Premarital Sexual Practice and Its Predictors Among Preparatory School Students Living with and Without Parents in Hossana Town, Southern Ethiopia

Globally, pre-marital sexual activities among adolescents have been reported to be increasing. Many studies in SubSaharan Africa, including Ethiopia, had reported that there were increasing premarital sexual activities among adolescents and youths. Besides, they are risk-takers who are more likely to make decisions about the future without adequately considering the consequences. The study aimed to assess the premarital sexual practice and its predictors among preparatory school students living with and without parents in Hossana Town, Southern Ethiopia. An institution-based comparative crosssectional study design was carried out using a self-administered questionnaire. The sample size was determined by using EPI INFO version 3.5.3 software of two population proportions. The sample size for students who were living without parents and with parents was 202 and 404, respectively, and the overall sample size including a 10% non-response rate was 606. The predictors of pre-marital sexual debut were assessed using bivariate and multivariable logistic regression. The magnitude of pre-marital sexual practice was 105 (27%) and 76 (39%) among students who were living with and without their parents, respectively. Watching pornography videos [AOR=4.9, 95% CI: 2.4, 10.2], discussing about sexual issues with their friends or peers [AOR=3.5, 95% CI: 1.72, 7.15], drinking alcohol [AOR=6.62, 95% CI: 2.26, 19.36], and educational status of the father were predictors for students who live with their parents while discussing about sex with [AOR=5, 95% CI: 1.12, 5.6], watching pornography videos [AOR=2.7, 95% CI: 1.16, 6.07] drinking alcohol [AOR=6.0, 95% CI: 1.2, 29.7] were also predictors for students who live without their parents. The prevalence of pre-marital sexual practice was high in both groups; especially students who live without their parents. Thus, public health interventions should predominately focus on behavioral, social, and environmental factors of pre-marital sexual practices.


Introduction
According to the World health organization (WHO) definition, adolescents are individuals in the age group 10-19 years old and youth are 15-24 years age group [1]. Youths highly concern with physical and sexual attractiveness, have an increased interest in the opposite sex, and are frequently changing relationships. In addition, they are risk-takers who are more likely to make decisions about the future without adequately considering the consequences [2]. Globally, premarital sexual activities among adolescents have been reported to be increasing [3]. Many studies in Sub-Saharan Africa had reported that there were increasing premarital sexual activities among adolescents and youths [4,5]. Youths often face strong peer, social and cultural pressure to engage in premarital sex. Significant numbers of adolescents are involved in sexual activities at an early age [3,6]. Previous studies documented that adolescents engage in premarital sex with insufficient knowledge of reproductive health, family planning, and the small proportion of use contraceptive [7][8][9].
According to the results of various studies were conducted in Ethiopian preparatory or high schools and universities, pre-marital sexual practice varies from 11.9% to 54.3% [7,[10][11][12][13][14][15][16]. In similar studies, being male, chewing chat, peer pressure, drinking alcohol, watching pornography film were factors statistically associated with the pre-marital sexual practice. The result of these findings showed that there is inconsistency among different settings in Ethiopia. In addition, adolescents who experienced peer pressure from their friends were found more likely to involve in premarital sexual practice than those adolescents who didn't experience peer pressure from their friends. Youth who begin early sexual activity are more likely to be exposed to high-risk sex, often having multiple partners. Risky sexual activity results not only in exposing youths to STIs and HIV/AIDS, but also unwanted pregnancy in females, which may cause serious health, social, economic problems, and a failure to complete their education [17,18].
In Ethiopian, due to the absence of preparatory schools in the rural and semi-urban settings, many students live in rental houses with friends or with their relatives. They often take advantage of autonomy from direct parental regulation and guidance to express their freedom by initiating sexual activity without adequate protection. Indeed, living far away from their parents give a high level of personal freedom and social interactions, this offers an opportunity for a high level of sexual networking. Especially, in the study area, a number of students come from the rural environment and are living far apart from their families. Consequently, there is an information gap regarding risky sexual behaviors [19]. Access to healthcare and sources of information, education, and support also vary extensively [9,20]. The key issues, barriers, and challenges, as well as potential solutions, can be identified across the county [21]. It is crucial to identify the determinants of pre-marital sexual activity to inform policymakers and local program managers. However, preparatory school students' premarital sexual practice and its predictors were not dealt with in-depth within the study area.
Therefore, studying premarital sexual practices and its predictors is an essential issue for policymakers as well as for organizations that work in the area. Thus, this study tried to identify premarital sexual practices and associated factors among preparatory school youths in the study area.

Study Design and Setting
An institution based comparative cross sectional study design was employed from 19 October to 17 November 2018. The study was conducted in Hossana town, Southern Ethiopia, which is located 230 km from Addis Ababa, capital city of Ethiopia. In the town, there are two governmental and two private preparatory schools and the total number of students were 3626 and 1776, respectively [22].

Sample Size Determination Sampling Procedure
All preparatory school students who were residing and learning in the study area were considered as source population while those respondents of preparatory school youths aged 15 to 24 years who were enrolled as regular daytime students in the study period and available during data collection period were taken as a study population.
The sample size was determined by using EPI INFO version 3.5.3 soft ware of two population proportion formulas by assumption of 95% confidence interval, 80% power and by considering "Pocket money" as a factor for pre-marital sexual activity to bring difference in two populations from the research conducted at Eastern Hararge zone school students.

n1 = =
Where: -n 1 =sample size for students living without parents and n 2 =sample size for students living with parents, then students living without parents to students living with parents ratio will be r= = 2 P=Pooled estimate of p1 and p2 P 1 =29%, the proportion of students who were having pocket money for students living without parents P 2 =18%, the proportion of students who were having pocket money for students living with parents (expected frequency of exposure among students who were living with parents). The sample size for students who were living without parents and with parents were 202 and 404, respectively and overall sample size including 10% non response rate was 606.

Sampling Procedure
There were three preparatory schools in the town and all of them were included in the study. The total number of the students was 5402; of these 2859 and 2543 were living without and with parents, respectively.
Based on this, a sampling frame that enlists all students was prepared at each school and section. The number of study units to be sampled from each school and section by using proportional allocation to the number of students in each section and systematic random sampling was applied to select each study subject. A first student in each section was selected by the simple random sampling method. The next student in the section was identified systematically by every sampling interval. Finally, by using a systematic random sampling method the study subjects were selected.
Study variables: Premarital sexual practice was a dependent variable, whereas age, sex of the student, religion, ethnicity, pocket money, educational status of the parents, family income, condom use, chewing khat, alcohol drinking, smoking cigarette, and watching pornographic movies were independent variables.

Operational Definitions
Premarital sex: -doing sexual intercourse with before marriage Living with parents: -living with one or both parents Living without parents: -living alone or with anyone except parents

Data Collection Procedures
Data was collected by self-administered using a structured and pre-tested questionnaire. The questionnaire was first prepared in English and then was translated into Amharic (a local language) to suit local applicability and finally, back to English to ensure its consistency. These questionnaires were adapted from different kinds of literature developed for similar purposes by considering the local situation of the study subjects. The Amharic version questionnaire was pretested for clarity or ambiguity. Based on the findings of pre-testing, the questions with certain ambiguity were modified to ensure validity and then the corrected questionnaires were distributed to the data collectors to collect the data. Data collectors and supervisors were trained for two consecutive days on the points on how to take informed consent, how to approach study participants, ethical procedure, and the objectives of the study.

Data Management and Analysis
All the questionnaires were entered, edited, coded and cleaned in the Epi-info version 3.5.3 and exported to SPSS version 24 software packages for analysis. The data were analyzed using logistic regression (bivariate and multivariable) to determine the effect of various factors on the outcome variable and to control the confounding effect. The results were presented in the form of tables, figures, and text using frequencies and summary statistics such as mean, standard deviation and percentage to describe the study population in relation to relevant variables. The degree of association between independent and dependent variables was assessed using odds ratio, 95% confidence interval and p-value <0.05 to be considered as significant.

Ethical Consideration
Ethical clearance and supportive letter to undertake the study was obtained from the Wachemo University Ethical review board and the formal letter of permission was taken from Hossana town educational office. All the study participants were informed about the objective and importance of the study and their verbal consents were obtained before commencing data collection. They were also informed about their right of not participating in the study at any time.

Socio-demographic Characteristics of the Study Participants
A total of 576 students participated in the study with a response rate of 95%. Of these, 192 and 384 were living without and with their parents, respectively. Among these, 209 males and 175 females were living with their parents and, 102 males and 90 females living without parents. The majority, 255 (66%) and 164 (85%) of the students were living with and without parents of age greater than 18 years, respectively. With regard to respondents religious, more than half of them 247 (64%) living with their parents and 117 (61%) living without parents were protestants. Pertaining to the ethnicity of the study participants, majority 228 (59%) and 126 (66%) who were living with and without their parents were Hadiya, respectively (Table 1).

Parental Socio-demographic Characteristics of Respondents
More than three-fourth 317 (83%) parents were living in the urban among students who were living with their parents while almost half 108 (56%) of parents were dwelling in rural among students who were living without their parents. Living with and Without Parents in Hossana Town, Southern Ethiopia Two-hundred six (54%) and 50 (26%) fathers had diplomas and above among students living with and without their parents, respectively. Regarding the occupational status of the mothers, around half 184 (48%) and two-third 119 (62%) of the students' mothers were housewives among students who were living with and without parents, respectively.

Predictors of Premarital Sexual Practice Among Preparatory School Students Who Were Living with Parents in Hossana Town, Southern Ethiopia, 2018
Variables which could persist in having a determinant effect in the multivariable analyses were watching pornography videos, educational level of fathers, discuss about sex with their friends and alcohol drinking. Students had watched pornography videos were five times more likely to practice premarital sex than their counterparts [AOR=4. 9

Predictors of Premarital Sexual Practice Among Preparatory School Students Who Were Living without Parents in Hossana Town, Southern Ethiopia, 2018
There were three variables had a determinant effect among many. Students had watched pornography videos were three times more likely to practice premarital sex than their counterparts [AOR=2.7, 95% CI: 1.16, 6.07]. Students who discussed about sex with their friends/peers were almost five times more likely practiced premarital sex than who didn't discuss [AOR=5, 95% CI: 1.12, 5.6] and Students drank alcohol six times more likely to exercise premarital sex than who didn't drink [AOR=6, 95% CI: 1.2, 29.7] ( Table 5).

Discussion
Youths have an increased interest in the opposite sex, highly concerned with physical and sexual attractiveness, and are frequently changing relationships. Besides, they are risk-takers who are more likely to make decisions about the future without adequately considering the consequences [2]. In this study, the prevalence of premarital sex was found to be 27% and 39% among preparatory school students who were living with and without parents, respectively. Students lived with relatives, friends or lonely instead of their biological parents, and thus lack familial control and liberal lifestyles, and then more exposed to premarital sex. This result was slightly higher than studies done in west Gojjam zone (19%), in Nekemte town (21.5%), Eastern Ethiopia (24.8%), Northern Ethiopia (21.1%) and Kolfe Keraniyo sub-city in Addis Ababa (19.8%) [7,11,13,23,24], whereas it was lower than from studies conducted in Jimma town (42.1%) [25], Madawalabu University (42.7%), Yabello town, Southern Ethiopia (71.9%), Bale Zone (51.9%) [4,20,26]. This discrepancy may be due to the difference in socio-cultural and schooling status among the study participants. Among students who were living without their biological parents 77% of them didn't use condom sometimes or at all during sexual activity, 50% of the female students encountered with abortion, 86% of the khat chewers, 90% of the alcohol users and 75% of the cigarette smokers engaged in premarital sex. On the other hand, among students who were living with their biological parents 73% of them didn't use condom sometimes or at all during sexual activity, 22% of the female students encountered with abortion, 71% of the khat chewers 54% of the alcohol users 50% of the cigarette smokers engaged in premarital sex. Living without biological parents attributes for risky sexual behavior [27]. Watching pornographic movies play a significant role in the commencement of earlier sexual practice which was consistent with the study done in Debre Berhan University [7,14,28,29]. A possible explanation might be because of the potential stimulating effect on sexual desire and its power to increase comprehended pleasure from sexual intercourse.
Alcohol use was one of the most powerful predictors of premarital sexual activity among both living with and without parents in this study and this was in line with the studies done in Gamo Gofa, South West Ethiopia [30] and Jimma Town [25]. Father's educational status was one of the associated factors for premarital sex for students living with parents but not for living without parents. When the educational level of the fathers increases, students' premarital sexual activity decreases. This might be due to more educated fathers have good knowledge about the risk of premarital sex and advise their sons/daughters. Youth face a higher risk of complications and death as a result of unwanted pregnancy than older women. Healthcare workers have an important role to play in the advancement and commitment to promoting adolescent sexual and reproductive health services. Addressing the global problems of adolescent health is critical to the future of a country's health and must be led by those at the front line healthcare workers.

Limitation
The major limitation of this study was the nature of the cross-sectional study which may not explain the temporal relationship between the outcome variable and some explanatory variables. The study topic by itself assesses personnel and sensitive issues related to sexuality which might have caused social desirability bias.

Conclusion
Many students are recently engaging in premarital sexual activities due to a number of reasons. The prevalence of premarital sexual practice in our study was high in both groups compared to other studies; especially students who live without their parents. Thus, public health interventions should predominately focus on behavioral, social, and environmental factors of the pre-marital sexual practices. Preparatory schools should avail or launch different antisubstance use clubs and appropriate guidance in the schools. Furthermore, parents have to follow their son/daughter day to day activities (i.e. either he/she is properly learning and attending class or not). Besides, Education, health bureaus, and healthcare workers should work cooperatively on students' behavior to minimize substance use and creating awareness on the disadvantages of premarital sexual activities.

Competing Interests
We declare that there are no conflicts of interest associated with this publication