International Journal of Reproductive Medicine
Volume 2021 (2021), Article ID 8272986, 8 pages
https://doi.org/10.1155/2021/8272986

Research Article

Substance Use among Homeless Reproductive Age People in Southern Ethiopia

Negash Wakgari,¹ Terefe Woyo,² Emnet Kebede,² Hirut Gemeda,² Wakgari Binu,³ and Gonfa Moti⁴

¹Department of Midwifery, Ambo University, Ambo, Ethiopia
²Department of Midwifery, Hawassa University, Hawassa, Ethiopia
³School of Public Health, Wolaita Soddo University, Wolaita, Ethiopia
⁴Ambo University Referral Hospital, Ambo, Ethiopia

Correspondence should be addressed to Negash Wakgari; negashwakgari@yahoo.com

Received 28 June 2020; Revised 28 February 2021; Accepted 9 March 2021; Published 16 March 2021

Academic Editor: Vikas Roy

Copyright © 2021 Negash Wakgari et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Introduction. Substance use by homeless reproductive age people may result to anxiety, involvement of risky sexual behaviors, and increasing the likelihood of unwanted pregnancy and sexually transmitted diseases (STDs). Therefore, this study assessed the magnitude of alcohol use, sexual intercourse after alcohol use, and its associated factors among homeless reproductive age people in southern Ethiopia. Methods. Community-based cross-sectional study design was conducted among homeless reproductive age people. The snowball sampling technique was used to recruit 842 participants. Pretested and structured interviewer-administered questionnaire was used to collect the data. Data were entered into Epidata version 3.1 and exported to SPSS version 23 for analysis. Binary logistic regression was used to determine the association of independent variables with the outcome variables. Odds ratio with their 95% confidence interval and value was used to identify the significant variables. Results. More than half 423 (53.2%) of the respondents had taken a drink that contains alcohol in the last one year of the study period. Out of 324 khat chewers, 190 (58.64%) had sex after chewing khat. More than one-thirds, 323(38.4%) homeless people were smoking cigarette during the study period. Factors associated with alcohol use were age 19-25 years (AOR: 0.49; CI: 0.34, 0.72), ≥26 years (AOR: 0.40; CI: 0.25, 0.65), level of education (AOR: 0.61; CI: 0.39, 0.94), place of residence: major urban (AOR: 0.31; CI: 0.18, 0.51), small town (AOR: 0.38; CI: 0.23, 0.63), ever heard about STDs (AOR: 0.14; CI: 0.07, 027), and being a cigarette smoker (AOR: 2.67; CI: 1.94, 3.71). Conclusions. In this study, significant percentage of respondents had taken a drink that contains alcohol. Age, level of education, place of residence, ever heard about STDs, and smoking cigarette were variables significantly associated with alcohol use. Awareness creation on the effect and outcome of substance use is recommended.

1. Introduction

The health effect of substance use among the general population is well documented [1–5]. A multiple use of substances such as tobacco, alcohol, marijuana, and khat is reported [2, 5]. Despite the awareness of its ill effect on the health, the severity of alcohol consumption among adolescents is highly prevalent [3, 6–9]. This would be much more problematic among homeless people due to their lifestyle and economic dependency [6, 10–13].

People who sleep on streets, main roads, railway terminals, bus stations, parks, religious centers, construction sites, and other public places are defined as homeless people [14]. Alcohol consumption by the street-dwelling population may result to anxiety, depression, stressful life events, relative abstinence, and low self-esteem [15, 16]. It may also lead the street-dwelling reproductive age group [15-49 years] to the involvement of risky sexual behaviors and increasing the likelihood of unwanted pregnancy, STDs, and its consequence [6, 17, 18]. In addition, sexual intercourse after alcohol use is linked to inconsistent condom use, commercial sex, and rape [19, 20]. Moreover, both executing a crime and being a victim of an offence are also associated with alcohol use [21].

The proportion of alcohol use and its associated factors varies from region to region based on the context and sociodemographic characteristics of the street-dwelling people. For instance, previous studies reported 38% in Texas [10], 40% in Toronto [22], 35% in Egypt [23], 63.5% in Democratic Republic of Congo [24], and 64% alcohol use among street-dwelling people in Addis Ababa, Ethiopia [18].

Factors such as gender, age, duration of stay on the street, and peer influence were reported in previous studies as the major triggers for substance use [12, 13, 18, 24–29]. Though there are some studies conducted on substance abuse, risky sexual behavior, sexual, and reproductive health status of street children and youths [17, 18], none of them focused specifically on alcohol consumption, sexual intercourse after alcohol use, and its associated factors among homeless reproductive age people [15-49 years] in the study setting. Similarly, few of the previous studies done in the study area were focused on homeless women and children [30–33] and fail to notice sexual intercourse after alcohol use among both sexes in small towns of Ethiopia considering the differences in sociodemographic characteristics, culture, and awareness about the substances uses across the country. Therefore, this study assessed the magnitude of alcohol use, sexual intercourse after alcohol use, and its associated factors among homeless reproductive age people in southern Ethiopia.

2. Materials and Methods

2.1. Study Setting, Design, and Population

Community-based cross-sectional study design was conducted among homeless reproductive age people in southern Ethiopia. Hawassa; Arba Minch, Soddo, Dilla, Hosanna, Durame, Jinka, Werabe, Welkite, Segen, Yergalem, Bench, Tercha, Masha, and Mizan Aman are major cities in the southern Ethiopia. All homeless reproductive age people [15-49 years] in the selected cities in the southern Ethiopia were considered as the study population.

2.2. Sample Size Determination and Sampling Procedure

The sample size was determined by using single population proportion formula the following assumptions: 95% confidence level, 5% margin of error, and taking 50% proportions ().

Thus, the calculated sample size became 845 by considering two design effects due to the multistage nature of the study and 10% nonresponse.

Selecting seven cities: Arba Minch, Dilla, Durame, Hawassa, Mizan Aman, Soddo, and Yergalem among fourteen major cities in the southern Ethiopia lottery method was employed. To estimate number of street reproductive age groups in each selected city and the venues they frequently used for the purpose of survival work, an individual was assigned by an authorized person from the social and labor affair office. In addition, information regarding number of street-dwelling people in each city was requested from all concerned stakeholders. Finally, 845 samples were allocated proportionally to each selected cities. By using an individual who assigned by an authorized person, the first study respondent was identified. Then, the snowball sampling technique was used to recruit the representative sample [34].

2.3. Data Collection Tools and Procedure

Pretested and structured interviewer-administered questionnaire was used to collect the data. Data collection tool was adapted from the previous studies [1, 3, 6, 9–11, 16–18] and modified to fit the local context. The questionnaire designed to assess sociodemographic characteristics, alcohol use, and factors associated with alcohol use and sex after alcohol consumption. The pretest was conducted among 5% of street-dwelling people in nonselected cities. The result of the pretest used to modify the instrument. Four BSc midwives with previous experience on the data collection used as data collectors, and MSc holders were employed as supervisors.

2.4. Data Quality Control

The quality of the data was maintained by pretesting the tool and giving training for the data collectors and supervisors before the actual data collection. Every day after data collection, data reviewed and checked for completeness, accuracy, and clarity by the supervisors, and the necessary feedback was offered to data collectors. Data cleanup and crosschecking was done before analysis. To verify the internal consistency of the instrument, Cronbach’s alpha analysis of alcohol use and sex after alcohol consumption-related questionnaire parts were done with the value of 0.81 which mean that the instrument items have good internal consistency.

2.5. Data Management and Analysis

The data were checked manually for completeness, coded, and entered into Epidata version 3.1 and exported to SPSS version 23.0 for analysis. Binary logistic regression was used to determine the association of independent variables with the outcome variables. Odds ratio with their 95% confidence interval and value was used to identify the significant variables. The variables with value less than or equal to 0.05 were considered as significant.

2.6. Operational Definition

Substance use: any substance that is taken into the living organism that may modify one or more of its function. In this study, the concept of substance use includes alcoholic drinks, tobacco, khat, and marijuana.

Alcohol use: street-dwelling people used alcoholic drinks such as beer and local alcohols [Tella and Xeji] during the previous one year of study either always, every day, or at least once a week reportedly were considered as alcohol use, while those who were not used at all and using less than once peer week were taken as not utilizing [29].

Sexual intercourse after taking alcohol: those respondents who had sexual intercourse after taking alcohols such as beer and local alcohols [Xeji and Tella] reportedly within one year prior to the study.

2.7. Ethical Consideration

Ethical approval was obtained from Hawassa University, College of Medicine and Health Sciences Ethical Review Board. Next, official letters were submitted to Regional Health Bureau. Letter of permission was obtained from Regional Health Bureau to Respective Zonal Health Department, Woreda Health Office, and City Administration. Furthermore, a written consent was obtained from Social and Labor Affairs Office. The written and verbal consent was obtained from each study subject prior to the data collection process proceeded. For those who were less than 18 years, written informed consent was obtained from their parent or guardian prior to the data collection process which was also approved by ethical review board [34].

3. Results

3.1. Sociodemographic Characteristics

A total of 842 street-dwelling people were included in the study with a response of 99. 6%. More than half 503 (59.7%) of them were males (Table 1).

Table 1: Sociodemographic characteristics of street dwellers in Southern Ethiopia, 2019 ().

Variables
Frequency
Percent

Gender

    Male
503
59.7

    Female
339
40.3

Age in years

    15-18 years
246
29.3

    19-25
407
48.3

     ≥26 years
189
22.4

Marital status

    Single/not ever married
521
61.9

    Married
233
27.7

    Divorced/separated
73
8.7

    Widowed
15
1.8

Educational status

    Illiterate
187
22.2

    Elementary
542
64.4

    High school
102
12.1

    College and above
11
1.3

Schooling status

    In school
97
11.5

    Out of school
745
88.5

With whom currently living

    Alone
257
30.5

    Peers
382
45.4

    Boyfriend/girlfriend
135
16.0

    Parents
50
5.9

    Relatives
18
2.1

Place of current residence

    Hawassa
281
33.4

    Soddo
165
19.6

    Dilla
138
16.4

    Arba Minch
117
13.9

    Mizan Aman
108
12.8

    Yergalem
20
2.4

    Durame
13
1.5

Place of residence prior to starting street life

    Major urban town
313
37.2

    Small town
369
43.8

    Rural area
160
19.0

Type of street

    Street “on”
274
32.5

    Street “off”
568
67.5

Duration of stay on the street

     < 5 years
621
73.8

    5-10 years
168
20.0

     > 10 years
36
4.3

    Could not estimate
17
2.0

Daily income in birr

    5-20
136
16.2

    21-50
518
61.5

     ≥ 51
654
77.7

3.2. Substance Use among Street Dwellers

More than half 423 (53.2%) of the respondents had taken a drink that contains alcohol (tella, tegi, areke, and beer) in the last one year of the study period. More than half, 265 (59%), of substance users ever had sex after taking alcohol in the last one year. Similarly, among the 324 khat chewers, 190 (58.64%) of the respondents ever had sex after chewing khat in the last one year (Table 2).

Table 2: Substance abuse among street dwellers in Southern Ethiopia, 2019.

Variables
Frequency
Percent

A frequency of the drink contains alcohol use in the last 30 days ()

    Every day(30 days)
99
11.8

    None in the last 30 days
56
6.7

    Not sure/do not remember
155
18.4

A frequency of the drink contains alcohol use one year prior to the study ()

    Almost every day
116
13.8

    At least once a week
193
22.9

    Less than once a week
80
9.5

    Not sure/do not remember
34
4.0

Sex after taking alcohol one year prior to the study

    Yes
265
31.5

    No
155
18.4

    Not sure/I do not know
1
0.1

Ever chewed khat one year prior to the study

    Yes
324
38.5

    No
518
61.5

A frequency of chewing khat 30 days prior to the study

    Every day (30 days)
229
27.2

    None in the last 30 days
36
4.3

    Not sure/do not remember
59
7.0

Ever had sex after chewing khat

    Yes
190
22.6

    No
127
15.1

    Not sure/do not remember
1
0.1

A frequencies of smoking cigarette

    Every day
114
17.1

    Some day
179
21.3

    Not all
519
61.6

3.3. Alcohol Use and Cigarette Smoking

During the last 12 months of the study, 309 (36.7%) of the respondents had taken a drink that contains alcohol [CI: 35.5-39.7]. About 116 (13.8%) were drinking almost every day, and 193 (22.9%) drink at least once a week during the last one year. Regarding the frequency of alcohol use within the last 30 days of the study period, 155 (18.4%) of them did not remember, and 99 (11.8%) were taken every day reportedly.

More than one-third, 323(38.4%), of the street-dwelling people were smoking cigarette during the study period. Among the smokers, 114 (17.1%) were smoking every day, while 179 (21.3%) of them were smoking some days.

3.4. Factors Associated with Alcohol Use

Bivariate analysis factors found to be significantly associated with alcohol use were age, level of education, marital status, prior place of residence, and type of street, duration of stay on the street, ever heard about STDs, and being cigarette smokers. However, age, level of education, prior place of residence, ever heard about STDs, and being cigarette smokers were variables remain to be significantly associated with alcohol use in multivariate analyses. Accordingly, those who aged 19-25 and ≥26 years were about 51% (AOR: 0.49; CI: 0.34, 0.72) and 60% (AOR: 0.40; CI: 0.25, 0.65) less likely to use alcohol compared to those who were 15-18 years, respectively. Literate street-dwelling people were about 39% (AOR: 0.61; CI: 0.39, 0.94) less likely to use alcohol than those who were illiterate. In addition, those who were living in the major urban and small town prior to joining street life were about 69% (AOR: 0.31; CI: 0.18, 0.51) and 62% (AOR: 0.38; CI: 0.23, 0.63) less likely to use alcohol than those who were living in the rural area before joining street life, respectively. Likewise, those who ever heard about STDs were 86% (AOR: 0.14; CI: 0.07, 027) less likely use alcohol than their counterpart. Further, being a cigarette smoker were about 3 times (AOR: 2.67; CI: 1.94, 3.71) more likelihood of alcohol use compared to nonsmoker (Table 3).

Table 3: Bivariate and multivariate analyses of factors associated with alcohol use among homeless reproductive age people in southern Ethiopia, 2019 ().

Variables
Alcohol use
OR (95% CI)

Yes
No
COR (95% CI)
AOR (95% CI)

Age in years

    15-18
71
175
1
1

    19-25
153
254
0.67 (0.48, 0.95)
0.49 (0.34, 0.72)

    26 and more
85
104
0.49 (0.33, 0.74)
0.40 (0.25, 0.65)

Educational status

    Illiterate
43
144
1

    Literate
266
389
0.48 (0.33, 0.70)
0.61 (0.39, 0.94)

Marital status

    Single
207
314
1
1

    Married
60
173
1.90 (1.13, 2.68)
2.29 (0.82, 2.43)

    Divorced
42
46
0.72 (0.46, 1.14)
1.22(0.73, 2.03)

Place of residence prior to joining street life

    Major urban town
136
177
0.31 (0.19, 0.49)
0.31 (0.18, 0.51)

    Small town
142
227
0.38 (0.25, 0.59)
0.38 (0.23, 0.63)

    Rural area
31
129
1
1

Type of street

    Street “on” [return to home at the night]
90
184
1.28 (0.95, 1.74)
1.27 (0.92, 1.77)

    Street “off”[sleep on the street]
219
349
1
1

Duration of stay on the street

     < 5 years
194
427
2.66 (1.21, 4.36)
2.37 (0.89, 3.46)

    5-10 years
86
82
1.15 (0.62, 2.14)
1.42 (0.73, 2.74)

     > 10 years
29
24
1
1

Ever heard about STDs

    Yes
299
431
0.14 (0.07, 0.27)
0 0.14 (0.07, 027)

    No
10
102
1
1

Cigarette smokers

    Yes
161
162
2.49 (1.87, 3.33)
2.67 (1.94, 3.71)

    No
148
371
1
1

3.5. Sexual Intercourse after Alcohol Use and Associated Factors

Out of the total 266 (62.9%) had sexual intercourse after taking alcohol within the last one year of the study period [CI: 58.2-67.4]. Bivariate analysis variables such as gender, age, educational status, type of street, history of rape, ever tested for HIV, and ever heard about STDs were significantly associated with having sexual intercourse after alcohol use. However, gender, educational status, history of rape, and ever heard about STDs were significantly associated with having sexual intercourse after alcohol use in multivariate analysis. Those who were females were about 80% (AOR: 0.20; CI: 0.12, 0.36) less likely to have sexual intercourse following alcohol consumption compared to those who were male. In addition, those who literate were also about 75% (AOR: 0.25; CI: 0.12, 0.51) less likely to have sexual intercourse following alcohol use compared to those who were illiterate. Furthermore, those who had a history of rape in the last one year of the study were about 5 times (AOR: 4.95; CI: 1.67, 14.65) more likely to have sexual intercourse following alcohol use than their counterpart. Those who ever heard about STDs were about 78% (AOR: 0.22; CI: 0.70, 0.68) less likely to have sexual intercourse following alcohol use than their counterpart (Table 4).

Table 4: Bivariate and multivariate analyses of factors associated with sexual intercourse after alcohol use among homeless reproductive age people in southern Ethiopia, 2019 ().

Variables
Sexual intercourse after alcohol use
OR (95% CI)

Yes
No
COR (95% CI)
AOR (95% CI)

Gender

    Male
126
129
1
1

    Female
140
28
0.19 (0.12, 0.31)
0.20 (0.12, 0.36)

Age in years

    15-18
48
37
1.04 (0.59, 1.82)
1.06 (0.56, 1.98)

    19-25
148
68
0.62 (0.39, 0. 98)
0.77 (0.46, 1.29)

    26 and more
70
52
1
1

Educational status

    Illiterate
26
28
1
1

    Literate
240
129
0.49 (0. 28, 0.89)
0.25 (0.12, 0.51)

Type of street

    Street “on”
70
52
1.39(0.90, 2.13)
1.70 (0.68, 2.78)

    Street “off”
196
105
1

Rape in the last 1 year

    Yes
61
4
11.38 (4.05, 31.98)
4.95 (1.67, 14.65)

    No
205
153
1
1

Ever heard about STDs

    Yes
261
144
0.21 (0.07, 0.61)
0.22 (0.70, 0.68)

    No
5
13
1

Ever tested for HIV

    Yes
218
105
2.25 (1.43, 3.55)
1.37 (0.83, 2.26)

    No
48
52
1

 = Stay on the street at the day time and return to home at the night for sleep;  = Stay on the street both during the day and night time.

4. Discussion

During the last 12 months of the study period, 309 (36.7%) of the respondents had taken a drink that contains alcohol [CI: 34.8-40.7]. This finding is in line with the studies conducted in Texas (38%) [10], Toronto (40%) [22], and Egypt (35%) [23]. The present result is lower than the studies conducted in Los Angeles (30.8%) [19], Democratic Republic of Congo (63.5%) [24], and Ethiopia (64%) [18]; however, it is higher than the studies done in Ghana (12%) [6]. This discrepancy might be due to the difference in sociodemographic characteristics of the study respondents, sample size, and measurement tool. For instance, the study of Ghana was conducted among 227 street connected youths, and daily reported alcohol use was considered. In this study, those respondents reported used alcohol every day and at least once a week were considered as an alcohol user. This finding indicates the desire of an intervention on how to minimize substance misuses and its consequences among homeless people in the urban of Ethiopia.

In the present study, as the age increases, the consumption of alcohol decreases. This is in line with the previous study conducted in Ghana [6]. It could also be explained by the possible commencement of alcohol in early age which is viewed as a normal to create enjoyable physical and psychological environment [35]. In addition, literate street-dwelling people had also a less likelihood of alcohol use than those who were illiterate. This concept is also supported by the previous study done in Korea [36]. This might be due to the fact that being literate may increase a likelihood of awareness about the consequence of alcohol consumption. Another possible explanation is in the present study that more than two-thirds 655(77.8%) of the respondents had either elementary, high school, or college and above.

Place of residence prior to join street life was also significantly associated with alcohol use. Those who were living in the major urban and small town prior to join street life had less likelihood of alcohol use compared to those were living in the rural area. This might be due to the fact that those who joined street life from the towns might have awareness about the effect of alcohol use on health and sexual behaviors compared to those who joined street life from rural area.

On the other hand, ever heard about STDs was positively associated with alcohol use compared to their counterpart. This might be due to the impact of the shared information, and there might also an opportunity to hear about the health consequence of alcohol use. Moreover, being a cigarette smoker had also a more likelihood of alcohol use than nonsmoker. As evident in the previous studies, this is might be due to the intercorrelation between cigarette smoking and alcohol use [37, 38]. This finding is also in line with the previous study conducted among adolescents in Ethiopia [1].

Being a female had a less likelihood to practice sexual intercourse after alcohol use compared to those who were male. This might be due to the fear of sexual assault following alcohol consumption consequently resulted to unwanted pregnancy and its consequence. As evidenced by the previous study, females had a more likelihood of practicing safe sex than males [39] which could be achieved by avoiding sexual intercourse after alcohol use. The other possible explanations are because being a female is a protective factor of substance use [40].

Literate street-dwelling people had a less likelihood of sexual intercourse after alcohol use than those who were illiterate. This might be due to the fact that those who were literate can easily understand the adverse outcomes of sexual intercourse such as unwanted pregnancy and STDs. On the other hand, having history of rape prior to the study had a more likelihood of sexual intercourse after alcohol use than the counterpart. Even though there is no clear mechanism for the causality, this might be due to the unpleasant life events and psychological problems they faced during sexual assault which could made them to drink alcohol more and prone to sexual intercourse after consuming alcohol [41–43].

Moreover, the respondents who ever heard about STDs had also a less likelihood of having sexual intercourse after alcohol use than the counterpart. This might be due to the impact of the information gained about STDs and a fear of undesired sexual intercourse following alcohol use.

5. Limitations of the Study

Due to the nature of the study design, causality cannot be concluded. Moreover, as in all self-reported studies, we cannot rule out social desirability bias to sensitive questions, which might have introduced biases of unknown magnitude and direction.

6. Conclusions

In this study, significant percentage of respondents had taken a drink that contains alcohol one year prior to the study. Age, level of education, prior place of residence, ever heard about STDs, and being cigarette smokers were variables significantly associated with alcohol use. Furthermore, gender, educational status, history of rape, and ever heard about STDs were also significantly associated with having sexual intercourse after alcohol use. Awareness creation on the effect and outcome of substance use is recommended.

Abbreviations

STDs:
Sexually transmitted diseases.

Data Availability

The data used to support the conclusions of this study are available from the corresponding author upon request.

Disclosure

The funding body has no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Conflicts of Interest

The authors declare that they have no conflict of interest.

Acknowledgments

We are grateful to the Social and Labor Affair office staff at the southern nation, nationality, and people region for assisting us during data collection. This study was supported by the Center for International Reproductive Health Training at the University of Michigan (CIRHT-UM).

References

S. Getachew, S. Lewis, J. Britton, W. Deressa, and A. W. Fogarty, “Prevalence and risk factors for initiating tobacco and alcohol consumption in adolescents living in urban and rural Ethiopia,” Public Health, vol. 174, pp. 118–126, 2019.

V. Benegal, M. Sathyaprakash, and D. Nagaraja, Alcohol Misuse in the Andaman and Nicobar Islands, Report on project commissioned by the Indian Council of Medical Research and funded by Action Aid, India, 2008.

M. Sharma and M. Chaudhary, “A study of drugs and substance abuse among adolescents of slum dwellers,” International Journal of Indian Psychology, vol. 3, no. 4, pp. 21–27, 2016.

J. Jacobus, L. M. Squeglia, S. Bava, and S. F. Tapert, “White matter characterization of adolescent binge drinking with and without co-occurring marijuana use: a 3-year investigation,” Psychiatry Research, vol. 214, no. 3, pp. 374–381, 2013.

G. Battistella, E. Fornari, J. M. Annoni et al., “Long-term effects of cannabis on brain structure,” Neuropsychopharmacology, vol. 39, no. 9, pp. 2041–2048, 2014.

K. O. Asante, A. Meyer-Weitz, and I. Petersen, “Substance use and risky sexual behaviours among street connected children and youth in Accra, Ghana,” Substance Abuse Treatment, Prevention, and Policy, vol. 9, no. 1, p. 45, 2014.

B. Lioul and H. Jemal, “Does exposure to sexually explicit films predict sexual activity of the in-school youth? Evidence from Addis Ababa high schools,” Ethiopian Journal of Health Development, vol. 23, pp. 183–189, 2005.

J. Francis, H. Grosskurth, J. Changalucha, S. H. Kapiga, and H. A. Weiss, “Systematic review and meta-analysis: prevalence of alcohol use among young people in eastern Africa,” Tropical Medicine & International Health, vol. 19, no. 4, pp. 476–488, 2014.

G. Tesfaye, A. Derese, and M. T. Hambisa, “Substance use and associated factors among university students in Ethiopia: a cross-sectional study,” Journal of Addiction, vol. 2014, Article ID 969837, 8 pages, 2014.

D. M. S. Maria, S. C. Narendorf, and M. B. Cross, “Prevalence and correlates of substance use in homeless youth and young adults,” Journal of Addictions Nursing, vol. 29, no. 1, pp. 23–31, 2018.

N. E. Walls and S. Bell, “Correlates of engaging in survival sex among homeless youth and young adults,” Journal of Sex Research, vol. 48, no. 5, pp. 423–436, 2011.

K. J. Hodgson, K. H. Shelton, M. B. van den Bree, and F. J. Los, “Psychopathology in young people experiencing homelessness: a systematic review,” American Journal of Public Health, vol. 103, no. 6, pp. e24–e37, 2013.

S. E. Hadland, B. D. Marshall, T. Kerr, R. Zhang, J. S. Montaner, and E. Wood, “A comparison of drug use and risk behavior profiles among younger and older street youth,” Substance Use & Misuse, vol. 46, no. 12, pp. 1486–1494, 2011.

WHO, Understanding sexual and reproductive health including HIV/AIDS and STDs among street children, WHO, Geneva, Switzerland, 2000.

S. Chaudhury, S. K. Das, and B. Ukil, “Psychological assessment of alcoholism in males,” Indian Journal of Psychiatry, vol. 48, no. 2, pp. 114–117, 2006.

D. R. Siri Gowri, L. N. Suman, S. L. Rao, and P. Murthy, “A study of executive functions in alcohol dependent individuals: association of age, education and duration of drinking,” Indian Journal of Clinical Psychology, vol. 35, pp. 14–23, 2008.

N. Tadesse, T. Awoke Ayele, Z. Birhanu Mengesha, and K. Addis Alene, “High prevalence of HIV/AIDS risky sexual behaviors among street youth in Gondar town: a community based cross sectional study,” BMC Research Notes, vol. 6, no. 1, p. 234, 2013.

D. Habtamu and A. Adamu, “Assessment of sexual and reproductive health status of street children in Addis Ababa,” Journal of Sexually Transmitted Diseases, vol. 2013, 20 pages, 2013.

J. S. Tucker, G. W. Ryan, D. Golinelli et al., “Substance use and other risk factors for unprotected sex: results from an event-based study of homeless youth,” AIDS and Behaviour, vol. 16, no. 6, pp. 1699–1707, 2012.

J. A. Heerde, K. E. Scholes-Balog, and S. A. Hemphill, “Associations between youth homelessness, sexual offenses, sexual victimization, and sexual risk behaviors: a systematic literature review,” Archives of Sexual Behavior, vol. 44, no. 1, pp. 181–212, 2015.

J. A. Heerde and S. A. Hemphill, “Sexual risk behaviors, sexual offenses, and sexual victimization among homeless youth: a systematic review of associations with substance use,” Trauma, Violence & Abuse, vol. 17, no. 5, pp. 468–489, 2016.

M. N. Grinman, S. Chiu, D. A. Redelmeier et al., “Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status,” BMC Public Health, vol. 10, no. 1, 2010.

K. H. Nada and E. D. A. Suliman, “Violence, abuse, alcohol and drug use, and sexual behaviors in street children of greater Cairo and Alexandria, Egypt,” AIDS, vol. 24, Suppl 2, pp. S39–S44, 2010.

P. K. Kayembe, M. A. Mapatano, A. B. Fatuma et al., “Knowledge of HIV, sexual behavior and correlates of risky sex among street children in Kinshasa, democratic republic of Congo,” East African Journal of Public Health, vol. 5, no. 3, pp. 186–192, 2008.

K. Ahamad, K. DeBeck, C. Feng, T. Sakakibara, T. Kerr, and E. Wood, “Gender influences on initiation of injecting drug use,” The American Journal of Drug and Alcohol Abuse, vol. 40, no. 2, pp. 151–156, 2014.

D. Hathazi, S. E. Lankenau, B. Sanders, and J. Jackson Bloom, “Pregnancy and sexual health among homeless young injection drug users,” Journal of Adolescence, vol. 32, no. 2, pp. 339–355, 2009.

L. Embleton, D. Ayuku, L. Atwoli, R. Vreeman, and P. Braitstein, “Knowledge, attitudes, and substance use practices among street children in western Kenya,” Substance Use & Misuse, vol. 47, no. 11, pp. 1234–1247, 2012.

D. Rosenthal, S. Mallett, N. Milburn, and M. J. Rotheram-Borus, “Drug use among homeless young people in Los Angeles and Melbourne,” The Journal of Adolescent Health, vol. 43, no. 3, pp. 296–305, 2008.

R. Gomez, S. J. Thompson, and A. N. Barczyk, “Factors associated with substance use among homeless young adults,” Substance Abuse, vol. 31, no. 1, pp. 24–34, 2010.

K. Haile, H. Umer, G. Ayano, E. Fejo, and T. Fanta, “A qualitative exploration of substance misuse among homeless women in Addis Ababa, Ethiopia,” BMC Psychiatry, vol. 20, no. 1, p. 204, 2020.

K. Haile, H. Umer, T. Fanta et al., “Pathways through homelessness among women in Addis Ababa, Ethiopia: A qualitative study,” PLoS ONE, vol. 15, no. 9, article e0238571, 2020.

M. Ayenew, T. Kabeta, and K. Woldemichael, “Prevalence and factors associated with substance use among street children in Jimma town, Oromiya national regional state, Ethiopia: a community based cross-sectional study,” Substance Abuse Treatment, Prevention, and Policy, vol. 15, no. 1, p. 61, 2020.

M. Kassa, G. Buruh, S. Berhe, A. Aregay, and H. Berhe, “Prevalence and determinants of substance abuse among street children in Mekelle city, Tigray, Ethiopia,” Journal of Bio Innovation, vol. 3, no. 6, pp. 269–282, 2014.

N. Wakgari, T. Woyo, E. Kebede, H. Gemeda, and S. Gebremedhin, “Sexually transmitted disease among street dwellers in southern Ethiopia: a mixed methods study design,” BMC Public Health, vol. 20, no. 1, p. 434, 2020.

S. Kingston, M. Rose, J. Cohen-Serrins, and E. Knight, “A qualitative study of the context of child and adolescent substance use initiation and patterns of use in the first year for early and Later initiators,” PLoS ONE, vol. 12, no. 1, article e0170794, 2017.

S. Park and Y. Kim, “Prevalence, correlates, and associated psychological problems of substance use in Korean adolescents,” BMC Public Health, vol. 16, no. 1, p. 79, 2015.

B. F. Grant, D. S. Hasin, S. P. Chou, F. S. Stinson, and D. A. Dawson, “Nicotine dependence and psychiatric disorders in the United States: results from the National Epidemiologic Survey on alcohol and related conditions,” Archives of General Psychiatry, vol. 61, no. 11, pp. 1107–1115, 2004.

J. K. Bobo and C. Husten, “Socio-cultural influences on smoking and drinking,” Alcohol Research & Health, vol. 24, no. 4, pp. 225–232, 2000.

L. Rew, M. Grady, T. A. Whittaker, and K. Bowman, “Interaction of duration of homelessness and gender on adolescent sexual health indicators,” Journal of Nursing Scholarship, vol. 40, no. 2, pp. 109–115, 2008.

W. Li and N. Caltabiano, “Prevalence of substance abuse and socio-economic differences in substance abuse in an Australian community-dwelling elderly sample,” Health Psychology Open, vol. 4, no. 1, pp. 205510291770813–205510291770817, 2017.

T. M. Caldwell, B. Rodgers, A. F. Jorm et al., “Patterns of association between alcohol consumption and symptoms of depression and anxiety in young adults,” Addiction, vol. 97, no. 5, pp. 583–594, 2002.

K. Graham, A. Massak, A. Demers, and J. Rehm, “Does the association between alcohol consumption and depression depend on how they are measured?” Alcoholism, Clinical and Experimental Research, vol. 31, no. 1, pp. 78–88, 2007.

C. F. Helen, L. B. Keri, G. Peihua, and S. Rajita, “Interactive effects of cumulative stress and impulsivity on alcohol consumption,” Alcoholism, Clinical and Experimental Research, vol. 34, no. 8, pp. 1376–1385, 2010.