Prevalence and associated factors of risky sexual behaviors among undergraduate students in state universities of Western Province in Sri Lanka: a descriptive cross sectional study

An institution-based descriptive cross-sectional study was conducted in four state universities in the Western Province of Sri Lanka (Univeristy of Colombo, University of Sri Jayewardenepura, University of Kelaniya and University of Moratuwa), representing around 17% of total undergraduates enrolled in state universities in the country.

The study population was undergraduate students studying in second and third years which were 18,280 in number [23]. Undergraduates from foreign countries and clergymen undergraduates were excluded. First year students were excluded as they are new to the environment. So their risk behaviors may not be due to as the same factors as second and third year students. Fourth and fifth year students were excluded as these advanced years are not conducted in every course. Exclusion of foreign students was done due to their different socio-cultural background.

Calculated sample size was 1314 with expected prevalence of 13% of heterosexual intercourse without condoms among unmarried, out of school adolescents [7], 1.96 Z value, 3% of precision and a correction for design effect of 2.45 [24, 25] and 10% of non-respondents.

A multistage cluster sampling technique with probability proportional to size (PPS) was used to select a representative sample of undergraduates (Fig. 1). A cluster was defined as a tutorial group or a whole batch according to the structure of the selected undergraduates group. The average cluster size was considered as 30. Then we allocated the clusters for each academic year and university according to the proportion of undergraduates. Undergraduates were stratified according to their respective university and academic years and academic streams. Finally clusters were identified within each stratum based on PPS according to the number of students in each university and academic year.

Data were collected on socio-demographic factors, other risk behaviors including consumption of alcohol, smoking and using narcotic drugs, sexual behavior and knowledge and attitudes in selected aspects of reproductive health (RH) among undergraduates. Sri Lanka Behavioral Surveillance Survey questionnaire [26], Youth risk behavior surveillance questionnaire used by CDC [1] and Illustrative Questionnaire for Interview Surveys with Young People [27] were used as guides to develop the questionnaire.

The validity of the questionnaire was ensured by assessing the judgmental validity which included face, content and consensual validity. Validity was determined by assessing the agreement of the experts on whether or not the conceptual definition has been used appropriately in the tool. A multi-disciplinary panel of experts in the fields of public health, reproductive health and language was used for assessment of validity. The questionnaire was forward-translated into Sinhala and back-translated to English. Data were collected using a pre-tested self-administrative questionnaire after obtaining permission. The filled questionnaires in an envelope were collected by trained research assistant. The data collection procedure was supervised by the first author. Informed written consent was obtained from the participants. Ethical clearance was taken from the Ethical Review Committee, Faculty of Medicine, University of Kelaniya.

Knowledge on some aspects of RH was measured with statements on unsafe abortions, contraceptives including condoms, STIs including HIV/AIDS and sexual and RH rights. Attitudes on RH was measured with statements on contraceptives, condoms and HIV/AIDS which contained five responses; strongly agree, agree, neutral, disagree and strongly disagree.

RSB was defined as reporting one or more following behavior/s; having more than one sexual partner, alcohol use with sexual activities, inability to use condom to prevent STI in sexual activities with commercial sex workers or non-commercial partners, unable to use contraceptive methods to prevent unintended pregnancy in sexual activities with commercial sex workers or non-commercial partners. RSB was defined as for the last 1 year and the last 3 months separately.

The study sample consisted of 1575 undergraduates from four state universities in the Western Province. Majority of respondents were females (n = 926, 58.8%) and unmarried (98.5%, n = 1551). Mean age was 23 (SD = 0.9) years. The sample consisted more Sinhalese (94.1%, n = 1480) than non-Sinhalese and Buddhists (89.8%, n = 1414) than non-Buddhists. Socio-demographic factors are shown in Table 1.

The prevalence of RSB among undergraduates were 12.4% (n = 196;, 95% CI: 11.8–13.1) and 12.1% (n = 190, 95% CI: 11.5–12.7) for last 1 year and last 3 months respectively. The highest percentage (16.8%, n = 57) of undergraduates with RSB was in University of Kelaniya followed by University of Sri Jayewardenepura (12.5%, n = 72). Males (19.1, 95% CI 16.1–22.2) had more RSB than females (7.2, 95% CI 5.5–8.9) (p < 0.001).

In the study sample 21.2% (n = 334) reported ever having had sexual exposure. Males (32.7%, n = 211) had more ever sexual exposure than females (13.1%, n = 122) (p < 0.001). Majority of undergraduates (63.9%, n = 205) who ever had sexual exposure experienced their first intercourse after 20 years of age. More females (75%, n = 87) than males (57.8%, n = 118) had their first sexual exposure before the age of 20 years (p = 0.002). Out of 334 undergraduates had sexual exposure ever, 3.3% (n = 11) stated that their first sexual experience was a forced sex. Majority (75.4%, n = 252) of the respondent’s first sexual partner was a girl/boyfriend.

Out of 334 with had ever sexual exposure only 18% (n = 60) of the respondents had used condoms in first sexual intercourse while only 1.5% (n = 5) of the respondents had used alcohol in first sexual intercourse. Out of all undergraduates, 13.7% (n = 216) had more than one life time sexual partners.

Percentage of undergraduates who had sexual intercourse within last 1 year was 87.7% (n = 293) out of 334 respondents who ever had sex. Majority of them had one sexual partner irrespective of whether they have engaged in sexual intercourse in last 1 year or last 3 months. Ninety four (5.96%) and 79 (5.01%) respondents had multiple sexual partners within last 1 year and 3 months respectively. The majority (85.8%, n = 176) of undergraduates those who had sexual intercourse within last 1 year had not used condoms in their last sexual activity. Out of 17 undergraduates that had sexual intercourse with commercial sex worker, 58.8% (n = 10) had used condom at their last sexual activity. The percentage used condoms at last sex with non-commercial sex partners were 12.4% (n = 24).

Being a male undergraduate and belonging to Sinhala ethnicity showed significant association with RSB in bivariate analysis. As shown in Table 2, RSB for last 3 months was negatively associated with engaging more religious activities and considering religion as more important to their lives. Having to the opportunity to talk with parents and siblings regarding sexual problems showed negative association with RSB.

Further, RSB were significantly associated with undergraduates who attended nightclubs more than once within last month, those who had used internet facilities > 2 h per day, those who went to cinema ≥2 per months, who had taken alcohol within last 3 months, who had smoked within last 3 months, who had taken ganja (cannabis) within last 3 months and who had physical fight within last 1 year in university (Table 3).

Good knowledge on contraceptives, good knowledge on condoms, good knowledge on sexual and RH rights, good overall knowledge on RH, favorable attitudes on contraceptives, favorable attitudes on condoms and favorable overall attitudes on RH showed statistically significant associations in bivariate analysis with RSB (Table 4).

Multiple logistic regression model included 1575 participants. RSB during the last 3 months showed significant association with four factors. Those who had taken alcohol within last 3 months (AOR 2.59, 95% CI: 1.82–3.70), those who had attended nightclub more than once in last month (AOR 3.61; 95% CI: 1.31–9.97), and those who had good knowledge on condoms (AOR 2.91, 95% CI: 2.00–4.24), showed positive association with RSB. Those who considered the religion to be important to their lives (AOR 0.67, 95% CI: 0.48–0.95), showed negative association with RSB. (Table 5) Reanalysis of data excluding the variable ‘use of alcohol within last three months’ had not changed the results.

The prevalence of RSB was 12.4 and 12.1% for last 1 year period and for last 3 months period respectively. Prevalence among male and female undergraduates were 19.1 and 7.2% respectively. A study carried out among first year Agricultural undergraduates of University of Ruhuna, Sri Lanka reported that 2% had multiple sexual partners during last 3 months which was considered as a risk behavior [28]. In the present study, having multiple partners during last 3 months was 5% and the observed difference may be due to the difference of the sample selected i.e. second and third year representing all study streams from four universities. Another study carried out among Ethiopian undergraduates revealed that 18.6% of them had lifetime multiple sexual partners which was 13.7% in the present study [29]. Their use of condoms during first sexual intercourse was 11.2%, much lower than the present 18% figure. Their figure for not using condoms within the last 1 year period was 39.4% from those who had sex in last 1 year. In the present study, not using condoms in last sexual activity was 85.8% which was much higher. The figure may be due to the reason that our young people are having “somewhat mutually monogamous” relationships which they would think the need of condom use is unnecessary.

In the present study, those who had good knowledge on condoms showed a positive association with RSB. This finding was in line with a study carried out in Washington which discussed an association with knowledge on condoms and condom usage. Failure to use protective method in risk behavior may not be due to the ignorance but may be the inability of perceiving the risk [30]. Undergraduates who had experienced or are interested in sexual behaviors may be enthusiastic in finding more information on preventive measures of STI i.e. usage of condoms. Peltzer has stated that those who had recent sexual exposures had correct knowledge on condoms [31].

The present study revealed that those who considered religion is more important to their lives were less likely to be associated with RSB than those who did not. Similar comparable results were also reported among adolescent and young adults in USA [22]. In contrast to the findings, a study done among undergraduates at the University of Kentucky revealed that students with higher religious beliefs but lower religious behaviors were at risk for risky sexual practices [32].

Frequently attending nightclubs showed significant positive association with RSB in the present study. In compatible with these findings, attending night clubs showed significant association with having sex ever, having multiple sexual partners and having sex with commercial sex workers in a study from Ethiopia [33]. The difference in the degree of association may be due to the different definitions of RSB in these two studies. Difference of academic year of selected study participants may have contributed to the observed dissimilarity. The Ethiopian study had selected undergraduates from all 5 years including 1st, 4th and 5th academic years which we have excluded in the present study. Another study conducted among undergraduates had showed different degree of positive association between RSB and attending night clubs [11].

Present study showed a statistically significant positive association with alcohol consumption within the past 3 months’ time. The results were compatible with few other studies [16, 25, 34, 35]. Alcohol use together with sexual activities itself are within the definition of RSB in our study, even though none of them had taken alcohol intake as a factor in their definition of RSB. The observed association may be due to an impaired decision making ability and dis-inhibition behavior due to alcohol consumption.

Kebede et al. revealed a positive association between unprotected sex and using alcohol daily [20]. Alcohol consumption has been measured for past 3 months’ time while unprotected sex for the period of last 1 year. Undergraduates in England perceived that life style in university provided opportunities for risky sex via high level of alcohol consumption along with other factors like increased sexual opportunities [35]. As described by Cooper, drinking alcohol may have an association that could not be described easily [21]. Therefore there exists a definite need for further research, both quantitative and qualitative in order to describe relationship between alcohol consumption and RSB.

Given the cross sectional nature of the study design, it was difficult to identify cause and effect association between the variables. As the discussed topic was very sensitive and the information was self-reported, there may be possibility of deliberately hiding of information in relation to unacceptable behavior. The results could be generalized to all the universities in Western Province and all university students in Sri Lanka as participants for the study are from all over the country.