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Abstract

The utilization of sexually transmitted infection prevention services is an important component in preventing different sexual and reproductive health problems. Little is known about the Sexually Transmitted Infections prevention service utilization in the study area. This study aimed to assess Sexually Transmitted Infections prevention service utilization and associated factors among University College Students in Nekemte city. Institution-based cross-sectional study mixed with a qualitative method was employed. The data were collected from May 1 to 31, 2022. Multi-stage sampling technique was used to select 710 study participants. Binary logistic regression was performed and variables with a p-value less than .25 were entered into multivariable logistic regression analysis. For the qualitative study, data saturation was used as a guide to decide on a number of focus group discussions and thematic analysis done. The overall Sexually Transmitted Infections prevention service utilization among university and college students was 19.5%, [95% CI = 16.5, 22.5]. Previous urban residence [AOR 3.73, [95% CI = 2.34, 5.94], having good Knowledge [AOR 4.17, [95% CI = 2.58, 6.76], Ever visited a health facility [AOR 2.88, [95% CI = 1.68, 4.92], Ever been diagnosed with STIs [AOR 3.28, [95% CI = 1.57, 6.85] and, Lack of confidentiality [AOR 0.30, [95% CI = 0.19, 0.49] were significantly associated with sexually transmitted infection prevention service utilization. The level of Sexually Transmitted Infection prevention service utilization was low. Therefore, health facilities should provide services in a private room and health professionals should keep confidentiality to improve Sexually Transmitted Infection prevention service utilization.

Keywords

STIs reproductive health Nekemte City utilization Wollega University

Background

Sexually Transmitted Infections (STIs) are infections that are transmitted from one person to another through vaginal, oral, or anal sexual contact (WHO, 2020). When left undiagnosed and untreated, STIs can result in serious complications and long-term health problems for women, such as pelvic inflammatory disease, ectopic pregnancy, miscarriage, and untreated gonorrhea and chlamydia can cause infertility in both men and women (FAWCO, 2021; Verywell Health, 2021; Yale Medicine, 2020). More than 30 different bacteria, viruses, and parasites are known to be transmitted through sexual contact; syphilis, gonorrhea, chlamydia, and trichomoniasis are currently curable, while hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV) are incurable (PAO/WHO, 2021) . Sometimes STIs can be transmitted non-sexually, such as from mothers to their infants during pregnancy or childbirth, or through blood transfusions or shared needles (CDC, 2021b).

The adolescent and youth population encounters daily countless challenges in accessing their primary needs (World Relif Web, 2021). Sexually transmitted infections prevention services are; STIs infection prevention counseling, pre-exposure prophylaxis for STIs, post-exposure prophylaxis for STIs, External condoms, Cervical diaphragms, Abstinence, partner services, partner therapy, Information services, peer education, VCT, STIs screening and treatment (CDC, 2020).

Young people are at greater risk of getting Sexually Transmitted Infections for several reasons (CDC, 2021a). Gender inequality, sexual coercion, early marriage, high levels of teenage pregnancy, unsafe abortion, and sexually transmitted infections (STIs) are among the sexual and reproductive health problems faced by many young Ethiopians (FMOHE, 2021).

In Ethiopia, youth have a limited understanding of STIs, with only 24% of girls and 35% of boys having comprehensive knowledge, Sexuality education programs are fragmented and non-standardized in schools and out-of-school government or NGO settings (FMOH, 2021).

Sexually Transmitted Infections (STIs) are major public health threats worldwide (WHO, 2021b). Globally, more than 1 million and 374 million sexually transmitted infections (STIs) are acquired every day and, each year respectively (WHO, 2019). According to the study, Youth accounts for half of the 20 million new STDs in the United States each year (Sieving et al., 2019). WHO estimates that sub-Saharan Africa bears approximately 40% of the global burden of STIs (Global Health Sector Strategy and Towards Ending Aids, 2021). According to a study done in Tanzania, 3.6% of males and 2.5% of females used a condom during the last sexual intercourse. According to a study conducted in Bahir Dar, the overall STIs prevention practice of students was 12.4% (Ayele et al., 2020).

According to a study, symptomatic and asymptomatic STIs are a major cause of morbidity in developing countries and can cause infertility, cervical cancer, pelvic inflammatory disease, and pregnancy complications (Crowley et al., 2021). Both ulcerative and inflammatory curable STIs increase the risk of acquiring and transmitting HIV by up to two- to threefold (Crowell et al., 2020).

The global health sector strategy on sexually transmitted infections focuses on Neisseria Gonorrhea, Treponema pallidum, and Human Papillomavirus that require immediate action for control and STIs are one of the key health targets of the SDGs Goals for a comprehensive package of essential preventive interventions against STIs (WHO, 2021a).

Ethiopia has sought to establish Youth Friendly Reproductive Health Services which include STIs prevention strategy in public health institutions since 2005 by Pathfinder International, which is now handed over by the Ethiopian Federal Ministry of Health (Kereta et al., 2021). Ethiopia is executing its second National Adolescent and Youth Health Strategy, which goes beyond sexual and reproductive health, and the government is giving comprehensive Youth-Friendly Service training to handle all the country’s young people (FMOH, 2020a).

Despite the efforts of the government on Sexual and Reproductive Health Services (Belay et al., 2021), little is known about the STIs prevention service utilization by university college students to prevent STIs in Ethiopia, particularly in the study area. Some literature lacks some important variables which are important for STIs prevention such as abstinence and faithfulness were not well studied and the previous study did not incorporate the qualitative method. Therefore, this study aimed at STIs prevention Service utilization and associated factors among University College Students in Nekemte City.

Study Area and Period

The study was conducted in three university colleges in Nekemte city. Nekemte city is located at 315 km away from Finfinne. Nekemte is a capital city of East Wollega. Nekemte city is located at a latitude and longitude of 9°5′N 36°33′E and an elevation of 2,088 m. Its altitude ranges from 1960 to 2170 above sea levels and annual rainfall ranges from 1,500 to 2,200 mm, which covers the months from April to the beginning of December. In 2020, the population of the city is 110,688 people (Statistics, 2021). One government university and eight university colleges, are located in Nekemte city. The study was conducted in three university colleges in Nekemte city from May 1 to 31, 2022.

Study Design

Institution-based mixed methods cross-sectional study design was employed.

Source Population

All public and private University and College students in Nekemte city.

Study Population

All randomly selected students from selected universities and colleges for the quantitative part and all purposively selected Students for the qualitative part.

Inclusion criteria

All regular students, who were attending their education at selected universities and colleges were included.

Exclusion Criteria

Students who were sick and could not avail themselves on the days of data collection.

Sample Size Determination

For the quantitative part of the study, a single population proportion formula was used to calculate the sample size for the first objective using the following assumption: 54% of condom use among undergraduate students at Addis Ababa Science and Technology University (Ayele et al., 2020), 5% margin of error, 95% confidence interval (Cl), 10% Non-response rate, and 2 design effect hence, a total 710 participants were considered.

Sampling Procedures

A multistage sampling technique was used to select the study samples. First, three study colleges were chosen by simple random sampling from eight University colleges found in the city. A simple random sampling technique was applied to select departments, years of study, and sections. The calculated sample size was allocated based on probability proportional to the size of students in each selected university college.

A systematic random sampling technique was applied to select study participants, the first sample was chosen at random, and the rest was based on the kth value, which was 3 until the required sample size was obtained from each University college and class.

For qualitative, a purposive sampling technique was applied to select the students for FGDs, and the sample size was determined by the data saturation point, Sampling and data collection were continued until reaching data saturation and obtaining no new data from the focus groups.

Dependent variable: Sexually transmitted infections prevention service utilization

Independent variables: Socio-demographic, Peer, Health workers related, Knowledge, Behavioral and Sexual factors

Measurements

Knowledge-based on twenty-four knowledge questions about STIs, the mean total knowledge score was calculated with standard deviation and, the students who scored above the mean were labeled as having good knowledge and those who scored below the mean were considered as having poor knowledge.

Overall STIs prevention service utilization: In this study, if respondents utilized, at least three of the services such as VCT, STIs diagnosis and treatment, information on STIs, Abstinence, and general counseling services; utilization was considered and if less than three of the above services, they were considered as non-users

Data Collection Procedures

For the quantitative phase of the study, after the students selected for the study were identified, the data collectors gathered selected students and gave them an orientation about the study and how to fill out the questionnaire, and where to put it after completion. Data were collected by facilitators guided structured self-administered questionnaire on the study’s objective. Data collection facilitators were two BSC nurses, two-level IV nurses, and one MPH, Supervisor

For the qualitative study, after being selected FGD discussants were moved to a quiet room. To enable participants freely communicate, they were grouped based on sex similarities. Each FGD was moderated by the principal investigator. The investigator, welcome the discussants, introduced the overview of the topic, set the ground rule, and started with the first question. The discussions were tape-recorded with the participants’ agreement, and notes were taken during the FGDs.

Data Collection Tools

For the quantitative phase of the study, the structured questionnaire was adapted after the literature review (Ayele et al., 2020). The questionnaire covers a wide range of issues, including socio-demographic factors, peer factors, knowledge factors, health workers-related factors, and Sexual and behavioral factors for STIs prevention service utilization.

For the Qualitative study, Open ended FGDs guide was prepared in English and translated to Afan Oromo to collect the qualitative data, with discussions taking place in Afan Oromo with FGD discussants until saturation was reached.

Data Quality Assurance

One-day training was given for data collection facilitators and supervisors on data collection methods, including the template for data collection, the research purpose, and data collection techniques. Questionnaires and FGDs Guides were translated to Afan Oromo and then back to English to maintain consistency, pretest was made on 5% of the study subjects at New Generation University college students who have similar socio-demographic characteristics with the study area before the actual data collection. Double data entry was used to minimize errors. Based on the findings and feedback obtained from the pre-testing process, a modification was done to the questionnaire for the objective of the study, and the pre-tested data was excluded from the final analysis.

Data Processing and Analysis

Data were coded, cleaned, and processed to identify missing values, outliers, and inconsistencies. The coded data were checked for completeness and entered Epi Data version 4.6, and data were exported to SPSS version 24 for analysis. The frequencies of different variables were determined and followed by cross-tabulations to compare their frequencies. The presence of multicollinearity was assessed using a Variance Inflation Factor (VIF) among independent variables. Binary logistic regression was conducted for dependent and independent variables and crude odds ratio (COR) with a 95% confidence interval was estimated to assess the association between dependent and independent variables. The variables with a p-value < .25 at binary logistic regression were transferred into a multivariable logistic regression analysis to assess their association with STIs prevention service utilization. Hosmer–Lemeshow goodness-of-fit was used to test for model fitness.

Adjusted odds ratio (AOR) with a 95% confidence interval was estimated to assess the presence of association at multivariable logistic regression. Variables with a p-value < .05 at multivariable logistic regression were considered statistically significant factors of STIs prevention service utilization. Finally, the analyzed data were summarized using text, graphs, and tables. For qualitative data, narrative descriptions were used to summarize the socio-demographic characteristics of FGD participants. The analysis followed a thematic approach with the following six steps:

Step 1: Verbatim transcription. Recorded information in an audiotape, and notes taken were transcribed verbatim, translated from Afan Oromo to English, typed in word, changed to plain text, and imported to open code 4.03 software for thematic analysis.

Step 2: Coding. Data was organized and coded in a meaningful and systematic way, each code corresponds to a particular theme, to which the text was relevant.

Step 3: Generating themes. The researcher looked over the codes for clarity and consistency by selecting a given text, and several codes were combined into a single theme.

Step 4: Reviewing themes. The themes[synthesis) was reviewed, to ensure thematic analysis going in the right way.

Step 5: Interpretation. The researcher interpreted the coded data, described the themes, and categorize the data. In this step, the final list of themes was named and defined.

Step 6: Write up. Finally the results were written, presented in the form of text, and tables, then triangulated with quantitative findings (Kiger & Varpio, 2020).

Ethical Clearance

The ethical clearance was obtained from Wallaga University research ethical Review Committee in its meeting held on March 22 (Reference Number 27/2021), Permission was obtained from each selected university college, and signed consent was obtained from individual participants. The right of the participant to refuse the study was respected.

Results

Socio-Demographic Characteristics of Study Participants

Out of 710, the response was obtained from 698 study participants making the response rate 98.3%. The mean age was 21.95 with a standard deviation of ±1.4, ranging from 17 to 28 years. The majority, 620 (88.8%) were single, 386 (55.3%) were protestant religion followers, 137 (19.6%) were Orthodox followers, the rest were Muslim, 55 (7.9%), Wakefata, 95 (13.6%), and Catholic, 25 (3.6%). By ethnicity, almost all the respondents, 675 (96.7%) were Oromo, while only 23 (3.3%) were from other ethnic groups. Two hundred fifty-four (36.4%), 218 (31.2%), and 226 (32.4) were first-year, second-year, and third-year attendants respectively (Table 1).

Table 1.

Socio-Demographic Characteristics of the Study Participants, Nekemte City, 2022.

Variables	Category	Frequency	Percent
Previous residence	Urban	221	31.7
Previous residence	Rural	477	68.3
Marital status of parents	Live together	648	92.8
Marital status of parents	Divorced	50	7.2
Educational status of participants’ mothers	Cannot read and write	176	25.2
	Can read and write	189	27.1
	Primary 1–8	127	18.2
	Secondary 9–12	44	6.3
	College and above	162	23.2
Educational status of participants’ fathers	Cannot read and write	112	16.0
	Can read and write	239	34.2
	Primary 1–8	128	18.3
	Secondary 9–12	89	12.8
	College and above	130	18.6
Fathers occupation	Government worker	94	13.5
	Farmer	472	67.6
	Merchant	59	8.5
	Others	73	10.5
Mothers occupation	Government worker	40	5.7
	Farmer	381	54.6
	Merchant	108	15.5
	Private	76	10.9
	Housewife	93	13.3

Note. Others = private workers, daily laborers, no known occupation.

Source of Information

Two hundred thirty-eight (34.1%) study participants heard about STIs from Mass media, 330 (47.3%) from social media, 346 (49.6%) from health workers, 354 (50.7%) from teachers, 103 (14.8%) and 234 (33.5%) heard from newspapers and books respectively (Figure 1)

Figure 1.

Source of information for STIs among study participants, Nekemte City 2022.

In this study, twenty-four items were used to assess the overall knowledge of STIs. The mean total knowledge score was 10.24 with a standard deviation of (±2.5). The Majority, 502 (71.9%) of study participants had poor knowledge about STIs. The students who had an overall good knowledge score about the types of STIs, signs, and symptoms of STIs, mode of transmission of STIs, and prevention of STIs were 196 (28.1%). About 653 (93.45%) know that HIV is STI, 424 (60.74%) know about gonorrhea, and 358 (51.29 %) and Syphilis respectively.

Regarding knowledge of signs and symptoms of STIs, 379 (54.3%) of the study participants knows that Urethral discharge 370 (53%), Vaginal discharge 270 (38.68%), Scrotal swelling 268 (38.40%), pain during urination 345 (49.43%), Genital ulcer 98 (14%), Dark urine, 107 (15.33%), the urgency of urination 226 (32.38%) and, lower abdominal pain was among sign and symptoms mentioned by the participants.

This study shows that 666 (95.42%) of participants know that STIs can be transmitted from person to person. Among the mode of transmission of STIs, 554 (79.42%) sexual contact, 303 (43.43%) through Mother to child transmission, 272 (38.97%) through infected blood transfusion, 324 (46.42%) through contaminated sharp materials, 169 (24.21%) through breast milk from infected mothers, 168 (24%) by body contact and 219 (31.38%) by infected body fluids. According to this finding, most study participants, 628 (89.97) answered that it is possible to prevent the transmission of STIs from person to person by different methods.

The Role of Peers in STIs Prevention Information

This study shows that about 463 (66.33%) had ever discussed STIs with their peer, and of those who had ever discussed STIs, 381 (82.2%) mentioned the importance of STIs services to their peer. Four hundred fourteen (89.4%) reported that they need their peer’s approval to use STIs prevention services, and nearly one-fifth 144 (31.0%) of them reported that they feared their peers to utilize STIs prevention services. About 248 (53.5%) reported that they had ever experienced discouragement from their peer, while 284 (61.3%) explained that they had ever experienced encouragement from their peer to utilize STIs prevention service utilization.

Health Providers Related Characteristics

Of the total number of 698 study respondents, 135 (19.3%) have ever visited the health facility for STIs services. Among those who visited the health facility for STIs services, only 58 (43%) of the respondents reported that they were satisfied with the services being offered, but 77 (57%) reported that they were not satisfied with the service being offered. The reasons for not being satisfied with the services offered were too long waiting hours 29 (37.7%), providers being unfriendly 23 (29.9%), health workers’ judgmental attitude 18 (23.4%), and missing service 7 (9%) were among the reasons mentioned by respondents. Regarding the preference of STIs prevention service providers, the majority of the respondents 331 (47.4%) prefer young providers of the same sex, 156 (22.3%) of them prefer young providers of any sex, 93 (13.3%) of them prefer adult provider of the same sex and 128 (18.3%) of them prefer any trained provider.

Sexual and Behavioral Characteristics of Study Participants

The majority, 480 (68.8%), of the study participants had boy/girlfriends, and 500 (71.6%) ever had sexual intercourse. About 421 (60.3%), 69 (9.9%), and 58 (8.3%) experienced vaginal sex, anal sex, and oral sex respectively. About 37 (5.3%), had multiple sexual partners, 38 (5.4%) smoke cigarettes, 55 (7.9%) had sex with commercial sex workers, 234 (35.5%) watched pornography, 226 (32.4%) drinks alcohol, and 100 (14.3%) chewed chat.

Level of STIs Prevention Service Utilization

The finding of this study shows that the overall STIs prevention service Utilization among university college students was nearly one out of seven, 136 (19.5%,) [ 95% CI 16.5, 22.5]. Accordingly, among STI prevention Services, Information service was 383 (54.9%), being faithfulness for their partners 314 (45%), Male condom users 313 (44.84%), Counselling services 298 (42.7%), VCT for HIV service 189 (27.08%), Abstinence 95 (13.61%) and, STIs diagnosis and treatment 52 (7.4%) (Figure 2).

Figure 2.

STIs prevention service utilization among university and college students of Nekemte City 2022.

Multivariable Logistic Regression Analyses

After controlling the effect of other variables, the odds of STIs prevention service utilization among previous urban residents were 3.73 times (AOR 3.73, 95% CI = 2.34, 5.94) more likely to utilize STIs prevention services than previous rural residents. Similarly, the students who had good knowledge about STIs were 4.17 times (AOR, 4.17, 95 % CI = 2.58, 6.76) more likely to utilize STI prevention services than students who had poor knowledge.

The odds of STIs prevention service utilization among the students who had ever visited health facility were 2.88 times more likely to utilize (AOR 2.88, 95% CI = 1.68, 4.92) than their counterparts, as well as the students who had ever been diagnosed with STIs were 3.28 more likely to utilize (AOR 3.28, 95% CI = 1.57, 6.85) than those students who had never been diagnosed with STIs. Furthermore, the students who perceived a lack of confidential service at the health facilities were 70% (AOR 0.30, 95% CI = 0.19, 0.49) less likely to utilize STIs prevention services than their counterparts (Table 2).

Table 2.

Bivariable and Multivariable Analysis of STIs Prevention Service Utilization and Associated Factors, Nekemte City, 2022.

		STI prevention service utilization
Variables		Yes (%)	No (%)	COR [95% CI]	AOR [95% CI]	p-Value
Residence	Urban	82 (37.1)	139 [62.9]	4.62 [3.12, 6.85]	3.73 [2.34, 5.94]	.001***
Residence	Rural	54 (11.32)	423 [88.68]	1
Mothers’ educational status	Cannot read and write	27 (15.34)	149 [84.66]	1
	Can read and write	47 (24.87)	142 [75.13]	1.83 [1.08, 3.09]	1.58 [0.85, 2.94]	.15
	Primary	28 (22.05)	99 [77.95]	1.56 [0.87, 2.81]	1.09 [0.54, 2.22]	.81
	Secondary	10 (22.73)	34 [77.27]	1.62 [0.72, 3.67]	1.21 [0.46, 3.15]	.70
	College and above	24 (14.81)	138 [85.19]	0.96 [0.53, 1.74]	0.95 [0.47, 1.90]	.88
Knowledge	Good	78 (39.8)	118 [60.20]	5.06 [3.40, 7.51]	4.17 [2.58, 6.76]	.001***
Knowledge	Poor	58 (11.55)	444 [88.45]	1
Read from books	Yes	56 (23.93)	178 [76.06]	1.51 [1.03, 2.22]	1.30 [0.80, 2.11]	.29
Read from books	No	80 (17.24)	384 [82.75]	1
Ever discussed with peer	Yes	106 (22.9)	357 [77.1]	2.03 [1.30, 3.15]	1.31 [0.78, 2.20]	.30
Ever discussed with peer	No	30 (12.8)	205 [87.2]	1
Ever visited a health facility	Yes	45 (33.33)	90 [66.67]	2.59 [1.70, 3.95]	2.88 [1.68, 4.92]	.001***
Ever visited a health facility	No	91 (16.16)	472 [83.84]	1
Lack of confidentiality	Yes	38 (11.55)	291 [88.45]	0.36 [0.24, 0.54]	0.30 [0.19, 0.49]	.001***
Lack of confidentiality	No	98 (26.55)	271 [73.45]	1
Ever been diagnosed with STI	Yes	24 (46.15)	28 [53.84]	4.08 [2.28, 7.31]	3.28 [1.57, 6.85]	.002**
Ever been diagnosed with STI	No	112 (20.98)	534 [82.66]	1
Vaginal intercourse	Yes	96 (22.80)	325 [77.20]	1.75 [1.17, 2.62]	1.08 [0.67, 1.76]	.73
Vaginal intercourse	No	40 (14.44)	237 [85.56]	1
Had intercourse with sex workers	Yes	19 (34.54)	36 [65.45]	1.77 [1.21, 2.58]	1.01 [0.49, 2.09]	.98
Had intercourse with sex workers	No	117 (18.2)	526 [81.8]	1
Chew chat	Yes	27 (27)	73 [73]	1.66 [1.02, 2.70]	1.38 [0.76, 2.5]	.29
Chew chat	No	109 (18.23)	489 [81.77]	1

p =< .05. **p =< .01. ***p =< .001, 1 = reference.

Qualitative Results

Socio-Demographic Characteristics of the Discussants

A total of 40 participants took part in the four focus group discussions, 16 female students and 24 male students. The mean age of the discussants was 20. with a standard deviation of ±2.0, ranging from 18 to 25 years, and the majority, 24 (or 60%), were in their third year. They were all single, with 45% of them being orthodox believers (Table 3).

Table 3.

Socio-demographic Characteristics of the FGDs, Nekemte City 2022.

Socio-demographic characteristics		Frequency	Percent
Sex	Male	24	60
Sex	Female	16	40
Age	18–20	30	75
	21–24	8	20
	>=25	2	5
Marital status	Single	40	100
Marital status	Married	0	0
Year of Study	1st year	8	20
	2nd year	8	20
	3rd year	24	60
Religion	Protestant	15	37.5
	Orthodox	18	45
	Muslim	6	15
	Catholic	1	2.5
Residence	Urban	12	30
Residence	Rural	28	70

Theme I: Barriers of STIs Service Utilization

According to qualitative data analysis, many barriers hinder university college students from getting STIs services. Political insecurity, Miss understanding of services, poor knowledge, wrong perception about the STIs, Residence, Lack of information, Poverty, Unwillingness to get the service, premarital sex, Shyness, Negative attitude, Culture, Religion, fear of disclosure, long waiting time at a health facility, lack of confidentiality, Lack of private place, social desirability was among barriers mostly explored by discussants as associated with low utilization of STIs services.

Socio-Demography

According to the discussants, socio-demographic characteristics and living arrangements play a vital role in STIs service utilization among university college students. Distance from a health facility, absence of clinics in the compound, living in a rural area, lack of information, religion, and premarital sex, were among the barriers mentioned by discussants.

I think many barriers prevent students from receiving services of sexually transmitted disease ……, distance from health facilities, weak trust between health facility and community, lack of understanding, Lack of knowledge about the dangers of sexually transmitted diseases, assuming sexually transmitted diseases as a trivial disease, social living conditions e.g., living in rural areas can limit usage as it leads to lack of sufficient information, those who live in urban areas are more understand than those who live in rural areas and can use it (A 23 years old from male discussant group).

The discussants also argued that religion, misunderstanding, shyness, and negative attitude toward STIs services is a major obstacle that affects their utilization.

I think it is called sexually transmitted disease, and it is not only sexually transmitted, but many people think so………. even if it is religiously premarital sex is not allowed, it is especially shameful for unmarried girls, they don’t want to be seen by the clergy when they get STIs services, no religion has a problem, God can forgive you, and if he judges you it will wait for a time, but man defames, it is quick to judge, so it is better to leave the service, or go and use it in a private place, but no private area (18 years old from female discussant)

Socio-Economic and Socio-Cultural

Socio-economic status and culture also hinder the utilization of STIs services by university college students according to this study. The majority of the discussants indicated that lack of pocket money, political insecurity, and lack of good neighborhoods affects the utilization.

……….as in our area, security problems, lack of money, and lack of good neighbors can prevent university college students from using STIs services like diagnosis and treatment, e.g., especially carrying things like condoms, complaining of symptoms of sexually transmitted diseases is embarrassing (22 years old from male discussant).

According to our culture, if girls lose their virginity before marriage, they are not accepted in society, so they don’t want to be served in public health facilities, unless it is a secret place, so that their secrets are not known, and no one provides secret services, this is a very serious problem, especially for female students who engaged in premarital sex and contract STIs. (19 years old from female discussant).

Health Facility and Health Workers Related

Participants from this study also reported that health facilities and health care providers’ conditions affect the utilization of STIs services. Distance of health facility, absence of clinic in the colleges, lack of private room for the service, too long waiting time with other patients, lack of confidentiality, and fear of disclosure by health workers affects the utilization greatly.

………Some health facilities don’t have private rooms, they sit in the treatment room being many, I don’t think they keep anyone’s privacy, because they are so many. Telling something to too many people is spreading your secrets (20 years old from male discussant).

Theme II: Consequences of Contracting Sexually Transmitted Infections

The study discussants repeatedly reported that sexually transmitted diseases can cause so much harm to individuals, families, and the community at large. The most common consequences of contracting STIs are morbidity, disability, sterility, death, despair, family breakdown, and economic loss.

As far as I know, STIs are not a simple disease, it is easily transmittable, a person with a sexually transmitted disease may die, be discriminated and be stigmatized. for example, a person with HIV may be treated with negative attitudes in society, may experience serious psychological problems, be hated in society, despaired, it hurts psychologically, destroys property, destroys families, and degrades loyalty. The infected person is unhappy, loses social relationships, feelings of inferiority, loss of life, leaving a family without help, and, can lead to marriage breakdown (20 years old from male discussant).

Theme III: Prevention of Sexually Transmitted Infections

According to focus groups, discussants of this study said that sexually transmitted infections can be prevented in many ways. STIs can be prevented by treatment of cases, health education, (awareness creation, by improving STIs knowledge), abstinence from unlimited sexual intercourse, having only one sexual partner, and faithfulness.

…. preventing all sexually transmitted diseases is not easy, but it can be minimized by proper health education starting in primary schools. I think the risk can be reduced, especially if the public attitude towards the disease improves further, prevention and control services are available for the student, and even it will be prevented if there is a screening service based on the student’s wishes starting from primary schools (21 years old male discussant).

Vaccination and Treatment

According to the thought of study discussants, sexually transmitted infections are treatable with medication at a health facility, but not all STIs, few study participants perceived that STIs are vaccine-preventable, for example, Hepatitis B virus, Human papillomavirus, and few students know that there is a vaccine for some STIs

As I know, there is no vaccine, but there is a vaccine for cervical cancer, but it is not being given to all girls as a routine service, so it is hard to say there is a vaccine. There is no vaccine against all sexually transmitted diseases, but there is a vaccine that can prevent type B hepatitis (20 years old female discussants).

I don’t think there is a vaccine against sexually transmitted diseases, there is no vaccine, and if there is, it cannot prevent HIV……the vaccine is to eradicate unemployment, to employ the unemployed youth, the vaccine is to trust each other, have only one sexual partner, get tested and treated if caught (22 years old male discussants).

Health Education

The qualitative study participants also stated that STIs can be prevented by giving health education to the community, the disease may be reduced if families talk openly with their children, by providing appropriate general information services to rural and urban residents, having only one sexual behavior, and by providing adequate awareness to ensure that the students know the mode of STIs transmission, and consequences of untreated STIs.

………the foundation of everything is knowledge, and STIs can be prevented by proper teaching in schools………the attitudes that can influence through religion and culture may also be broken through knowledge. if so, the disease may be reduced, if families talk openly with their children, by providing appropriate general information services to rural and urban residents, and teaching abstinence from unrestricted sex, use of condoms, blood tests, trust in each other, abstinence from premarital sex, treatment with a sexual partner if infected, Not sharing sharp objects, and vaccination of children can prevent the transmission of STIs (20 years old from male discussant).

Sexual Partner

According to discussants, having only one sexual partner, avoiding Unlimited sexual intercourse, Abstinence from sex until marriage, and being faithful to one partner prevent STIs.

……… as it is well known, the prevention of sexually transmitted diseases is to have only one sexual partner, live with only one partner, and avoid unlimited sexual intercourse…… (23 years from male discussant).

Theme IV: Sign and Symptom

The study discussants stated Genital itching, genital ulcer, injury to genitals, urinary frequency, vaginal discharge, and yellow urine, as the sign and symptoms of STIs.

The majority of the study participants did not know the most common sign and symptoms, and some participants had misconceptions about the sign and symptoms of STIs.

…… If I’m not mistaken, sexually transmitted diseases can show a lot on the human body. STIs can cause injury to the genitals and foamy discharge from the genitals. it can also change the color of urine to yellow or other colors, urinary urgency, genital ulcers, discharge-like pus may drain, genital itching, vaginal discharge, loss of appetite, e.g., HIV decreases body weight, HIV decreases immune system, and may even be infertile (19 years old from male discussant).

Theme V: Transmission

The majority of the study participants stated that STIs are transmitted from a person to person by different mechanisms. Having multiple sexual partners, contact with contaminated blood, sharing sharp objects, Mother to child transmission, sexual intercourse with an infected person, transfusion of infected blood, and sharing closes.

As far as I know, STIs can be transmitted, through unrestricted sexual intercourse, from mother to child, e.g., HIV, and syphilis can be transmitted by taking infected blood, I do not know what else it is transmitted by (18 years old from male discussant).

Theme VI: Utilization

According to the FDG of discussants, the most common services utilized by the students were male condoms, counseling, and testing for HIV, General counseling services, and information services.

…………. Yes, they use it but, it is difficult to say they use everything. There may be many sexually transmitted disease services, but the most commonly used by the students is something like male condoms or VCT occasionally. Therefore, this service cannot be said to be fully serviced (19 years old male discussant).

Yes, they do, a person can get it before marriage e.g., HIV test, they are not allowed to marry, because the Christian church cannot bless an HIV-positive person to marry each other, and they can get it when they voluntarily donate blood for some TTIs including Hepatitis B virus and HIV (A 21 years old from male discussant group).

Themes

From the analysis and coding of focus group data, Barriers, consequences of contracting STIs, prevention, sign and symptoms, the transmission of STIs, and utilization, were identified as main themes, and codes were identified for each main theme (Table 4).

Table 4.

Identified Themes, Subthemes, and Codes from Focus Group Discussion Data Among Study Participants, Nekemte City, 2022.

Theme	Sub-theme	Codes
Barriers	Socio-demography	Residence, religion, premarital sex, fear of disclosure, miss understanding, poor knowledge, low perception, lack of information, unwillingness, embarrassment, shyness, negative attitude, social desirability
	Socio-economic and socio-cultural	Political insecurity, poverty, culture
	Health facility	Lack of confidentiality, lack of private place, waiting time
Consequences of contracting STIs	Individual	Infertility, death, shame, despair
	Family	Breakdown
	Community	Economic loss
	Social	Social stigma, discrimination
Prevention	Vaccination and treatment	Cervical cancer vaccine, Hepatitis B vaccine, condom, blood test, diagnosis
	Education	Awareness creation, employment opportunity, knowledge, family discussion, information service, clergy
	Sexual partner	Only one sexual partner, unlimited sexual intercourse, abstinence, faithfulness
Sign and symptom	Symptoms	Genital itching,
Sign and symptom	Signs	Genital ulcer, injury to genitals, urinary frequency, vaginal discharge, yellow urine
Transmission	Person to person	Multiple sexual partners, contaminated blood, sharing sharp objects, MTCT, sexual intercourse, blood donation, sharing closes
Utilization		Marriage, condom, blood test, voluntary blood donation

Discussion

This study revealed that 136 (19.5%, [95% CI = 16.5, 22.5) had used the overall STIs prevention services. This finding is less than the national STI prevention service utilization (FMOH, 2020a), and the study conducted in Indonesia reported that only 24.3% utilized services to prevent the transmission of HIV and other STIs (Violita & Hadi, 2019). The possible reason for the difference in this finding could be the difference in analysis methods.

Concerning faithfulness to their partners, five out of eleven (45%) of the study participants reported that they were faithful to their sexual partners. This study showed that about 313 (44.84%) of the study participants used male condoms. This finding was greater than the study done in Mlimba Division, Ifakara, Tanzania, 42.2% (19), and 37.2% in the study done among College Students at West Arsi Zone in Oromia Region, Ethiopia (Wachamo et al., 2020).

However, less than the national AYHS findings, and less than the national target which was 75% (FMOH, 2020b). The possible explanation for this variation would be the availability of the service, accessibility, willingness to utilize it, knowledge difference, and sociocultural variation among the study participants.

This study revealed that three out of seven (42.62%) students utilized a general counseling service for STIs among the study participants. This finding was greater than the study findings of Debre Tabor town, Northwest Ethiopia, which was 14.9% (Simegn et al., 2020). The possible explanation for this discrepancy would be an absence of student clinics that provide STI services in the current study

This study revealed that three out of eleven (27.08%) utilized voluntary counseling and testing for HIV. This finding was greater than the study conducted in Dabre Tabor town which was 14.9% (Simegn et al., 2020). However much less than the study done among College Students at West Arsi Zone in Oromia Region, Ethiopia which is 80.6% (Wachamo et al., 2020). The possible reason for this discrepancy could be the accessibility and availability of the service.

Additionally, this study revealed that one out of seven (13.61%) had utilized abstinence as means of sexually transmitted infections prevention service and, almost one out of twelve study participants (8.31%) had utilized STI diagnosis and treatment services. This finding is slightly greater than the study conducted among School Youths in Ambo Town, Oromia Regional State, Ethiopia which was 5.3% (Fikadu et al., 2020), and 7.7% among rural female adolescents in Asgede-Tsimbla district Northern Ethiopia (Gebreyesus et al., 2019). However less than the study findings of the study conducted among College Students at West Arsi Zone (Wachamo et al., 2020), and 26.8% among in-school young people with disabilities in Ghana (Kumi-Kyereme et al., 2019). The possible explanation for the discrepancy in this result would be access to information, availability of health services, sociocultural differences, and study population differences.

In this study, the odds of STIs prevention service utilization were 3.73 times higher among previous urban residents than their counterparts. This finding is similar to findings among College Students in the West Arsi Zone which indicate previous urban residents were nearly two times more likely to utilize SRH services (Wachamo et al., 2020), This finding is supported by the qualitative part of this study, the FGD discussants stated that living in the rural area can affect the utilization of STIs prevention services since the information of STIs is scanty due to many reasons in rural areas. This study revealed having good knowledge was found to be significant for STIs prevention service utilization. The students who had good knowledge were 4.17 times more likely to utilize STIs prevention services than students who had poor knowledge.

This finding is in line with the study finding is supported by qualitative findings of this study which stated that lack of knowledge is a barrier to service utilization, but it contradicts with the finding from North Ethiopia which indicates no association between knowledge and SRH service utilization (Gebreyesus et al., 2019). The difference may be due to the difference in the study design, and study participants, the study done in North Ethiopia used only rural females while this study used University and college students which involve both females and males, as well as students from both rural and urban.

Furthermore, this study revealed that the students who had ever visited a health facility and, who had ever been diagnosed with STIs were significantly associated with STIs prevention service utilization. The odds of STIs prevention service utilization among those who had ever visited a health facility were 2.88 times and those who had ever been diagnosed with STIs were 3.28 times more likely to utilize STIs services than their counterparts respectively. Additionally, the finding of this study revealed that a lack of confidentiality reduces STI prevention services by 70%. Which is in line with the national adolescent and youth health strategy (2016–2020) which stated lack of confidential service hinder the utilization of SRH services (FMOH, 2020b), also in line with qualitative findings of this study, FDG discussants from this study reported that health facilities and health care providers’ conditions affect the utilization of STIs services, lack of private room for the service, too long waiting time with other patients, lack of confidentiality and fear of disclosure by health workers affects the utilization greatly. The possible explanation for this difference could be the difference in the study population, data collection methods, and study design difference

The qualitative findings explored different factors which hinder the students from STIs prevention service utilization, barriers like rural residence, religion, political insecurity, risky behavior, lack of confidentiality, absence of the student’s clinic in the compound, lack of private room at a health facility, fear of disclosure, poor knowledge, and culture were among identified barriers.

Conclusion

The overall STIs prevention service utilization among university and college students was low. Previous urban residency, good knowledge about STIs, ever been diagnosed with STIs, and ever visited a health facility were positively associated, whereas lack of confidentiality was negatively associated with STIs prevention service utilization.

The qualitative study reveals that numerous barriers prevent university and college students from obtaining STI prevention services. Political insecurity, a lack of understanding about STIs prevention, inadequate knowledge, poor perception, residence, a lack of information, poverty, a lack of willingness, shyness, a negative attitude, culture, and religion, as well as fear of disclosure, a long waiting time, a lack of confidentiality, a lack of private space, and social desirability were among the obstacles most frequently linked to low STIs prevention service utilization.

Limitations of the Study

The study deals with very sensitive issues, social desirability bias may be introduced. There may be recall bias because the questionnaire was filled out by the participants themselves, and some of the questions may be misunderstood.

Footnotes

Acknowledgements

We would like to thank Nekemte Teachers Training college, Nekemte Health Science college, Dandi Boru University, and New Generation university, all data collectors, supervisors, and participants who took part in the study.

Abbreviations

CI: confidence interval

FGD: focus group discussion

HIV: human immunodeficiency virus

HPV: human papilloma virus

HSV: herpes simplex virus

NGO: non-governmental organization

SDGs: sustainable development goals

STIs: sexually transmitted infections

VCT: voluntary counseling and testing

VIF: variance inflation factor

WHO: World Health Organization

WURERC: Wallaga University Research Ethical Review Committee

ORCID iDs

Abiriham Rata

Fedasa Guja

Habtamu Oljira

Ethical Considerations

The ethical clearance was obtained from WURERC in its meeting held on March 22 (Reference Number 27/2021).

Consent to Participate

Permission was obtained from each selected university and college, and signed consent was obtained from individual participants. The right of the participant to refuse the study was respected.

Authors Contributions

The overall duty of this research has incorporated the multiple efforts of authors from inception to accomplishment. Abiriham Rata carried out the conception and initiation, design, analysis, and writing of this research article and was involved in the drafting of the manuscript. All authors approved and agreed with its submission to sage open.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data set used and /or analyzed during the current study is available from the corresponding author upon reasonable request.

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Sexually Transmitted Infections Prevention Service Utilization and Associated Factors Among University and College Students in Nekemte City: A Mixed-Methods Study