Sexually transmitted infections (STIs) are major universal public health concerns. The infections cause an acute illness, infertility, disability, and death [
Adolescents, particularly students in developing countries, travel far away from their families and stay away for a long time when they attend secondary education. In their stay, they usually live in rented homes and come in contact with people from different sociocultural and behavioral background. Coupled with a lack of knowledge and available services about STIs, adolescents are more likely to practice unprotected sex and have multiple sexual partners and thereby have a higher chance of getting infected with STIs [
Most people in general and adolescents in particular might be aware of HIV/AIDs since the awareness created by media and government programs played a role. This, in turn, resulted in lower knowledge about STIs other than HIV/AIDS and the knowledge could be much lower in developing countries [
Working on prevention is an ideal level to control STIs. Therefore, this study was aimed to assess knowledge, attitude, preventive practice, and associated factors towards sexually transmitted infections including HIV/AIDS among preparatory school students in West Gojjam zone.
School-based cross-sectional study was employed among 845 preparatory school students.
The study was conducted in West Gojjam zone, Amhara region, Northwest Ethiopia from October 24 to November 4, 2018. West Gojjam zone is one of the administrative zones in Amhara regional state and based on a projected population of the 2007 Census [
The source population for this study was all regular preparatory school students in West Gojjam zone public schools who were registered at the academic year of 2018, whereas students who were attending their class at 4 of 14 randomly selected schools during the study period were study population.
The sample size was determined by using single population proportion formula by considering 95% confidence level, 5% margin of error, and prevalence of respondents who had good knowledge on STIs from the previous study which was 50.83% [
A one-stage random sampling technique was used to select four woredas (districts), namely, Finoteselam, Degadamot, Adet, and Gonij kolela, randomly with the assumption that all woredas in the zone are homogenous regarding knowledge of STI. Each selected district has 1 preparatory school and a total of 6576 students were enrolled in 2018 academic year in four selected districts. Then, the sample size was distributed to each school based on the number of students in 11th and 12th grades. Finally, we used students’ list of each grade as a sampling frame, and a total of 845 students were selected by lottery method.
It is the level of students’ knowledge, attitude, and preventive practices towards sexually transmitted infections.
Data were collected using pretested and semistructured self-administered questionnaire. The questionnaire was developed in English by reviewing literature and then translated into local language Amharic and was retranslated back to English in order to check the consistency. The tool comprised of four parts: part one was a sociodemographic background of students and their parents, part two focused on the knowledge of students regarding STIs, part three focused on the attitude of the students towards STIs, and the fourth part was on the preventive practice of the students on STIs. Data collection was done by three diploma nursing professionals, and two BSc nurses supervised the data collection process.
The tool was evaluated by investigators and a pretest was conducted on 5% of the sample size among students in the schools not selected for the study. Based on pretest result, some modification was done on the tool. Moreover, one-day training was given for data collectors and supervisors on the objectives of the study, data collection methods, and the contents of the tool. Furthermore, the collected questionnaires were checked for completeness and on-spot corrective measures were taken both by data collectors and supervisors.
The collected data were checked for completeness before the analysis. The data were entered in to Epi-Info version 7.2 and then exported to SPSS version 25 for analysis. Outcome variables were dichotomized and measured as follows: Knowledge: for fifty items used to measure knowledge on the STIs, each right answer was given 1 and wrong or uncertain answer was scored 0. Students who scored above the mean score for knowledge were considered as having a good knowledge regarding STIs [ Attitude: the 8 questions on the five-level Likert scale that had positive and negative responses were arranged from strongly disagree to strongly agree. Each question was then categorized as 0 = strongly disagree, disagree, and neutral and 1 = strongly agree and agree for statements requiring agreement. Whereas, “neutral” considered as agreement, the reverse category was used for statements requiring disagreement. Then, students who scored 50% and above were considered as having favorable/appropriate attitude towards STIs [ Preventive practice: students who answered above the mean score for 8 preventive practice questions were taken as having a good preventive practice [
Bivariate analysis was used to identify factors associated with outcome variables. Then multivariable logistic regression model was fitted to control the possible effect of confounders. Variables that had a
A total of 828 out of 845 preparatory students completed and returned the questionnaire. The age of respondents ranged from 16 to 29 with a mean age of 20.0 years and standard deviation of 2.3. About 461 (55.7%) respondents were male and the majority of the respondents, 701 (84.7%), were orthodox Christians. Nearly two-thirds, 547 (66.1%), of students were 11th grade. Most of the students were living with their parents and, in more than two-thirds of cases, parents of students didn’t attend formal education (Table
Sociodemographic characteristics of preparatory school students in selected West Gojjam zone schools, Northwest Ethiopia, 2018.
Variable | Frequency ( |
Percent |
---|---|---|
Age | ||
16–19 | 374 | 45.1 |
20–24 | 402 | 48.6 |
25–29 | 52 | 6.3 |
Sex | ||
Male | 461 | 55.7 |
Female | 367 | 44.3 |
Religion | ||
Orthodox | 701 | 84.7 |
Muslim | 127 | 15.3 |
Grade | ||
Grade 11 | 547 | 66.1 |
Grade 12 | 281 | 33.9 |
Marital status | ||
Single | 719 | 86.8 |
Married | 109 | 13.2 |
Cohabitant | ||
Family | 569 | 68.7 |
Friend in rental home | 160 | 19.3 |
Myself in rental home | 94 | 11.4 |
With my relatives | 5 | 0.6 |
Original resident | ||
Rural | 514 | 62.1 |
Urban | 314 | 37.9 |
Educational level of mother | ||
No formal education | 615 | 74.3 |
Primary (1–8) | 88 | 10.6 |
Secondary (9–12) | 69 | 8.3 |
College and above | 56 | 6.8 |
Educational level of father | ||
No formal education | 549 | 66.4 |
Primary (1–8) | 117 | 14.1 |
Secondary (9–12) | 64 | 7.7 |
College and above | 98 | 11.8 |
Mather’s occupation | ||
Farmer | 343 | 41.4 |
House wife | 288 | 34.8 |
Merchant | 106 | 12.8 |
Private org employee | 28 | 3.4 |
Government employee | 63 | 7.6 |
Father’s occupation | ||
Farmer | 443 | 53.5 |
Merchant | 215 | 26.0 |
Private org employee | 54 | 6.5 |
Government employee | 116 | 14.0 |
Earning monthly pocket money | ||
Yes | 585 | 70.7 |
No | 343 | 29.3 |
Of the total of 828 participants, 698 (84.3%) had heard about STIs. The source of information was from school for 479 (68.7%), from TV/radio for 276 (39.6%), from friends for 105 (15.1%), from families for 54 (7.7%), and from other sources such as books and internet for 2 (0.3%).
Concerning the causes of STIs, 350 (42.3%) identified bacteria as a primary cause for STIs, 306 (37%) virus, and 150 (18.1%) fungus. However, bad hygiene of women or men, 127 (15.3%), using unclean water, 93 (11.2%), and sex during menstruation, 135 (16.3%), were mentioned as a cause for STIs and 107 (12.9%) didn’t know the cause of STIs.
For the question asked to identify different types of STIs, 129 (15.6%) of the respondents didn’t know any types of STIs, whereas 55 (6.6%) of respondents had mentioned TB as one of the causes of STIs.
Students were also asked to point out curable STIs. Accordingly, 422 (51%) of them identified syphilis, 336 (40.6%) gonorrhea, and 282 (34.1%) candidiasis. On the contrary, 16 (1.9%) participants replied erroneously HIV/AIDS as curable STIs, while 159 (19.2%) of respondents didn’t know curable STIs.
More than three-quarters, 640 (77.3%), of students mentioned sexual intercourse as a mode of transmission for STIs. Seven hundred sixteen (86.5%) declared that STIs can be prevented and all of the respondents pointed out at least one possible preventive method. One hundred twenty-nine (15.6%) of respondents didn’t know the signs and symptoms of STIs, and 201 (24.6%) also didn’t know complications of STIs (Table
Knowledge on the mode of transmission, prevention methods, signs, and symptoms and complication of STIs among preparatory school students in West Gojjam zone, Northwest Ethiopia, 2018.
Variable ( |
Frequency | Percent |
---|---|---|
Modes of transmission of STIs (multiple responses possible) | ||
Sexual intercourse | 640 | 77.3 |
Sharing needle | 259 | 31.3 |
Blood transfusion | 163 | 19.7 |
Sharing clothes | 74 | 8.4 |
Mosquito bits | 68 | 8.2 |
Kissing | 252 | 30.2 |
STIs are preventable | ||
Yes | 716 | 86.5 |
No | 112 | 13.5 |
Prevention methods of STIs (multiple responses possible) | ||
Abstinence | 435 | 63.7 |
Condom | 256 | 37.5 |
Not having multiple sexual partners | 118 | 17.3 |
Signs and symptoms of STIs (multiple responses possible) | ||
Lower abdominal pain | 165 | 19.9 |
Discharge from penis and vulva | 278 | 33.6 |
Itching on the genital area | 319 | 38.5 |
Failure to urinate | 218 | 26.3 |
Loss of weight | 169 | 20.4 |
Weakness | 139 | 16.8 |
Pain during intercourse | 191 | 23.1 |
Genital ulcers or open sores | 269 | 32.5 |
Don’t know | 129 | 15.6 |
Complications of STIs, if untreated (multiple responses possible) | ||
Infertility | 311 | 37.6 |
Premature birth | 199 | 24.0 |
Stillbirth | 201 | 24.3 |
Ectopic pregnancy | 155 | 18.7 |
Miscarriage | 180 | 21.7 |
Cervical cancer | 261 | 31.5 |
Don’t know | 201 | 24.6 |
In an attitude response, 496 (60%) students disagreed on the vulnerability of adolescents for STIs. On the other hand, about 45% of students agreed on the presence of curable and noncurable STIs. Six hundred twenty-seven (75.7%) of respondents also agreed on the idea “person infected with STIs can go to health institution for treatment,” whereas 446 (54%) disagreed on the concept “by treating an individual who had STIs, spread of the disease can be prevented” (Table
Attitudes of preparatory school students towards STIs, West Gojjam zone, Northwest Ethiopia, 2018.
STIs attitude items | Scale | ||||
---|---|---|---|---|---|
Strongly disagree | Disagree | Neutral | Agree | Strongly agree | |
Adolescents are more vulnerable to STIs | 99 (12.0%) | 134 (16.1%) | 85 (10.3%) | 247 (29.8%) | 263 (31.8%) |
STIs can cause social stigma and discrimination | 144 (17.4%) | 237 (28.6%) | 129 (15.6%) | 179 (21.6%) | 139 (16.8%) |
Patients with STIs are easily identified in the community | 189 (22.8%) | 277 (33.5%) | 131 (15.8%) | 156 (18.8%) | 75 (9.1%) |
There are both curable and noncurable STIs | 89 (10.7%) | 180 (21.7%) | 182 (22.0%) | 267 (32.3%) | 110 (13.3%) |
Anybody can get condom simply when the need arises | 111 (13.4%) | 169 (20.4%) | 175 (21.1%) | 207 (25.1%) | 166 (20.0%) |
Person infected with STIs can go to health institution for treatment | 30 (3.6%) | 65 (7.9%) | 106 (12.8%) | 327 (39.5%) | 300 (36.2%) |
By treating an individual who has STIs, spread of the disease can be prevented | 232 (28.0%) | 214 (26.0%) | 110 (13.3%) | 197 (23.6%) | 76 (9.1%) |
Being infected with one of STIs other than HIV can increase the risk of acquisition of HIV | 179 (21.6%) | 190 (23.0%) | 101 (12.0%) | 171 (20.6%) | 187 (22.8%) |
From the total of 828 participants, 277 (33.5%) had a history of sexual intercourse in the period of the last six months. Thirty-six (12.9%) of those who had sex had sex with their teachers and 9 (3.2%) had sex with commercial sex workers.
More than half of the students were practicing abstinence and faithfulness as a means of preventive practice. Nearly one-tenth of the students practiced washing genitalia before and after sexual intercourse as a preventive measure for STIs (Table
Sexual practice and prevention practices for STIs among preparatory school students, West Gojjam zone, Northwest Ethiopia, 2018.
STIs preventive practice items | Frequency ( |
Percent |
---|---|---|
Have you had sexual intercourse in the last six months? | ||
No | 551 | 66.5 |
Yes | 277 | 33.5 |
If yes, whom with did you had sexual intercourse? | ||
Had no sexual intercourse at all | 551 | 66.5 |
With my boy/girlfriend | 140 | 16.9 |
With my classmate | 89 | 10.7 |
With my teacher | 36 | 4.3 |
With commercial sex workers | 9 | 1.1 |
Wives/husbands | 3 | 0.5 |
What measures did you take to prevent yourself from STIs ever? (multiple responses possible) | Yes response | |
Abstinence | 461 | 55.7 |
Being faithful | 422 | 51.0 |
Use condom | 198 | 23.9 |
Avoid sex with commercial sex workers | 96 | 11.6 |
Wash genitalia before sex | 745 | 90.0 |
Wash genitalia after sex | 761 | 91.9 |
Decrease number of sexual partners | 464 | 56.0 |
Not receiving unscreened blood | 326 | 39.4 |
This study revealed that 50.5% (95% CI: (47.1%–53.9%)) of students had a good knowledge of STIs. The proportion of appropriate attitude towards STIs among preparatory school students was 38.4% (95% CI: (34.9%–41.7%)). Less than half, 46.4% (95% CI: (43.0%–50.0%)), of the students in this study also had a good preventive practice for STIs (Figure
Proportion of knowledge, attitude, and preventive practice of preparatory school students on STIs, West Gojjam zone, Northwest Ethiopia, 2018.
The results of multivariable logistic regression analysis showed that sex of students and fathers’ occupation were significantly associated with students’ knowledge of STIs. Accordingly, male students were more likely to have good knowledge (AOR: 1.58 (95% CI: (1.19, 2.09)) than female students. Likewise, students whose fathers were employed were also more likely to have good knowledge (AOR: 1.97 (95% CI: (1.18, 3.30)) than farmers.
Regarding the attitude of students, fathers’ level of education and occupation found to predict the attitude of students towards STIs. Consequently, students of fathers who attended secondary and above level education (AOR: 2.16 (95% CI: (1.28, 3.64)) and whose occupation was farmer (AOR: 1.77 (95% CI: (1.04, 3.02)) had the appropriate attitude towards STIs.
In this study, the preventive practice of STIs among students was predicted by students’ age, history of ever practice of sexual intercourse, and knowledge of students on STIs. Students aged 25–29 years had more than two times the odds of good preventive practice (AOR: 2.33 (95% CI: (1.27, 4.28)). Similarly, those students who never practiced sexual intercourse had good preventive practice for STIs (AOR: 1.44 (95% CI: (1.07, 1.94)). Likewise, students who had good knowledge of STIs were more likely to have good preventive practice (AOR: 1.53 (95% CI: (1.16, 2.02)) (Table
Factors associated with knowledge, attitude, and preventive practice on STIs among preparatory school students, West Gojjam zone, Northwest Ethiopia, 2018.
Variable | Knowledge | AOR (95% CI) | Attitude | AOR (95% CI) | Practice | AOR (95% CI) | |||
---|---|---|---|---|---|---|---|---|---|
Good (%) | Poor (%) | Appropriate | Inappropriate | Good (%) | Poor (%) | ||||
Age of students | |||||||||
15–19 years | 160 (42.8) | 214 (57.2) | 1 | ||||||
20–24 years | 193 (48) | 209 (52.0) | 1.29 (0.96, 1.72) | ||||||
25–29 years | 16 (69.6) | 7 (30.4) | 2.33 (1.27, 4.28) | ||||||
Sex of the students | NA | ||||||||
Male | 254 (55.1) | 207 (44.9) | 1.58 (1.19, 2.09) | 222 (48.2) | 239 (51.8) | ||||
Female | 164 (44.7) | 203 (55.3) | 1 | 162 (44.1) | 205 (55.9) | ||||
Religion of students | NA | NA | |||||||
Orthodox christianity | 346 (49.4) | 355 (50.6) | 303 (43.2) | 398 (56.8) | |||||
Muslim | 72 (56.7) | 55 (43.3) | 81 (63.8) | 46 (36.2) | |||||
Grade of students | NA | ||||||||
11th grade | 262 (47.9) | 285 (52.1) | |||||||
12th grade | 122 (43.4) | 159 (56.6) | |||||||
Cohabitant | NA | NA | |||||||
With my parents or relatives | 211 (36.8) | 363 (63.2) | 255 (44.4) | 319 (55.6) | |||||
With my friend in rental home | 62 (38.8) | 98 (61.2) | 88 (55.0) | 72 (45.0) | |||||
Myself in rental home | 45 (47.9) | 49 (52.1) | 41 (43.6) | 53 (56.4) | |||||
Original residence | NA | NA | |||||||
Rural | 250 (48.6) | 264 (51.4) | 227 (44.2) | 287 (55.8) | |||||
Urban | 168 (53.5) | 146 (46.5) | 157 (50.0) | 157 (50.0) | |||||
Mother’s level of education | NA | NA | |||||||
No formal education | 302 (49.1) | 313 (50.9) | 280 (45.5) | 335 (54.5) | |||||
Primary level of education (1st–8th grade) | 50 (56.8) | 38 (43.2) | 44 (50.0) | 44 (50.0) | |||||
Secondary and above | 66 (52.8) | 59 (47.2) | 60 (48.0) | 65 (52.0) | |||||
Father’s level of education | NA | NA | |||||||
No formal education | 275 (50.1) | 274 (49.9) | 202 (36.8) | 347 (63.2) | 1 | 247 (45) | 302 (55.0) | ||
Primary level of education (1st–8th grade) | 51 (43.6) | 66 (56.4) | 42 (35.9) | 75 (64.1) | 1.18 (1.04, 3.02) | 58 (49.6) | 59 (50.4) | ||
Secondary and above | 92 (56.8) | 70 (43.2) | 74 (45.7) | 88 (54.3) | 2.16 (1.28, 3.64) | 79 (48.8) | 83 (51.2) | ||
Mother’s occupation | NA | NA | |||||||
House wife | 163 (47.5) | 180 (52.5) | 155 (45.2) | 188 (54.8) | |||||
Farmer | 143 (49.7) | 145 (50.3) | 127 (44.1) | 161 (55.9) | |||||
Merchant | 57 (53.8) | 49 (46.2) | 57 (53.8) | 49 (46.2) | |||||
Employee | 55 (60.4) | 36 (39.6) | 45 (49.5) | 46 (50.5) | |||||
Father’s occupation | NA | ||||||||
Farmer | 207 (46.7) | 236 (53.3) | 1 | 178 (40.2) | 265 (59.8) | 1.77 (1.04, 3.02) | 193 (43.6) | 250 (56.4) | |
Merchant | 111 (51.6) | 104 (48.4) | 1.35 (0.95, 1.93) | 72 (33.5) | 143 (66.5) | 1.14 (0.69, 1.89) | 107 (49.8) | 108 (50.2) | |
Employee | 100 (58.8) | 70 (41.2) | 1.97 (1.18, 3.30) | 68 (40.0) | 102 (60.0) | 1 | 84 (49.4) | 86 (50.6) | |
Ever practiced sexual intercourse | |||||||||
No | 268 (48.6) | 283 (51.4) | 1.44 (1.07, 1.94) | ||||||
Yes | 116 (41.9) | 161 (58.1) | 1 | ||||||
Earning monthly pocket money | NA | ||||||||
No | 116 (47.7) | 127 (52.3) | |||||||
Yes | 268 (45.8) | 317 (54.2) | |||||||
Knowledge on STIs | |||||||||
Poor | 169 (41.2) | 241 (58.8) | 1 | ||||||
Good | 215 (51.4) | 203 (48.6) | 1.53 (1.16, 2.02) |
This study revealed that about half of the students had a good knowledge of STIs. And 46% of students had a good preventive practice for STIs. However, only about 38% of students had an appropriate attitude towards STIs.
The proportion of students who had good knowledge about STIs in this study is comparable with a study conducted at Arsi Negelle; the use of equivalent items to measure knowledge and similar categorization could be an explanation for the similarity [
Male students are more likely to have a good level of knowledge than females in this study. This finding is in line with the finding from Arsi Negelle town study [
In the current study, those students whose fathers had attended secondary and above level of education had two times more likely odds of having an appropriate attitude towards STIs. As reported in some studies, parental education [
Students who had good knowledge of STIs in this study were more likely to have good preventive practice for STIs. This finding is also supported by a study done in Arsi Negelle [
This study determined the proportion of knowledge, preventive practice, and attitude of students towards STIs. Further, the study identified some important factors that predicted students’ knowledge, attitude, and preventive practice. However, some behavioral and sociocultural factors that had not been addressed here could seek a qualitative design.
The proportion of respondents that had good knowledge, appropriate attitude, and preventive practice of STIs among preparatory school students in this study were not satisfactory. Personal sociodemographic as well as behavioral and parental factors predicted students’ knowledge, attitude, and preventive practices. Since youthhood, particularly at the end of preuniversity school, is a critical age, it is imperative to reinforce strategies which would improve adolescents’ knowledge, attitude, and preventive practice towards STIs.
Adjusted odds ratio
Sexually transmitted infections
Tuberculosis
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethical clearance was obtained from the ethical committee of the School of Midwifery, College of Medicine and Health Sciences, University of Gondar. The committee is a delegate of the institutional review board of the university to provide ethical clearance for observational studies to masters and below level of students. After getting ethical clearance, support letter was written to West Gojjam zone educational office and the zone then wrote a support letter to selected preparatory schools.
In case students under the age of 16 years are selected in the study, a written informed consent form was prepared to obtain approval from their parent or guardian. All study participants were clearly informed about the purpose of the study and, along with self-administered questionnaire, a written consent was attached to be signed if they agree to participate. Then students were assured that all data they offer will be confidential and none of the personal identifiers are part of the data. Students were also guaranteed that they have the right to not to respond to the questions they are not interested in and that they have the right to withdraw at any point from the study.
The authors declare that they have no conflicts of interest.
AAK conceived and designed the idea, participated in data management, analysis, interpretation, and paper write-up. TWG and BMA participated in design, data analysis, and interpretation. Finally, all authors developed and approved the manuscript.
The authors would like to express their gratitude to data collectors and supervisors for their commitment. The authors would also like to extend their appreciation to officials of the zonal educational office, directors and teachers of each school, and study participants. Data collection fee was covered by the Amhara Regional Health Bureau.