Early sexual debut and associated factors among secondary school students of central zone of Tigray, Northern Ethiopia, 2018

Introduction Early sexual debut is common among young people and it has several sexual and reproductive health consequences. But, its burden and the associated factors leading to this behavior haven't received due attention. The main purpose of this study was to investigate the prevalence and associated factors of sexual debut in the preparatory and high school students of Aksum town. Methods A school-based quantitative cross-sectional study design was used for this research work. A total of 519 preparatory and high school regular students participated in the survey. The sample population was obtained by using a simple random sampling technique from each schooling proportion with their number of students. Data, that were collected using self administered questionnaires, were entered into EpiData 3.02 and analyzed in SPSS 22.0. Results were presented using frequencies, tables and graphs. Statistical significance was declared at a P-value <0.05. Results Of the total participants, 266 (51.3%) were males. The age of the participants ranged from 13 to 23 years with a mean age of 16.3 ± 1.47 years. Of the total participants, 137(26.2%) had sexual experience, among which 119 (87.5%) had an early sexual debut at an average age of 13.7 + 1.4 years. Factors that were found to be significantly associated with an early sexual debut were gender (AOR=3.41; 95% CI: 1.54, 6.99), residence (AOR=0.44; 95% CI: 0.27, 0.81), alcohol drinking (AOR=5.5; 95% CI: 2.2, 14.8), cigarette smoking (AOR=3.3; 95% CI: 2.3, 7.5), exposure to pornography, such as reading/seeing pornographic materials (AOR=7.4; 95% CI: 4.4, 11.78), living arrangement for educational purpose (AOR= 0.43; 95% CI: 0.13, 0.89), grade (AOR=0.38; 95% CI: 0.06, 0.68) and monthly living allowance (AOR=0.419; 95% CI: 0.2, 0.9). Conclusion A significant number of students reported early sexual debut. Gender, place of residence, alcohol drinking, cigarette smoking, exposure to pornography, grade and living arrangement for educational purpose and monthly living allowance were significant predictors of an early sexual debut.


Introduction
Adolescence is a period of human development that everyone passes through and experiences new situations as well as experiments different life events. The result of these experiments might be good or bad depending on the different personal and environmental factors [1]. Almost half of the world's population's age is concentrated under the age of 25 years. Most of this segment of the population lives in developing countries with Sub-Saharan Africa youths constituting 20%-30% of this population. According to the 2007 Ethiopian census, youths aged 15-24 years contribute to 20.6% of the whole population (more than 15.2 million). Early sexual debut is common among young people and it has several sexual and reproductive health consequences such as sexual coercion, female genital cutting, unplanned pregnancies, closely spaced pregnancies, abortion, sexually transmitted infections (STIs) and HIV/AIDS. Each of these consequences contributes to further other physical, psychological, social and economic problems [2][3][4][5].
Around 11% of the worldwide births are from people less than 20 years of age. Of this, 95% were reported from developing countries with Ethiopia being one of the countries with a high birth rate from this age group. Internationally, around 26 million adolescent pregnancies occur yearly and abortion, miscarriage or still birth happened in 10 million of those. Findings from demographic health surveys from developing countries indicated that about 10% of adolescent girls became mothers at 16 years old, the majority of them being from sub-Saharan Africa and South-Central and South-Eastern Asia [6]. Adolescents, which constitutes are sizable proportion worldwide, are exposed to many health problems. For instance, around 60,000 adolescent women die every year related to these health problems. Worldwide, around one million pregnancies happen each day; of this, 50% are out of plan and 25% are unwanted pregnancies [7]. Different studies were done in different regions of the world to identify the prevalence and associated factors of early sexual debut. Based on the finding from these studies, sexual activities among youths and adolescents have been reported to be increasing worldwide [5]. Despite the significance of the worldwide magnitude of early sexual debut, no research had been done to identify the prevalence and associated factors of early sexual debut in the study area of this research. It is anticipated that investigating this behavior and associated factors in this study area will contribute to identifying the magnitude and factors which may be utilized by schools, zonal and regional health bureaus to design appropriate interventions based on the finding.

Methods
Study area and design: school-based cross-sectional study was conducted from March 1 to March 30, 2018, in the Central Zone of Tigray, Northern Ethiopia in public preparatory and high schools. This is located 1024 km away from the capital city of Addis Ababa. There are 2 preparatory and 3 secondary public schools found in the town, with the total students of 6,939 during the study period.
Sample size: single population proportion was used to calculate the sample size in Epi Info version 7 with the following assumptions: prevalence= 19% [8], 95% CI, a margin of error 5% for a prevalence of early sexual debut and power=80% and the ratio of unexposed to exposed was almost =1. A sample of 519 students (initially 236 samples, 2 design effect and 10% non-response rate) was taken randomly after stratification was made according to their grade level.
Data collection tool and analysis: data were collected using semistructured self-administered questionnaire. This included the respondents' Socio-demographic characteristics, parent characteristics as well as other pertinent data such as alcohol drinking, cigarette smoking and living arrangement for educational purpose, monthly living allowance and exposure to pornography.
Training was given for data collectors about the purpose and procedures of the study. To control the quality of the data, double data entry was done by two data clerks and the consistency of the entered data was cross-checked by comparing the two separately entered data on Epi Data. The raw data was cleaned, coded and entered into the computer as soon as data were generated and analyzed using SPSS version 22. Data were summarized using descriptive and inferential statistics. Bivariate analysis at 95% confidence interval was used to infer an association between the independent and outcome variables. Independent factors, with a Pvalue ≤ 0.25 in the bivariate logistic regression, were entered into the multiple logistic regression model to obtain the significant variables.
Statistical significance was declared at P< 0.05 and variables which were statistically significant at p-value < 0.05 were identified as factors of early sexual debut.

Operational definition
Early sexual debut: having sexual intercourse at or before the age of 14 years old [9].
Ethical approval and consent to participate: this study was reviewed and approved by the Research Committee, Health Science College and Comprehensive Specialized Hospital of Aksum University.
Consent was also obtained from both the educational bureau of the town and directors of each school. The objective and importance of the study were explained clearly to the study participants. Moreover, participants were informed that their participation is not compulsory and can leave the participation at any time during the interview.
Respondents were also assured that their information will be kept confidential. Data were collected after full informed oral consent/assent was obtained from each study subjects whose age was less than 16 years. In order to keep the confidentiality of respondents' data, their name was kept anonymous.

Discussion
This study investigated the magnitude of early sexual debut and its determinants among preparatory and high school regular students of Aksum town. The prevalence of having sex in their life in the study area was 26.2%. This finding was higher than the finding from Northern Ethiopia [7] and Nigeria [10] but lower than the studies in South West Ethiopia [11], United States [12], Tanzania [13], Kenya [14], Debremarkos, Ethiopia [15] and EDHS, 2016 [16]. This may be because of the sample size differences, the study area and the study population. Among the students who had experienced sex, 87.5% had an early sexual debut. This finding was higher than the finding in Tanzania, 57.8% [13] and South Africa, 39% [17]. In this study, the mean age of an early sexual debutant was 13.7 + 1.4. This finding was lower than the results from a study done in Debremarkos, Ethiopia and higher than the finding from Nigeria, South Africa and Tanzania [10,13,15,17]. This study also showed that the mean age of early sexual debut was lower among females ( [14,18,20]. Living with family had a significant association with an early sexual debut. Students who live with their families were 0.43 times less likely to be an early sexual debutante than those who were not living with their family, (AOR= 0.43; 95% CI: 0.13, 0.89). This was in line with the study conducted in Eastern Ethiopia [21]. The students' monthly living allowance was significantly associated with early sexual debut.
Students who had ≤ 5.5 US dollar pocket money per month were 0.42 times less likely to be an early sexual debutante than those who had greater than 18.5 US dollars, (AOR=0.419; 95% CI: 0.2, 0.9). This is comparable with a study done in northern Ethiopia [7]. The grade of the students was significantly associated with an early sexual début.
Students in the lower grade (grade 9), were 0.4 times less likely to be an early sexual debutante than those in the higher grade level, (AOR=0.38; 95% CI: 0.06, 0.68). This may be due to the fact that lower grade students are usually younger in age and hence have less knowledge about sex than students in the higher grade. This means that being in the lower grade decreases early sexual debut by 17%.

Conclusion
A significant number of students had an early sexual debut, the magnitude being 88 out of 100 students. Gender, place of residence, alcohol drinking, cigarette smoking, exposure to pornography, living arrangement for educational purpose, grade and monthly living allowance had a significant association with an early sexual debut of students.
Limitation of the study: since this study is a cross-sectional study, it does not show the direction of relationships among variables and because the subject is quite a sensitive one, some significant information might be under-reported.
What is known about this topic  Prevalence of early sexual debut among preparatory and high school students in Africa is high and it is a major public

Competing interests
This manuscript maintains no competing financial interest declaration from any person or Organization or non-financial competing interests such as political, personal, religious, ideological, academic, intellectual, commercial or any other.

Acknowledgments
We would like to thank all study participants and data collectors for their contribution to the success of this work.