complication after sexual intercourse. The other reason may be due to family support for females, in which most of the time females were oriented on sexual issues than males due to the family considered them as victim. In the study area there was a restriction of female student's movement due to unsupported from communities' custom. However, male students were free for movements and involved in activities out of the campus. Therefore, this may be the reason for the difference in HIV/AIDS preventive self-e cacy between males and females in this study area.
This study revealed that eld of study was signi cantly associated with HIV/AIDS Preventive self-e cacy. In this study health science students were almost 2 times more likely to have higher HIV/AIDS preventive selfe cacy when compared to non-health science students. The nding was consistent with study done in university of Turkey (12) . The probable reason may be health science students were more informed about reproductive health and they could get HIV/AIDS education in their course. The other reason maybe they had course like family planning which supports them to use condom in consistent way than non-health students.
This study found drinking alcohol was associated with higher HIV/AIDS preventive self-e cacy. The nding was inconsistent with study conducted on Taiwanese adolescence (13) . Literatures showed there were association between substance use and risks for acquiring HIV/AIDS infection (30)(16) (15) .The reason may be substance user's inability to controlling their emotion after utilization of the substances. However, in this study area participants who were drinking alcohol had 2.9 times more likely had higher HIV/AIDS preventive selfe cacy compared to those who were not drinking. The probable reason may be participants who drinking alcohol may not fear for talking about sexual issues freely before having the sexual intercourse with their counterpart than who were shying to talk about the sexual and related issues but involved in practice.
The study found that there was signi cant association between exposure to pornography and HIV/AIDS preventive self-e cacy. Participants who had ever watched pornography were 0.53 times less likely to have higher HIV/AIDS preventive self-e cacy compared to who were not ever had watched. Exposure to pornography may be the risk for infection increase. This idea is supported by study conducted on Debre Berhan University in which pornography exposure shows signi cant association with risky sexual behavior (14) and qualitative study carried out in higher educational institution of Ethiopia were reported exposure to pornography as a problem for the infection increases (16) . The reason may be increasement in internal motivation of the students towards sexual intercourse after watching the pornography which push them unintentionally to be involved in sexual activities. The other may be just due to their age, adding pornography on their re age will put them in risk for this infection. Therefore, exposure to pornography was associated with HIV/AIDS preventive self-e cacy and risk for infection increase.

Conclusion And Recommendations
The mean HIV /AIDS preventive self-e cacy of the participants in this study area were found to be low.
Variables like sex, eld of study, year of study, drinking alcohols and ever had watched pornography were found to be factors associated with HIV/AIDS preventive self-e cacy. The study found more than half of the participants (51.4%) were knowledgeable about HIV/AIDS. However, the nding showed signi cant number of participants involved in risk taking behavior. Availability of data and materials: The data set analyzed during the current study will be available from the corresponding author on reasonable request.

Ethical consideration
Ethical approval was obtained from the ethical review committee of Department of Midwifery, school of Nursing and Midwifery Institutional Review Board, Addis Ababa University. Permission was obtained from of Madda Walabu University management and respective schools. Voluntary written consent was obtained from each study participants. To protect students' con dentiality and increase chances of releasing honest information, questionnaires was kept anonymous and class was designed as students were never read over others' shoulder.

Consent for publication
Not applicable.