Peer Pressure Is the Prime Driver of Risky Sexual Behaviors among School Adolescents in Addis Ababa, Ethiopia

Abstract

Background: Understanding ecological factors that influence risky sexual behavior of adolescents is vital in designing and implementing sexual risk reduction interventions in specific contexts. Interventions undertaken without under-standing the critical factors may not produce the desired results. Objective: The objective of this study was to identify the factors associated with adolescent risky sexual behavior among school adolescents in Addis Ababa, Ethiopia. Methods: This cross-sectional study was done among randomly selected school adolescents in Addis Ababa, Ethiopia. Data were collected by an anonymous self administered questionnaire. Risky sexual behavior was assessed by asking question about sexual activity, consistent condom use and faithfulness to a single partner. Logistic regression analysis was done to identify factors related to sexual behavior using the ecological framework. Result: Overall 377 (10.6%) of the 723 sexually active students were involved in risky sexual practices. Risky sexual behavior was significantly and very strongly associated with perception of peers' involvement in sexual intercourse [AOR = 11.68 (95% CI: 8.76 -15.58)]. Conclusion: This study demonstrated that peer pressure is the most important factor associated with risky sex-ual behavior among school adolescents in Addis Ababa. Interventions aimed at reducing sexual behavior among school adolescents should target adolescents as a group rather than individually.

Full text

World Journal of AIDS, 2012, 2, 159-164
doi:10.4236/wja.2012.23021 Published Online September 2012 (http://www.SciRP.org/journal/wja) 159
Peer Pressure Is the Prime Driver of Risky Sexual
Behaviors among School Adolescents in Addis Ababa,
Ethiopia
Amsale Cherie1*, Yemane Berhane2
1School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia; 2Addis Continental Institute of Public Health, Addis
Ababa, Ethiopia.
Email: *amsalec2002@yahoo.com, Yemaneberhane@ethionet.et, Yemane_b@hotmail.com
Received April 23rd, 2012; revised May 28th, 2012; accepted June 28th, 2012
ABSTRACT
Background: Understanding ecological factors that influence risky sexual behavior of adolescents is vital in designing
and implementing sexual risk reduction interventions in specific contexts. Interventions undertaken without under-
standing the critical factors may not produce the desired results. Objective: The objective of this study was to identify
the factors associated with adolescent risky sexual behavior among school adolescents in Addis Ababa, Ethiopia.
Methods: This cross-sectional study was done among randomly selected school adolescents in Addis Ababa, Ethiopia.
Data were collected by an anonymous self administered questionnaire. Risky sexual behavior was assessed by asking
question about sexual activity, consistent condom use and faithfulness to a single partner. Logistic regression analysis
was done to identify factors related to sexual behavior using the ecological framework. Result: Overall 377 (10.6%) of
the 723 sexually active students were involved in risky sexual practices. Risky sexual behavior was significantly and
very strongly associated with perception of peers’ involvement in sexual intercourse [AOR = 11.68 (95% CI: 8.76 -
15.58)]. Conclusion: This study demonstrated that peer pressure is the most important factor associated with risky sex-
ual behavior among school adolescents in Addis Ababa. Interventions aimed at reducing sexual behavior among school
adolescents should target adolescents as a group rather than individually.
Keywords: Risky Sexual Behavior; School; Peer Norms; Adolescent
1. Introduction
Risky sexual behavior predisposes young people to a
variety of sexuality associated problems including HIV.
Strategies to prevent the spread of HIV and other sexu-
ally transmitted infections have focused on abstinence,
being faithful, condom use and delayed sexual activity.
However available evidences show that significant pro-
portion of adolescents are engaged in risky sexual be-
haviors that expose them to a variety of sexually trans-
mitted infections including HIV [1-5].
Approximately half of the new HIV infections globally
occur in the age group 15 to 24 years [6]. In Ethiopia
about 90% of the people living with HIV are believed to
have acquired the infection before the age of 25 mainly
through unprotected sexual intercourse [7,8].
Although significant proportion of young people in
Ethiopia are known to be involved in risky sexual be-
havior such as early sexual initiation, multiple partner
sexual relationships, low use of condom, and sex in ex-
change of money identifying the factors associated with
these behaviors so far have been focused on individual-
level factors [9-11]. Extant literatures revealed that peer
norms influence sexual initiation and subsequent sexual
behaviors [12-14]. Adolescents who perceive their
friends are engaged in sexual practices are more likely to
adopt those same behaviors [12-14]. Sexual risk behavior
is affected and effected by a complex web of factors at
the individual, family, school and peer levels [15-17].
Understanding these interwoven and interconnected
factors that influence sexual behaviors of adolescent is
vital in designing and implementing sexual risk reduction
interventions. Using the ecological framework in study-
ing adolescent sexual behavior can widen the scope of
investigation in assessing factors that influence adoles-
cent sexual behaviors in specific contexts. Thus, this
study was intended to assess the factors associated with
risky sexual behavior among school adolescents using
the ecological framework.
*Corresponding author.
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Peer Pressure Is the Prime Driver of Risky Sexual Behaviors among School Adolescents in Addis Ababa, Ethiopia
160
2. Methods and Materials
This was a cross-sectional study conducted among high
school adolescent living in Addis Ababa, Ethiopia. The
city of Addis Ababa is divided into 10 sub cities and each
sub city is divided into 10 districts. The study population
was randomly selected using a multi-stage sampling
method that aimed at selecting 3840 eligible students
from 10 high schools in Addis Ababa. The total sample
size was distributed to each school proportionate to their
size. In the first stage schools were randomly selected
from each sub city then sections were selected randomly
from each school proportionate to the student population
size.
Data were collected using a self administered ques-
tionnaire that had several sections dealing with sexual
behaviors and elements of the ecological framework in-
cluding individual, family, school and peer level factors.
The questionnaire was primarily prepared in English
based on similar questionnaires used elsewhere [1,16,17]
and then translated and administered in Amharic which is
the official language of the country. Prior to the study a
pretest was conducted in schools not selected for the
study and the necessary adjustment in language and con-
tent was done. Data collection was facilitated by ten
nurses under the supervision of two public health experts.
Risky sexual behavior was computed by considering
several key questions, which included “have you ever
had sexual intercourse, Have you had sex in the past 12
months how many partners have you had in the 12
months; have you consistently used condom during sex-
ual intercourse in the past 12 months, and have you re-
ceived or given gift/money at the exchange of sex”.
Those having more than one partner or not consistently
used condom, or engaged in exchange sex in the last 12
months were considered to be in risky sexual behavior.
Then, those engaged in risky sexual behavior were coded
“1” and the remaining “0”.
The questionnaire also consisted of individual level
factors such as sex, age, self-esteem, college aspirations,
knowledge about HIV, perception of condom use self
efficacy, attitude towards condom and perceived negotia-
tion of condom use. Students were also asked about fam-
ily factors such as parental education, parental connect-
edness, parental communication about sex, parental norm
and parental monitoring. The questionnaire comprised of
also questions related to school connectedness and peer
factor perceived engagement of peers in sex.
The study received ethical approval from the Institu-
tion Review Board of Faculty of Medicine of Addis
Ababa University. In addition, verbal consent of indi-
vidual participants was obtained after being fully in-
formed of the study purpose and procedures. Confidenti-
ality and anonymity were ensured. No name or other
identifying information was included in the instrument.
3. Data Analysis
Data analysis was done using SPSS version 15 statistical
package. We first conducted bivariate analysis between
risky sexual behavior as dependent and a range of inde-
pendent variables. Then a series of four step regression
models were fitted using the variables found to be sig-
nificant in the bivariate analysis to assess associations
between risky sexual behavior and various elements of
the ecological framework-individual, parental, school
and peer level factors. In the first step individual level
variables such as sex, age, self-esteem, college aspira-
tions, knowledge about HIV, perception of condom use
self efficacy, attitude towards condom and perceived
negotiation of condom use were entered. In the second
step parental monitoring and parental norms towards
premarital sex was added in the model. The third model
comprised of the entry of school connectedness in the
model. The fourth model included perceived engagement
of peers in sex. Finally, we constructed a final reduced
model, which included only those variables significantly
associated with sexual risk behavior.
4. Results
From the 3840 eligible respondents, 3543 (92.5%) in
school adolescent fully responded to the self adminis-
tered questionnaire. Of all the respondents nearly half
1789 (50.5%) were females. Nearly a quarter of students
were in the age group 15 - 16 years and more than half of
students were living with both parents. One sixth of stu-
dent’s fathers and one fifth of students mothers were
with out formal education. A total of 723 (20.4%) stu-
dents reported ever having sexual intercourse (Data not
shown).
Risky sexual behavior of participants is depicted in
Table 1. Over all 377 (10.6%) of the study participants
were involved in risky sexual behavior in the past 12
months sex. A total of 574 (79.4%) of the sexually active
students had reported that they have been sexually active
in the 12 months preceding the survey, 262 (45.6%) had
sex with more than one sexual partner, 319 (55.6%)
didn’t use condom consistently and 118 (20.6%) were
involved in sex at the exchange of money.
Model 1 (individual) variables predicted 26.1% of the
variance in sexual activity. When parental factors were
added in the model in the second step the explanatory
power of the model increased to 32.9%. School connect-
edness was added to the model in the third step. The third
step accounted for 37.8% of the variance. In the fourth
step peer level factor was entered. When perceived en-
gagement of peers in sex was added in model 4 the ex-
planatory power of the model increased to 54.3%. The
final model accounted for 58.5% of the variance in sex-
ual activity.
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Peer Pressure Is the Prime Driver of Risky Sexual Behaviors among School Adolescents in Addis Ababa, Ethiopia 161
Table 1. Risky sexual practice among high school adolescents in
Addis Ababa, Ethiopia.
Variables No (%)
Ever had sex
Yes
No
723 (20.4)
2820 (79.6)
Had sex in the past 12 months
Yes
No
574 (79.4)
149 (20.6)
Number of partners at past 12 months sex
One
Greater than one
312 (54.4)
262 (45.6)
Condom use at the past 12 months sex
Yes
No
255 (44.4)
319 (55.6)
Sex at the exchange of money
Yes
No
118 (20.6)
456 (79.4)
Risky sexual behavior
Yes
No
377 (10.6)
3166 (89.4)
The independent correlates of risky sexual behavior
are shown in Table 2. Respondents were likely to ex-
perience risky sexual behavior if they had low knowl-
edge of HIV [AOR = 1.50 (95%CI: 1.15 - 1.96)], re-
ported low self esteem [AOR = 1.42(95%CI: 1.06 - 1.89)]
and manifested low perceived efficacy to use condom
[AOR = 1.93 (95%CI: 1.46 - 2.55)].
Parental monitoring was significantly associated with
risky sexual behavior [AOR = 1.42 (95%CI: 1.06 - 1.89)].
Restrictive parental norms towards sex were a protective
from risky sexual behavior [AOR = 0.77 (95%CI: 0.61 -
0.99)]. Students who were less connected to school were
more likely to be involved in risky sexual behavior than
their counterparts [AOR = 1.39 (95%CI: 1.03 - 1.86)].
Most importantly students who perceived their peers are
involved in sexual relationships were more likely to re-
port risky sex behavior compared to those who did not
have this perception [AOR = 11.68 (95%CI: 8.76 -
15.58)].
5. Discussion
This study revealed that one in five high school students
have initiated sexual activity and about half of those who
initiated sex were involved in risky sexual practices.
Analysis of the factors associated with risky sexual be-
havior using the ecological framework indicated peer
pressure is the most important predictor.
The study used an extensive sampling procedure and
large sample size to maximize the representation of the
sample to high school students in Addis Ababa and simi-
lar settings. Although, social-desirability biases are likely
and can lead to underestimation of risky sexual behaviors,
efforts were made to minimize this bias by proving a safe
environment to complete the questionnaire and omitting
all identifying variables from the questionnaire to ensure
anonymity. The cross sectional nature of the study does
not allow the full exploitation of temporal relationships
and establishing causality. Nonetheless the risky sexual
behavior observed in this study is still very high requir-
ing carefully designed interventions that consider break-
ing peer influences, the prime predictor of risky sexual
behavior in this population.
Individual level factors had significant association
with risky sexual behavior. In agreement with previous
studies [18-24] low self esteem and perceived low self
efficacy to use condom were significantly associated
with risky sexual behavior in this study as well. Pro-
grams that are known to increase the self esteem of
young people and condom use skill training need to be
integrated in school curriculum to promote healthy sex-
ual life for school adolescents.
In accordance with studies made elsewhere low pa-
rental monitoring and permissive parental norms were
significantly associated with greater involvement in risky
sexual behavior [25-29]. Parents are the primary social-
izing agents and have significant influence on their chil-
dren’s behavior. Up until know there is no institution or
programme in Ethiopia providing training on the appro-
priate way of parenting. Therefore, training parents on
how to nurture their children have supreme importance in
risk behavior reduction and there by diminution of HIV
acquisition.
Corroborating with previous studies adolescent who
perceive their friends are engaged in risky sexual behav-
ior, were more likely to adopt those same behaviors.
[18,29,30]. Peers have significant influences on young
peoples behavior. Therefore, strengthening school peer
education programmes to create a culture of positive peer
influence is critical.
Students who perceived connected to school were less
likely to be engaged in risky sexual behavior in this study.
There are also evidences that showed poor connectedness
to school were significantly associated with risky sexual
behavior [30-32]. Students need to get more opportuni-
ties to stay longer and safely in school environment to
promote appropriate student-teacher relationship that can
promote sexual risk reduction behaviors. Furthermore,
interventions and programmes are needed that reinforce
access to positive social connections at school and pro-
vide nurturing and caring social contexts in schools.
Encouraging safe sexual behavior is one of the strate-
gies in the prevention of HIV and other sexually trans-
mitted infections. The study clearly showed the priority
intervention among high school students is to promote
positive peer-to-peer influence to promote safer sexual
behavior among high school students. At the same time,
promoting appropriate parenting and improving the school
environment can augment the effectiveness of peer tar-
geted interventions.
This study assessed the determinants of sexual behav-
ior at various levels of the ecological space. However, to
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Peer Pressure Is the Prime Driver of Risky Sexual Behaviors among School Adolescents in Addis Ababa, Ethiopia
Copyright © 2012 SciRes. WJA
162
Table 2. Independent correlates of risky sexual behavior among 3543 high school students in Addis Ababa, Ethiopia, 2009.
Risky sexual behavior (n = 3543)
Sources of effect Yes No
Un adjusted OR (95%CI) Adjusted OR (95%CI)
Model I: Individual factors
knowledge about HIV
Low
High
272
105
2041
1125
1.43 (1.13 - 1.81)
Reference
1.49 (1.14 - 1.94)
Reference
Self esteem
Low
High
259
118
1356
1810
2.93 (2.33 - 3.68)
Reference
1.43 (1.07 - 1.92)
Reference
Attitude towards condom
Negative
Positive
274
103
1683
1483
2.34 (1.84 - 2.97)
Reference
1.65 (1.28 - 2.13)
Reference
Perceived Self efficacy to use condom
No
Yes
219
158
891
2275
3.53 (2.84 - 4.40)
Reference
1.90 (1.44 - 2.52)
Reference
Model II: Parental factors
Parental monitoring
No
Yes
253
124
1659
1507
1.85 (1.47 - 2.32)
Reference
1.39 (1.08 - 1.79)
Reference
Parental norms towards sex
Restrictive
Non-restrictive
182
195
2011
1155
0.53 (0.43 - 0.66)
Reference
0.78 (0.61 - 0.99)
Reference
Model III: School factors
School connectedness
Low
High
104
273
433
2733
2.40 (1.87 - 3.08)
Reference
1.37 (1.02 - 1.84)
Reference
Model IV: Peer factors
Perceived involvement of peers in sex
Yes
No
92
285
101
3065
9.79 (7.20 - 13.32)
Reference
11.49 (8.49 - 815.55)
Reference
Final Model P < 0.1
Knowledge about HIV
Low
High
272
105
2041
1125
1.43 (1.13 - 1.81)
Reference
1.50 (1.15 - 1.96)
Reference
Perceived self efficacy to use condom
No
Yes
219
158
891
2275
3.53 (2.84 - 4.40)
Reference
1.93 (1.46 - 2.55)
Reference
Self esteem
Low
High
259
118
1356
1810
2.93 (2.33 - 3.68)
Reference
1.42 (1.06 - 1.89)
Reference
Parental monitoring
No
Yes
253
124
1659
1507
1.85 (1.47 - 2.32)
Reference
1.42 (1.09 - 1.83)
Reference
Parental norms towards sex
Restrictive
Non-restrictive
182
195
2011
1155
0.53 (0.43 - 0.66)
Reference
0.77 (0.61 - 0.99)
Reference
School connectedness
Low
High
104
273
433
2733
2.40 (1.87 - 3.08)
Reference
1.39 (1.03 - 1.86)
Reference
Perceived involvement of peers in sex
Yes
No
92
285
101
3065
9.79 (7.20 - 13.32)
Reference
11.68 (8.76 - 15.58)
Reference
better understand the causes of adolescent risky sexual
behavior longitudinal investigations that track the ante-
cedents of sexual behavior are needed. Secondly, studies
on factors contributing to positive adolescent develop-
ment are needed to assess the assets in and outside stu-
dents so that, interventions and programmes which can
foster positive behavior can be developed and imple-
mented.

Peer Pressure Is the Prime Driver of Risky Sexual Behaviors among School Adolescents in Addis Ababa, Ethiopia 163
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