Risky Sexual Behavior and Associated Factors among Street Youth Age (10-24years) in Dilla Town Gedeo Zone South Ethiopia 2024 G.C.

Background: Street youth are exposed to situations that make them vulnerable to sexual and reproductive health problems. The majority of street youth are living in conditions of severe deprivation, which place them at all kinds of health risks. Street youth have risky sexual behaviors that increase the likelihood of adverse sexual and reproductive health consequences.

Objectives and methods: A cross sectional survey were conducted among 275 street youth with key informant interview to assess risky sexual behavior and associated factors of street youth in Dilla Town. The total number of street youth in the town was determined to be 784 after conducting census for two days. The study subjects were identified by using systematic sampling from the sampling frame. Data was collected using structured pre tested questionnaire, data was entered in to EPI DATA version 3.1 and then exported in to SPSS version 20 for analysis. Bivariate and Multivariate logistic regression were used to identify independent predictors of risky sexual behavior. A P-value <0.05 was declared as statistically significant. For qualitative data, 5 key informant interviews were conducted.

Results: Majority, 56.1%, of the respondents ever had sexual intercourse with the mean age of 15.5 years. Risky sexual behavior (sexual intercourse earlier than 18 years, more than one sexual partner inconsistent use of condoms, sex with commercial sex workers) was associated with being female (AOR =6.70, 95% CI (1.09-15.38), more than one year on the street (AOR=3.99, 95% CI (1.67- 10.6), educational status being primery level (AOR=5.30, 95%CI (1.41-19.91), sexual intercourse in the past 12 month (curently sexualy active) (AOR=.00,95%CI (.00-.022). Among sexually active study participants, eighty-nine-point seven percent of started sexual intercourse earlier than 18 years of age.54.3% of the respondents have more than one sexual partner and the mean lifetime number of sexual partners was 2.06. Among sexually active street youth, 52.3 % had ever used condom. Consistent use of condoms was found to be low, 13.5%. Out of those who are currently sexually active males 25.8% reported having had sexual intercourse with commercial sex workers in the past 12 months.

Conclusion: It was concluded that significant number of street youth engages in high-risk sexual practices. This fact calls for a coordinated and comprehensive effort by responsible organizations to mobilize peer-based interventions to bring behavioral change in reducing risky sexual practices.

Keywords: risky sexual behavior, street youth

Background

More than half of the world’s population is below the age of 25, and four out of five young people live in developing countries. Sub-Saharan Africa has one of the world’s youngest populations. In Ethiopia, the sexual and reproductive health of young people has become a major public concern due to a high prevalence of STIs like HIV/AIDS among young people. It is estimated that young people age10-24 years constitute more than a third of the population, 26.5 million (33%) [1].

Estimating numbers of ‘street children’ is fraught with difficulties. The exact number of street children is impossible to quantify, but the figure almost certainly runs into tens of millions across the world which shows that the numbers are in increasing trend [2].

Ethiopia is one of the countries where child with street life is high. The extent and nature of street children is one of the most serious social problems in urban areas of Ethiopia and become a countrywide problem today [3]. Thus, there are a large number of children live and/or work on the streets of different cities of the country. According to IRIN (2004) report revealed that there are about 150,000 children living and/or working on the streets of Ethiopian cities [4]. However, different non-governmental organizations estimated that the problem is far worse, with nearly 600,000 street children and 100,000 of these in Addis Ababa [3].

Even though there is no published data, various reports from zonal Labor and Social Affairs Division indicate a rapid increase of street children in many parts of Southern Nation, Nationalities and Peoples’ Region Hawassa, Wolkete, Dilla and Wollayta Soddo are the major towns of the region encountering a growing number of street children [4].

Street children live and work in conditions that are not conducive for healthy development. They are exposed to the street subculture such as smoking, drug, alcohol and substance abuse, gambling, engaging in sexual activities, or selling sex for survival [5].

Street youth are exposed to situations that make them vulnerable to sexual and reproductive health problems on a day-to-day basis. A risky sexual behavior is one that increases the likelihood of adverse sexual and reproductive health consequences [6].

Risk sexual behavior is a behavior related to sexuality which increases the susceptibility of an individual to problems related to sexuality and reproductive health like sexually transmitted disease (STIs), human immune deficiency virus (HIV), unwanted and unplanned pregnancy, abortion, and psychological distress [7]. Risk behavior includes having more than one sexual partner, early sexual initiation, inconsistent use of condom, and having sex with commercial sex workers [8].

Statement of the problem

The problem of street children is becoming a worldwide phenomenon since these children exist in every part of the world. The vast majorities of these children work and live in large urban areas of developing countries [9].

Globally, street children’s behaviors include activities known to be high risk for contracting STIs and unintended pregnancy. Several studies that exist on the sexual behaviors of street children show that these children engage in behaviors that put them at risk of sexually transmitted infections [10].

Available data shows that HIV sero-prevalence rates for street children are 10-25 times higher than non-street children. This is because street children are reported to become sexually active earlier than the other groups of children. They engage in sex with many sexual partners and are likely to be raped or forced into sexual relationships to ensure their survival. They use condoms inconsistently and get inadequate information about sexuality [6].

A study conducted in Addis Ababa shows that the prevalence of rape among female street children was 15.6%which is higher than high school students and most of them started sexual intercourse as a result of rape [6].

There is evidence that these children engage in sexual activity either in exchange for money or seeking protection and sometimes either by being forced [11] One of the similar studies by Sharma depicts that street children both at pre-puberty and puberty indulge in unsafe sexual activity not only with the opposite sex but also with the same sex and mostly elder boys forcibly indulge in anal sex with the younger boys [12].

Similar studies also support that street children, (mainly boys) prefer homosexual relations and practice anal sex with fellow boys as boys are easily available [13]. It was however suggested that street children are high risk group to STIs, HIV and unwanted pregnancy. Exposure to high-risk sexual behaviors increases their vulnerability to HIV and STIs. Studies by USAID (2008) and Southon & Gurung (2006) stated that street children in Nepal were among the most vulnerable groups at risk of HIV infection. Southon & Gurung’s study reported that 10-30% of street children were HIV positive, and that 30-40% of them were using drugs [14].

A study conducted by (Tadesse N, Ayele TA, Mengesha ZB, Alene KA) on street youth in Ethiopia revealed that 62% of their sample were sexually active and 97% of the sexually active had multiple sexual partners [11]. The same study further showed that 80.5% of the street youth used condoms inconsistently [11].

Different interventions have been established to support and fulfill the needs of street children.  The focuses of these interventions usually differ from one another.  Some of them focus on delivering basic services, others on providing health care or educational services, and some others on promoting and protecting the human rights of these children [15].

Almost all studies conducted so far in Ethiopia in the area of sexuality and HIV/AIDS are among high school and college students. Though there are very limited number of studies conducted based on out school adolescents and street children, most were carried out in bigger urban centers [6]. To date, little is known about the sexuality of out of school (street children and youth), in general the risky sexual behavior of this group. Therefore, this study is expected to give insight into the risky sexual behavior and associated factors of street children and will generate relevant information that could help to design appropriate reproductive health programs for this disadvantaged segment of the population.

 Significance of the study

The Significance of this study is that, there is little data concerning risky sexual behavior of street children in Dilla Town though risky sexual behavior is an emerging public health problem. And also, as far as my knowledge and searching effort, no study was conducted on risky sexual behavior and associated factor among street children in Dilla town.

Understanding the risky sexual behavior of street children and identifying its associated factors would assist policy makers and program planners, implementers to make evidence-based decisions about how best to direct program activities and maximize positive outcomes for children. The study findings would help government, non-government organizations and others to design better strategy to improve the reproductive health of street children. This study would also help to suggest concrete preemptive measures to reduce vulnerabilities of street children to risky sexual practice, exploitation and thereby reduce STI and HIV/AIDS.

Magnitude of risky sexual behaviors among youth

Globally, it is estimated that 5.4 million young people aged 15 to 24 are living with HIV; 3.2 million reside in sub-Saharan Africa (SSA). In fact, in SSA the youth lack access to HIV prevention education programs, with only 8 per cent of out of school youth having access such programs. This indicates that out-of-school youth are more at risk of getting HIV infection due to lack of access to HIV prevention programs [16].

A study conducted in Adiss Ababa among street children showed that most participants (72.5%) were already sexually active, and 67.6% have had multiple sexual partners. Among sexually active children 90.4% were girls and 66.2% were boys. The mean and median ages of first sexual intercourse in this study were (15.4 and 15 years) for boys and (14.3 and 14 years) for girls. The reasons for early initiation of sexual intercourse among street children were also explained in this study. More than two-fifth (42.7%) of sexually active street children mentioned personal desire as the main reason for initiation of sex followed by love 34.4%. In this study, high proportion 284 (67.3%) of street children reported that they consumed some kind of substance. Chat was the dominant substance used by almost all 95.1% children. cigarette, ganja and shisha were reported as commonly used substance [9].

Study done in Dessie town on reproductive health behavior and needs of street youth reported that 67.9% of the respondents claimed to have practiced sexual intercourse, the mean age at sexual debut among respondents was found to be 15.2(SD ±1.51).in this study significant proportion, 80.6%, of respondents had reported that they had more than one lifetime sexual partners and the mean lifetime number of sexual partners was 4.85. Among the sexually active respondents, 172 (73.8%) had ever used condom. Consistent condom use was low; only 37(22.8%) reported consistent use of condoms during sexual intercourse in the last 12 months. This result found out that 41.0% of male study subjects reported having had sexual intercourse with commercial sex workers in the past 12 months [6].

Another study conducted on the effect of youth centers on reduction of risky sexual behaviors among youth in Addis Ababa reported that the overall prevalence of risky sexual behavior was 43.1% and the prevalence of risky sexual behavior among users and non-users were 38.5% and 47.7% respectively. In this study almost half, 48% of the respondents ever had sexual intercourse. The mean age of the respondents having sexual intercourse for the first time were 18.56 years Moreover, in this study 37% of the respondents had started sexual intercourse before the age of 18 years. According to this study, 17% of the sexually active youth ever had sexual intercourse with commercial sex workers [17].

The reproductive health behavior of street youth and associated factors were studied in Gondar. Among sexually active study participants, 65.9% started sexual intercourse earlier than 18 years of age. Of youth who had been sexually active, 62.4% had more than one lifetime sexual partner and the mean number of sexual partners for them were 3.15 ± 4.5. In this study (40.6%) sexually active males reported having had sexual intercourse with sex workers in the past 12 months. Of the sexually active youth, 46.1% reported consistent use of condoms in the last 12month [1].

This study done on sexual behavior, exploitation and its determinants among orphan and vulnerable children in addis ababa, showed that, 27.5% of orphan children were engaged in early sexual intercourse., Participants who were under the influence of alcohol were about 1.5 and 2 times more at risky sexual behavior compared to their counterparts. The proportion of condom use at regular sexual inters-course was low for both males and females with more males (14.6%) using condoms compared to females (11%). Among males, the most common reason given for not using condoms was the perception that there was no risk of HIV infection (30.7%) and7.5% indicated that their partner did not want to use condoms [18].

A study conducted in Tanzania on high-risk sexual behavior among youth reported that among the study participants who had sexual intercourse 84.4% started sexual intercourse below the age of 18years, 45.6% of them having two and more than two sexual partners and 58.9% of them never used condom during sexual intercourse due to trust on sexual partner and the mean age at first sexual intercourse was 14.61±2.89 SD for male and 15.74±2.165 SD years for females [27].

A study conducted among high school students in Gurage zone Agena woreda showed that About 108(25.8%) of the total participants reported as they had sexual intercourse in their life time and out of whom about 72(66.7%) were sexually active during the last one year. The overall condom use at first sexual debut was only 43(39.8%). Out of 108 sexually practiced in their life time, 58(53.7%) have committed multiple sexual practice. Out of those who committed multiple sexual intercourse, 26(24%) reported persistent condom use. Out of 70 male students who had sexual practiced before, about 20(28.6%) of them had sexual intercourse with commercial sex workers in their life time [19].

Factors associated with risky sexual behaviors

A study conducted among in-school youths of shendi town in west Gojjam showed that almost half of youths claimed that the main reason for initiation of first sexual intercourse was falling in love. In addition to this most of them didn’t use or use condom inconsistently due to trusting partner, a shamed to ask partner to use, fear to buy from shops or pharmacies and reduce sexual pleasure. It was supported qualitatively that majority of the focus group discussants didn’t consider the use of condom as an acceptable means of prevention because of perceived reduction in sexual pleasure [20].

A study conducted among university students in Kenya showed that socio-economic factors, negative beliefs towards condom use, inadequate information about risk reduction, condom inaccessibility and perceived benefit of condom use were the determinant factors for risky sexual behaviors [21].

The main reasons for early sexual initiation among youth were sexual desire and boy/girlfriend’s pressure. On the other hand, youth free from family control, substance use, peer pressure and existence of night clubs and video houses were the determinant factors for having risky sexual behaviors. In addition to this current substance users were about 3 times more likely to ever had sexual intercourse as compared to non-users (OR=3.03; 95% CI: 2.00, 4.59) [21].

A study conducted among female youth in Tiss Abay showed that respondents had risky sexual behavior such as having sex without using condom. Refusal of sexual partners to use condom, low perceived benefit of using condom by the respondents, inaccessibility and cost of condoms were the main reasons for these risky sexual behaviors [22].

Peer pressure is the prime driver of risky sexual behaviors among school adolescents in Addis Ababa. Respondents were likely to experience risky sexual behavior if they had low knowledge of STIs and/ or unwanted pregnancy, reported low self-esteem and manifested low perceived efficacy to use condom. Parental control was significantly associated with risky sexual behavior. Restrictive parental norms towards sex were a protective from risky sexual behavior [AOR = 0.77 (95%CI: 0.61 – 0.99]] [9].

Increased use of Khat among youth is associated with unprotected sex. A majority of the key informants interviewed expressed concern regarding the increased use of Khat by young people. In particular, they talked about the chain of events that commonly accompanies use of the drug. Adults and youth alike mentioned that frequent Khat -chewing often leads to increased alcohol use, which ultimately leads to young people having unprotected sex [16].

Study conducted on Ghanaian youth indicates that, all the substance use measures were independently associated with the number of sexual partners such that if an adolescent smokes, he/she had 8 and 16 folds the chances of having a sexual partner or multiple sexual partners, respectively, compared to a non-smoker. Tobacco users had higher likelihood to have a sexual partner or multiple sexual partners. In like manner, those who were often drunk had nearly 2 folds the likelihood of having a sexual partner and 3 folds the likelihood of having multiple sexual partners compared to their colleagues who never got drunk or did so less often [23,24].

Risky Sexual Activities:

Commercial Sex/Survival Sex/Prostitution

It has been estimated that 25% of Ethiopia’s street children are girls and there is indisputable evidence that street girls in Ethiopia are often obliged to take on commercial sex work for survival. Unfortunately, recent information on the number of street girls engaged in it is lacking [9]. One of the studies done in Addis Ababa showed that a significant number, 69.6%, of the study subjects (who were commercial sex workers) were between the ages of 13 and 15 years [9].

Unprotected Sexual Intercourse

Unprotected sex is common among street children. This could result in a variety of sexual and reproductive health problems. Street children spend a lot of time in settings where casual sexual encounters occur (bar or “crack houses”) [9]. Their risk of acquiring blood borne diseases and STDs such as HIV, syphilis, and hepatitis is increased by the fact that they often have sex with persons at high risk for these diseases like people with multiple sexual partners or those sharing injection equipment for substances [13]. Research results highlight the critical need for sexual and reproductive health programs for street children. For example, a study in Hawassa showed that, Among the 280 respondents who practiced sex, 216 (77.1%) did not use any of the modern methods of contraception [4].

Conceptual Frame Work

Figure 1. Conceptual frame work of the study (NURU, FEBRUARY, 2018).

General Objective

To assess the magnitude and associated factors of risky sexual behavior among street youth (10-24yrs) in Dilla town Gedeo zone South Ethiopia (2024).

Specific Objectives

To assess the magnitude of risky sexual behavior among street youth (10-24yrs) in Dilla town Gedeo zone South Ethiopia (2024).

To identify associated factor of risky sexual behavior among street youth (10-24yrs) in Dilla town Gedeo zone South Ethiopia (2024).

Study area and study period

The study was conducted in Dilla Town, Gedeo zone SNNPR which is located from 360km from Addis Ababa, the capital city of Ethiopia, 90 km from the capital city of SNNPR (Hawasa). According to the new structural arrangement the town is divided into three sub cities and nine kebeles. The total population of the town is 111,314 out of which 56,770 (51%) are males and 54,543 (49%) are females and youth live in the street of the city is 784 (by conducting survey)

The study was carried out from March 19- May 13/2023.

Study design

Community based cross-sectional study design supplemented by qualitative study was employed.

Population:

Source population

All street youth age 10-24 yrs residing in Dilla town, for the quantitative part stakeholders from zonal labor and social affair, police station, city administration, women and child affair and community members was source population for qualitative study.

Study population

Street youth age 10-24yrs who have resided in Dilla town for at least six months.

For the qualitative study members from zonal labor and social affair, police station, city administration and women and child affair and community members were involved.

Eligibility criteria:

Inclusion criteria

Street children age group between 10-24yrs.

Exclusion Criteria

Those who were seriously ill

All street youth who are unable to hear

Sample Size Determination:

The sample size (n) was determined using Epi Info version 7 statistical package with the following assumptions: 70% expected prevalence [11] 95% CI: a 5% margin of error (d= 0.05) the required sample size was =323 then the total source population in the town is 784 which is<10000 then, the required sample was obtained from the above estimate by making some adjustments for finite population correction formula.

n=323/ (1+(323/1103)) =250

Adding 10% non-respondent, the final sample size becomes= 275

Where;

n= sample size

d=margin of error (0.05)

p= expected proportion (0.7)

For the qualitative study 5 key informants was selected purposively from stakeholders (social affair, women and child affair, City administration, the Police, community representatives)

Sampling procedures and Sampling Technique:

Sampling procedure

To develop the sampling frame complete census was done for two days during the night with the help of the local Ministry of Labour and Social Affairs (MOLSA), police, women and child affairs, and city administration staff to get the required sample size among street youth aged 10-24 in the town and 784 were found. Then sampling frame was develop in 11 sites were street youth known to congregate (commonly named the site as: police station area, yederomeneharia, sebategna ,aseramestegna. getemesefer, genbgebeya, around police station, molagolja, Michael church, Aboye church, waleme,) then the study subjects were selected by systematic sampling from the sampling frame. The first sampling unit from the sampling frame was selected by using simple random sampling using lottery method. Then the next study unit was selected through systematic sampling technique (every three-study unit), and those, who were eligible for the study, were identified and interviewed by the data collector.

For the qualitative part the study subjects were identified purposively from members from zonal labor and social affair, police station, city administration and women and child affair and community members were involved.

Figure 2: Schematic presentation of sampling procedure (quantitative method)

Measurement of variables:

Dependent variables

Risky sexual behavior

Independent variables

Socio-demographic variables (sex, age, educational status)

• income
• Substance use (like alcohol drinking, smoking, chat chewing, and use of drugs like shisha/hashish).
• Former residence
• duration of street life
• reason to start sexual intercourse
• sexual activity under the influence of substances(alcohol)
• sexual intercourse in the last 12 month

Operational definitions:

Risky sexual behaviors (practice): In this study it is defined as one of the following: never use of condom or inconsistent, having more than one sexual partner or have sex with non-regular sexual partner or and starting sex before age 18 years or commercial sex worker/having sex with sex workers.,

Substance abuse: Youth, who drink alcohol, chew khat, smoke ganja and cigarette and sniff benzene regardless of the amount and frequency of use.

Street youth: In this study, youth is defined as the people between age 10 and 24 years comprising only off-street type. Youth, adolescent and children are used interchangeably.

Multiple sexual Partners: More than one sexual partner at the different time

Unprotected sex: Nonuse or inconsistent use of condoms during sexual intercourse with multiple partners or multiple partners in the last 12 months

Data collection Procedures:

The quantitative data was collected by using interviewer-administered questionnaire (or face- to-face interview) adapted and modified after reviewing different literature as appropriate as to address the study objectives. The questionnaire consists of socio demographic characteristic; experience of substance use and questions related to risky sexual behavior of the respondents.  The questionnaire was prepared originally in English and then translate in to Amharic and back to English and finally was administered to the respondents in Amharic to make the information easily understood by the data collectors and respondents during data collection and to get consistence information. To avoid interviewing a participant more than once, no incentive was given. Participants were asked if they had already given a similar interview in the two or three preceding days. A selected study site was visited only once. eight data collectors (who were diploma nurses) and two supervisor was recruited and training on the objective of the study and techniques of data collection for one day was given. Pre-testing of the questionnaire was done in 5% (14 participants) of the sample in dilla zuria. During the pre-test, the questionnaire was assessed for its consistency, clarity, Understandability, completeness, reliability, how much it answers the objectives and the Sensitivity of the subject matter was assessed.

The qualitative data was collected using semi structured open-ended questions to explore the risky sexual behavior and associated factors by key informant interview. All interview was conduct in a private place. Permission to use a tape recorder for the interview was obtained from the participants prior to the interview.

Data quality Assurance:

To assure the data quality high emphasis was given in designing data collection Instrument. Before starting the actual survey, the questionnaire was pre-tested on 5% of the sample in dilla zuria to assess for clarity of questions,

The quality, validity and reliability of data had been assured through, careful design, translation and retranslation and, proper training of the data collector and supervisors, close supervision of the data collectors and proper handling of the data.

Data collection was also monitored frequently in the field the collected data was been reviewed and checked for completeness and consistency before data entry. Data entry was done carefully by the principal investigator

Data Analysis Procedures:

For quantitative data, the data was entered into EPI data version 3.5.1, and then exported to SPSS version 20 statistical program.

Descriptive statistics

Frequency distribution of the continuous and categorical data has been conducted to describe the data by examining and summarizing the distribution of each individual variable. Descriptive was done for a continuous variable and the mean, median, range; maximum, minimum value, standard deviation, variance, skewedness and kurtosis of each data were summarized.

The data were assessed for symmetry using frequency and explore; each used to test variables for fulfilling assumptions. These the continuous variables have been tested for their symmetrical distribution then followed parametric test.

Under explore Plots and Normality plots with test were selected. After assessing the symmetry and identifying the variables as normally distributed and not, different test has been selected. If symmetry, each independent data was undergone through independent student t test for mean comparison on dependent variable.

Cross tab has been done for categorical variables to see the distribution of each independent variable on dependent variable.

Inference statistics

Chi square was done for categorical independent variables; to see the presence or absence of association with outcome variable.

Bivariate logistic regression has been done for each independent variable with outcome variable to see the association and if P value <0.05, 95% C.I. doesn’t touch 1; it was interpreted as there is statistically significant association between independent and dependent variable by competing the crude odd ratio. Variables which were significant at p value <.25 has been further assessed for association and to kept those potential confounders under control by multivariate analysis. Hosimer Lemshow test was used to assess the fitness of the overall model at p-value >0.05 and it was 0.25.

The qualitative inquiry will be analyzed using content analysis. The transcribed note will be translated. Following this, coding will do using themes that were priory listed and those developed during translating and reading the transcript. The results were triangulated with quantitative data so as to strengthen the findings.

Ethical consideration

Ethical clearance letter to conduct this study was obtained from Dilla University, institutional review board then submitted to zonal Labor and Social Affairs Division and city administration.

In addition, oral consent and or assent was obtained from each study participant who was agreed to participate by informing and discussing the purpose of the study (As the standard practice with self-reliant youth populations (< 18yrs) not in contact with or otherwise supervised by an adult guardian, the researchers considered this as an appropriate means to seek informed consent from the participants). Participants were assured for their personal profile and the response they would give not exposed to anyone in any circumstances.

Disseminations of the results & findings

The findings of the study will be submitted to Dilla University College of Health sciences and Medicine department of public health. The result of the study will be disseminated to CBE office, zonal Labor and Social Affairs Division, Dilla city administration and relevant stakeholders using the book of the university and also for publishing on reputable journals. After then it is the university’s authority to use in any preferable method to disseminate in publishing and/or electronics media.

Socio demographic characteristics of respondents

A total of 275 street youth interviewed, of which 6 respondents were excluded for gross incomplete and inconsistent responses making the response rate 97.8%. Analysis was made based on the 269 completed questionnaires. Out of the total 269 street youth, From the total study participants, 248 (92.2.2%) were males and 21 (7.8%) were females. The mean age was 16.56 (SD± 3.086). The majority of street youth (41.2%) were between the age of 15 and 19 years. Most participants, 154 (56.9%) reported that they were educated up to grade 8, 34 (12.6%) were can read and write only. It is shown in Table 1.

Out of the total interviewee; 106(39.4 %), 79 (29.4 %), 63 (23.4 %), and 11 (4.1) were, engaged in carrying small items, delivering messages, begging, and Washing cars respectively. and shoe shining, exchange of money for sex and peddling were the means of survival for few participants and most of them 139(51.70 %) earn on average 10 to20 birr per day.

170 (63.2%) of the street youth came from places out of Dilla (rural areas). The duration on the street varied from less than one year up to >3 years. 242 (90.0%) and 27 (10.0%) of the study subjects were living on the street and in plastic shelter respectively.

Socio demographic characteristics of street youth in Dilla town N=269

Table 1. Socio demographic characteristics of street youth

The participants left their home for many reasons; among the reasons mentioned were, poor family by 72 (26.8%), peer pressure by 56 (20.8%), to look for a job by 49 (18.2%), death of parent by 41 (15.2%), lack of peace in the family by 37(13.8), illness of family by 7 (2.6%), change of life by 4 (1.5%) and due to alcoholic family by 3(1.1%) (Figure 1).

Substance use:

Substance use is widely practiced among the street youth. Of the total street youth, 188(84.3%) reported that they drink alcohol; out of which, 140 (52.2%) of them drink some times, 41(15.3%) drink most of the time, and 7 (2.6%) reported that they drink daily. Among the interviewee who drink alcohol 172(91.4%) and 16 (8.5%) of them were male and female, respectively. 119 (44.2%) of them smoke Cigarette; out of which, 80 (67.2%), 19 (15.9%) and 20 (16.8%) smoke Cigarette sometimes, most of the time and daily, respectively. 167 (62.0) of them chew khat; out of which, 87 (52.0%), 46 (27.5%) and 34 (20.3%) chew khat sometimes, most of the time and daily, respectively, benzene sniffing was also prevalent 113 (42.0%).

Figure 3. Reasons to be on the street.

Reproductive and sexual health behavior of street youth in Dilla town:

Out of the total respondents, 151 (56.1%) have reported to have ever had sexual intercourse in their lifetime which included 132 (87.4%) of the boys and 19 (12.5%) of girls. The overall prevalence of risky sexual behavior was 150 (55.8%).

The mean ages at sexual commencement were found to be 15.5(SD ±2.74). There were 2 individuals who reported first sexual intercourse at an early age of 10 years (both of them were female) and the maximum age was 21 years. Among sexually active study participants, 122 (89.7%) started sexual intercourse earlier than 18 years of age.

The main reasons provided for sexual initiation includes Personal desire 54 (20.1), Fell in love 29 (10.8), Peer pressure 26 (9.7), Influence of khat/alcohol 12 (4.5), To get money and other gift 6(2.2) of female respondents mentioned that they initiated sex as a result of Raped 9 (3.3). Of those sexually active, the first sexual partner includes with a casual partner 68 (49.6), steady boy/girlfriend 34 (24.8), with a family member 12 (8.8), and commercial sex worker 21 (15.3), of those sexually active street youth, 79 (52.3 %) had ever used Condoms out of which, 13.5% use condom consistently, of those ever-used Condoms 33 (21.8%) had used Condoms during their first sexual intercourse.

Of youth who had been sexually active, 82 (54.3%) had more than one lifetime sexual partner. The mean lifetime number of sexual partners per sexually active participant was high, that is 2.06 (SD ±1.2). 103 (75.7%) of street youth had sexual intercourse at least once in the past 12 months. Of those who are currently sexually active, 48 (47.6%) of them reported that they had sexual intercourse with more than one partners and the mean number of sexual partners for them was 1.7 (SD± .8).

Out of those who are currently sexually active males 39 (25.8%) reported having had sexual intercourse with commercial sex workers in the past 12 months. Of these, 25 (58.1%) of them used condoms, out of which, only 33.3% of them use condoms constantly. The main reasons mentioned for not using condoms constantly include: not available 36 (13.0%) don’t like them 26(9.7%), perceived reduction of sexual desire 24 (8.9%), Don’t think of it (negligence) 24(8.9%).

Sexual History among respondents of street youth in Dilla town’s=269

Table 2. Sexual History among respondents.

Factors associated with risky sexual behavior:

The binary logistic regression in table 3shows that, female respondents were about eight times more likely to engage in risky sexual behaviors than the male respondents [(COR = 8.48 (95%CI (1.93, 37.2, p=0.005)]. risky sexual behavior had increased with increasing age of the study participants whose age were between 20-24 were about forty times more likely to engage in risky sexual behavior than the respondents whose age were between 10-14 [(COR 13.92(95% CI (5.48,35.36) p.=0.000)]

Street youth who were primary school (grade 1-8) were three times more likely to exercise risky sexual behavior (COR= 3.16(95% CI (1.79-5.57) than those street youth who had no formal education(illiterate) and there is no statistically significant difference on read and write and no formal education(illiterate) (COR=2.07(95%CI (0.91-4.71).

Street youth who are from Dilla were 1.67 times more likely to engage in risky sexual behavior than street youth who were from rural area (out of Dilla) [(COR=1.67(95%CI (1.00-2.77)] and youth who stay on the street for greater than one year were 2 times more likely to engage in risky sexual behavior than those stay for less than one year [(COR=1.92(1.17-3.14)].

According to substance use, street youth who drunk alcohol were 3 times more likely to engage in risky sexual behavior [(COR=3.00(955(CI1.74-5.14)] than street youth who never drunk alcohol. street youth who smoke cigarette were 1.7 times more likely engage in risky sexual behavior [(COR=1.70(95%CI (1.04-2.78) than those who never smoke, street youth who chew khat were 2.7tmes more likely to practice risky sexual behavior [(COR= 2.71(95%CI (1.63-4.48)] than those who never chew khat.

Concerning to current sexual activity street youth who had sexual intercourse in the past 12 month were 99.7% more likely had risky sexual behavior than those who are not currently sexually active.

Multivariate logistic analysis

Finally, after adjusting for potential confounders using multivariable logistic regression model, sex being female (AOR=6.70(1.09-15.38)), P value=0.04), educational status (AOR=5.30, 95%CI (1.41, 19.91), P value=.014) duration of street life being more than one year [AOR=3.99 (95% CI: (1.6, 10.), p value=0.02] and sexual intercourse in the last 12 month [AOR=0.003 (95% CI: (.00, .022.), p value=0.00] were statistically significant association with risky sexual behavior.

Relationship between selected variables and risky sexual behavior of street youth in Dilla town

Table 3 Relationship between selected variables and risky sexual behavior of street youth.

NB * P value < 0.05, ** P value < 0.001, CI: confidence interval, OR: odd ratio, 1 – Reference category

Results of key informant interview

A total of five key informants were interviewed consisting one female and four males with age range from 32-40 years. All of the interviewer was protestant in religion and the minimum level of education for them were diploma. According to occupational status all of the key informants are governmental employees. The interview centered on “factors that influence risky sexual behavior of street youth” such as causes and consequences of early sex, multiple sexual partners, use of condoms and substances abuse by the youth were assessed.

The interview was started by asking the general questions: the informants were asked what they understood by the term “risky sexual behavior” the response fell in to two broad categories;(1) risky sexual behavior leads to disease transmission (2), unplanned pregnancy and moral decline.

  Risky behavior is identified as practicing un safe sex, using drugs and alcohol whereas sub   practice might influence a person to be involved in un planed sex. (IDI)

    Risky behavior is any behavior or action practiced by street youth that might lead them to unethical behaviors, which affect their health, security and the community security as well. (IDI)

The interviewer was also asking about the reason “why they joined the street life”. Almost all interviewers from both sexes mentioned the reasons that were listed in the quantitative part like poor family, peer pressure, searching jobs, conflict with family, and so forth.

The interviewer reported that the most common age at sexual commencement is 14 for girls and 15 years for boys. Majority of participants stated that girls start sex earlier than boys at age of 10. According to the participants, the main reason for early sex is peer pressure, experimentation by the youth, alcohol and khat abuse, rape and economic problems (sex for the exchange of money for female only). The participants also mentioned that due to early sex females are exposed to STIs and unwanted pregnancy.

Majority of the interviewer stated condoms is not usually used because of perceived reduction in sexual pleasure, they do have unplanned sex and they may not get in the nearby (not accessible)

Three of the Interviewees said that, their main income on the street is through begging, sex work, participating in labor work, carrying small items and spend their time at bus stand, in doing so they connect to social network that push them in risky sexual behavior.

Multiple sexual partners and having sex with out condoms. It was interviewed that it is common for both male and female street youth to have more than one sexual partner, especially for females. The main reasons mentioned for having more than one sexual partner were excessive sexual urge as a result of abuse of substances, rape and practice sex for the exchange of money, there was no any separate space for female and male they spend over the night they slept as a group which put them on high sexual risk behavior.

On the other hand, selling illegal traditional alcoholic drink in the household (like tella and areqe) is another contributing factor leading the street youth to engage in risky sexual behavior (IDI).

The interviewer perceive they are emotionally unstable due to lack of family support, problems of life on the street and lack of vision. Peer pressure was also mentioned as an important factor that pushes street youth to abuse substances. For the question of the relation between abuse of substances and risky sexual behaviours all the interviewer responded that abusing alcohol impairs their judgment, increases sexual drive and urges them to have unprotected casual sex.

This study revealed that, the prevalence of risky sexual behavior among street youth was 55.8%. This risky sexual behavior was reported among street youth who were primary school level, youth who stay on the street for greater than one year and street youth who are currently sexually active (have sexual intercourse in the past 12 month) in multivariate analysis. The qualitative findings were also in line with the quantitative one. Most of key informants agreed that the age itself, substance use and duration of street life are initiators of sexual practice among street youths.

In this study about 56.1% of the participants ever had sexual intercourse this finding is lower than the study conducted among street children in Adiss Ababa (72.5%) [9], in Dessie town (67.9) [6]. This variation could be due to age group difference of the study participants as this study included younger age groups of 10-24 years old as compared with older age groups of 15-24 years. Other possible reason for the difference might be because of the small sample size use in this study. This finding was higher than the previous studies conducted in Ethiopia among non-street youth: in Jimma University in 2012 (26.9.%) [9], in Addis Ababa urban youth (48%) [6], Benishangul Gumuz High School Youth (24.1%) [7], and Jiga preparatory school (16%) [25]. This showed that street youth were high risk sexual behaviour when compared with non-street youth in this study. The higher prevalence of sexual activity among street youth could be explained by being street youth, which exposes them to early sexual activity and higher prevalence of substance abuse and lack of access to information.

The findings of the qualitative study also supported the quantitative one. Majority of the key informants have similar opinion that sexual practice among street youth seems somewhat prevalent.

The mean age at sexual debut among respondents was found to be 15.5(SD ±2.74) which is almost comparable to studies conducted among street youth in Dessie town (15.2) [6], in Adiss Ababa (15.4%) [9]; however, it is lower than studies done among street youth in Gonder (16.5) [1]; in high school adolescents in Ethiopia (16.6) [26] and Adiss Ababa (18.56) [17], and Jimma university students (17.7) [16] and higher than the mean age reported from Tanzania (14.61) years [27]. The results of the key informant interview complement this result. This study reveals earlier engagement of sexual practice during which most adolescents lack accurate knowledge about reproduction and sexuality and lack access to reproductive health information, including condom use which all lead to increased risk of sexually transmitted infections, unwanted pregnancy and unsafe abortion

A significant proportion, (54.3%) of sexually active respondents had reported that they had more than one lifetime sexual partners and the mean lifetime number of sexual partners was 2.06. This was lower than from previous studies done on street youth in Desei town 80.6%, (4.85) [6], Gonder 62.4% (3.15) [1]. This proportion of having multiple sexual partners among street youth might be explained by unstable life style of street youth, a higher level of exposure to sexual exploitation and sexual practice for the exchange of money due to economic problems.

In this study (25.8%) sexually active males reported having had sexual intercourse with commercial sex workers in the past 12 months. This finding was in agreement with the study done in Accra Ghana (23.2%) [15]. However, the present finding lower than the study finding among street youth in Gonder city which showed (40.6%] [1]. A high level of sexual contact with commercial sex workers among street youth suggests these groups of the population are involved in high-risk sexual practices.

Of the sexually active youth, 13.5 % reported consistent use of condoms in the last 12 month. This finding is comparable to the study done on Adiss Ababa on orphan and venerable children (14.3) [18]. However, this result was much lower than the finding reported among street youth who were consistent use condoms in Gonder city (46.1%) [1]. Dessie town (22.8%) [9,15,18], and the study done in Gurage Zone preparatory school (24%) [19]. This showed that the low utilization rate of consistent condom in this study is an indication of the fact that high risk behaviors are widely practiced by the study group.

This study found out that about (21.8%) of sexually active participants reported to have used condom during their first sexual encounter which is consistent with reports done in street children in Kinshasa (20.2%) [10], and Dessie town (23 %) [6].

The level of substance abuse was assessed considering as it is predisposing factor to risky sexual behaviors and reported as being practiced among the youth. Of the total street youth, 84.3% reported that they drink alcohol. About 62.0 % of the respondent’s chew khat; cigarette smoking, ganja smoking and benzene sniffing were also prevalent. This finding was higher than prevalence of substance abuse (67.3%) among street children in Adiss Ababa [9].

This study finding revealed that a significantly high numbers of street youth have started sexual activity and the majority of them had initiated sexual activity earlier than 18 years. Street youth had multiple sexual partners and at the same time consistent use of condom is very low in this group of population. A significant proportion of street youth had sexual contact with commercial sex workers and significant number of street youth reported to abuse substances such as khat, cigarette and alcohol which engage them in risky sexual behavior

Recommendations

Addressing the problem of street youth in a holistic manner requires involvement of policy makers to focus on preventive, corrective and rehabilitative measures to alleviate the problem of streetism.

 For general population

Early sexual initiation was one indicator of risky sexual behavior and large proportion street youth had early sexual initiation. Therefore, the wider public should be aware on the disadvantages of early sexual debut.

For health care providers

Information, education and communication (IEC) programs should be established and emphasis should be put on reproductive health in order to encourage the street youths to delay sex, negotiate to use condom and to be faithful for their sexual partner.

For programmers/policy makers

Large proportion of street youth had risky sexual behaviors and the proportion was higher. Therefore, emphasis should be given for street youth through social and behavioral change communication (SBCC) and launching other youth-friendly services.

Moreover, the youth center reproductive health clinics have to be scaled-up in areas where they are not available.

For researchers

Further study needs specifically qualitative study to be conducted to explore the reasons why youth are involved in risky sexual behaviors and to see the wider social norms that may encourage risky sexual behaviors among street youth.

All stakeholders should work in an organized manner in order not to duplicate effort and misuse resources. In view of the danger, the government should allocate adequate budget, formulate a national strategy to tackle this problem.

Strength

This study could be considered as a baseline study to assess the magnitude of risky sexual behavior and associated factors.

Combining quantitative and qualitative data to triangu- late the findings is strength of this study.

Limitation

The study design was cross- sectional in nature and may not explain the temporal relationship between the outcome variable and some explanatory variables.

Face-to-face interview was used which may not be convenient to study sexuality in a conservative society like ours.

The study topic by itself assesses personal and sensitive issues related to sexuality which might have caused underreporting of some behaviors. Thus, the finding of this study should be interpreted with these limitations.

First and foremost, I would like to thank the almighty God who gives me complete health to develop this thesis, thank you lord.

I would like to thank my advisor’s Mr.Eshetu A.(MPH/RH), Mr. Alemneh A. (MPH/PH) and Dr. Ahmed Mohammed (GP/MPH/Epidemiologist) for their endless support. They consistently allow this paper to be my own work and direct me in the right tract. Without their passionate follow-up this paper could not have been successful.

I also thank Dilla University College of Health and Medical Sciences for providing insight and expertise that greatly assisted the research and for their continuous and very valuable comments on this research.

My deepest gratitude also goes to NORHED/SENUPH project for providing this kind of golden chance and fund to conduct the study.

My heartfelt thanks also go to the office of social affair, city administration, police station and women and child affair for their contribution

I wish to express my deep appreciation and thank to all my study participants who allowed me to get the necessary information needed for my thesis work. I am also very much grateful to the data collectors and supervisors who have given their precious time.

At the last but not the least I would also like to thank My Mother, my kids Eliana and Fiona for her unconditional love, support and pray.