# Knowledge, Attitude, and Preventive Practices towards Sexually Transmitted Infections among Preparatory School Students in West Gojjam Zone, Ethiopia

Authors: Ayalnesh Asmamaw Kassie; Temesgen Worku Gudayu; Bilen Mekonnen Araya
Journal: Advances in Public Health
 (2020)

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## Abstract

Background. Sexually transmitted infections are major public health concerns that mostly affect adolescents and young people. Hence, the aim of this study was to assess students’ knowledge, attitude, and preventive practice towards sexually transmitted infections and the associated factors. Methods. A school-based cross-sectional study was conducted from October 24 to November 4, 2018. A sample size of 845 was calculated and a 1-stage sampling technique was employed. Data were collected through a self-administered questionnaire. The data were entered into Epi-Info 7.2 and analyzed using IBM SPSS version 25 software. The descriptive result was presented in text, figure, and tables. Also, bivariate and multivariable logistic regression analyses were done to identify associated factors. Then the adjusted odds ratio and its 95% confidence interval were computed. And a p value of <0.05 was considered to assert statistical significance. Results. Half of the respondents (50.5%) had good knowledge on sexually transmitted infections. Also, 46.4% of students had a good preventive practice. However, only 38.4% of students had an appropriate attitude towards sexually transmitted infections. Being a male (AOR: 1.58 (95% CI: (1.19, 2.09)) and having employed father (AOR: 1.97 (95% CI: (1.18, 3.30)) predicted good knowledge. Similarly, secondary and above level of paternal education (AOR: 2.16 (95% CI: (1.28, 3.64)) and having a farmer father (AOR: 1.77 (95% CI: (1.04, 3.02)) predicted appropriate attitude. Predictors of preventive practices included elder age (AOR: 2.33 (95% CI: (1.27, 4.28)), never had sexual intercourse (AOR: 1.44 (95% CI: (1.07, 1.94)), and having good knowledge on STIs (AOR: 1.53 (95% CI: (1.16, 2.02)). Conclusion. The proportion of students that had good knowledge, appropriate attitude, and good preventive practice towards STIs were low. Personal and parental factors predicted students’ knowledge, attitude, and preventive practices. Hence, creating awareness need to be strengthened.


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## Body

## 1. Background

Sexually transmitted infections (STIs) are major universal public health concerns. The infections cause an acute illness, infertility, disability, and death [1]. Young people and adolescents are among the vulnerable groups for sexually transmitted infections (STIs). In a global report, there was an annual estimate of 357–376 million curable new cases of STIs that were diagnosed among adolescents and adults [2].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 [3].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 [4]. In most cases, sexually transmitted infections are asymptomatic and that makes it difficult to diagnose [5]. In addition, most adolescents, those particularly from a rural society, might not have access to the required information and services to prevent STIs [3]. So, such a condition coupled with syndromic management of STIs in resource-limited countries, could further facilitate the transmission of infection. As a result, particularly females who were infected with STIs could experience acute symptoms, chronic infection, and serious delayed consequences such as ectopic pregnancy, infertility, and cervical cancer [6].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.


## 2. Methods

### 2.1. Study Design

School-based cross-sectional study was employed among 845 preparatory school students.


### 2.2. Study Area and Period

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 [7], the Zone has a total population of 2,422,296 people, and 273,620 of them were urban inhabitants. West Gojjam zone had 13 woredas and 1 administrative town and a total of 14 preparatory schools found in the zone. Preparatory schools in the country provide education for two years at the level of 11th and 12th grade. The schools in the study area enrolled 22,728 students in the year 2018 in both 11th and 12th preparatory classes.


### 2.3. Population

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.


### 2.4. Sample Size Determination

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% [8], 10% nonresponse rate, and the design effect of 2. Then the final sample size of 845 was calculated.


### 2.5. Sampling Procedure

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.


### 2.6. Study Variables

#### 2.6.1. Dependent Variable

It is the level of students’ knowledge, attitude, and preventive practices towards sexually transmitted infections.


#### 2.6.2. Independent Variable

(1) Sociodemographic Factors. They include age, sex, religion, ethnics, living with a friend or with a parent, family’s education, family’s occupation status, family’s income, and student’s pocket money.(2) Inducing Factors. They include peer pressure, drinking alcohol, watching porn movies, chat chewing, and sexual desire.


### 2.7. Data Collection Procedures

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.


### 2.8. Data Quality Control

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.


### 2.9. Data Processing and Analysis

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 [8].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 [9].Preventive practice: students who answered above the mean score for 8 preventive practice questions were taken as having a good preventive practice [8].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 ap value less than 0.2 in the bivariate analysis were fitted to multivariable logistic regression model. Then, adjusted odds ratio (AOR) and its 95% confidence interval were reported, and a p value <0.05 was used to determine statistically significant association.


## 2.1. Study Design

School-based cross-sectional study was employed among 845 preparatory school students.


## 2.2. Study Area and Period

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 [7], the Zone has a total population of 2,422,296 people, and 273,620 of them were urban inhabitants. West Gojjam zone had 13 woredas and 1 administrative town and a total of 14 preparatory schools found in the zone. Preparatory schools in the country provide education for two years at the level of 11th and 12th grade. The schools in the study area enrolled 22,728 students in the year 2018 in both 11th and 12th preparatory classes.


## 2.3. Population

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.


## 2.4. Sample Size Determination

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% [8], 10% nonresponse rate, and the design effect of 2. Then the final sample size of 845 was calculated.


## 2.5. Sampling Procedure

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.


## 2.6. Study Variables

### 2.6.1. Dependent Variable

It is the level of students’ knowledge, attitude, and preventive practices towards sexually transmitted infections.


### 2.6.2. Independent Variable

(1) Sociodemographic Factors. They include age, sex, religion, ethnics, living with a friend or with a parent, family’s education, family’s occupation status, family’s income, and student’s pocket money.(2) Inducing Factors. They include peer pressure, drinking alcohol, watching porn movies, chat chewing, and sexual desire.


## 2.6.1. Dependent Variable

It is the level of students’ knowledge, attitude, and preventive practices towards sexually transmitted infections.


## 2.6.2. Independent Variable

(1) Sociodemographic Factors. They include age, sex, religion, ethnics, living with a friend or with a parent, family’s education, family’s occupation status, family’s income, and student’s pocket money.(2) Inducing Factors. They include peer pressure, drinking alcohol, watching porn movies, chat chewing, and sexual desire.


## 2.7. Data Collection Procedures

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.


## 2.8. Data Quality Control

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.


## 2.9. Data Processing and Analysis

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 [8].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 [9].Preventive practice: students who answered above the mean score for 8 preventive practice questions were taken as having a good preventive practice [8].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 ap value less than 0.2 in the bivariate analysis were fitted to multivariable logistic regression model. Then, adjusted odds ratio (AOR) and its 95% confidence interval were reported, and a p value <0.05 was used to determine statistically significant association.


## 3. Results

### 3.1. Sociodemographic Characteristics of the Respondents

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 1).Table 1
Sociodemographic characteristics of preparatory school students in selected West Gojjam zone schools, Northwest Ethiopia, 2018.
Variable
Frequency (n = 828)
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


### 3.2. Knowledge of Preparatory School Students about STIs

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 (Table2).Table 2
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 (n = 828)
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


### 3.3. Attitude of Preparatory School Students towards STIs

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” (Table3).Table 3
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%)


### 3.4. Preventive Practice of Preparatory School Students on STIs

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 (Table4).Table 4
Sexual practice and prevention practices for STIs among preparatory school students, West Gojjam zone, Northwest Ethiopia, 2018.
STIs preventive practice items
Frequency (n = 828)
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


### 3.5. Proportion of Knowledge, Attitude, and Preventive Practice of STIs

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 (Figure1).Figure 1
Proportion of knowledge, attitude, and preventive practice of preparatory school students on STIs, West Gojjam zone, Northwest Ethiopia, 2018.


### 3.6. Factors Associated with Knowledge, Attitude, and Preventive Practice of Students towards STIs

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)) (Table5).Table 5
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)


## 3.1. Sociodemographic Characteristics of the Respondents

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 1).Table 1
Sociodemographic characteristics of preparatory school students in selected West Gojjam zone schools, Northwest Ethiopia, 2018.
Variable
Frequency (n = 828)
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


## 3.2. Knowledge of Preparatory School Students about STIs

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 (Table2).Table 2
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 (n = 828)
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


## 3.3. Attitude of Preparatory School Students towards STIs

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” (Table3).Table 3
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%)


## 3.4. Preventive Practice of Preparatory School Students on STIs

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 (Table4).Table 4
Sexual practice and prevention practices for STIs among preparatory school students, West Gojjam zone, Northwest Ethiopia, 2018.
STIs preventive practice items
Frequency (n = 828)
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


## 3.5. Proportion of Knowledge, Attitude, and Preventive Practice of STIs

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 (Figure1).Figure 1
Proportion of knowledge, attitude, and preventive practice of preparatory school students on STIs, West Gojjam zone, Northwest Ethiopia, 2018.


## 3.6. Factors Associated with Knowledge, Attitude, and Preventive Practice of Students towards STIs

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)) (Table5).Table 5
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)


## 4. Discussion

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 [8]. A different classification with fewer items which has shown a wide variation in proportion could farther support this elucidation [10]. Concerning attitude, the Jimma town study [9] showed a higher proportion of appropriate attitude among students than the current study. Though similar categorization was used to measure attitude, students from a single urban school could have a better understanding of each item. The higher proportion of preventive practice of STIs among students in the current study with that of Arsi Negelle study [8] which used related measurement and items could be attributed to using all students in our case versus those who are sexually active in their study.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 [8], in which males were nearly two times more likely to have good knowledge about STIs than females. Males in Ethiopian society in most cases spend much of their time outdoor than females. This could increase the exposure of males to different information including STIs. Likewise, the association of father’s occupation as an employee with STIs knowledge among students in this study might play a key role in students’ level of knowledge as employed parents could have better exposure to information.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 [11] found to increase adolescent-parent communication on reproductive health issues and such communication also keeps them from risky sexual behavior [12]. Similarly, students whose fathers are farmers were about two times more likely to have an appropriate attitude towards STIs than those having employed fathers. A study [12] identified that authoritarian parenting style and parental monitoring found to protect from risky sexual behavior. This nature could be more practiced by rural families mostly among farmers, so that children might be more normative.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 [8]. Also, older students were more likely to have good preventive practice than younger students. As revealed in a study [13], being older student had a significant association with good knowledge which could reflect that the more advanced the age, the better the knowledge, and thereby the better the preventive practice. Further, good practice among students who never had sexual intercourse could be attributed to the higher proportion of abstinence in the current study as a component of preventive practice.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.


## 5. Conclusion

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.



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*Source: 6894394-2020-05-12.xml*