Sexual Behaviors and Lexicons of Words Used to Talk on Sexual Issues among Young People: The Case of Debre Berhan University Students, Ethiopia

Background: Sexual practices among the young have been reported to be on the increase worldwide. Young people are more likely to engage in risky sexual behaviors. Therefore, sexual behaviors among young people need more attention. The aim of this study was to explore sexual behaviors and lexicons of words used to talk about sexual issues among Debra Berhan University students. 
Methods: Qualitative study was conducted using 8 Focus Group Discussions (FDGs) and participant observation. Participants were selected using criterion purposive sampling. Semi-structured focus group discussion guides and observation checklists were used as data collection tools. Information was audio-recorded and transcribed verbatim. ATLAS.ti 7 software was used for coding and memo developing process. Data collection and analysis were undertaken simultaneously using constant comparative analysis. 
Results: A total of 69 students were participated in this study. Sexual behaviors among the University students were risky. Having multiple sexual partners and sexual practice without condom with non-regular partner was common among the students. Besides, students leave the responsibility of contraceptive use for one another. Globalization, peer pressure, substance abuse, financial constraint and lack of parental control were among the main reasons for sexual practices. University students commonly use unique terms when they talk about their sexual practices than formal language used by the community. They consider these terminologies as modern languages to talk about sexual issues. 
Conclusion: Sexual behaviors among the University students were unsafe and affected by multiple factors. Therefore, strategies that reduce risky sexual behaviors should be considered and strengthened targeting university students. Strengthening promotion of condom use, peer education and life skill training are helpful for the university students to get rid of risky sexual practice.


Background
Sexuality is a central aspect of being human throughout life. Sexuality encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. It is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships [1][2][3][4]. Young people are defined by World Health Organization (WHO) as the age group 10-24 years and make up over one-quarter of the world's population [1,2].
The health threats for young today are predominantly behavioral rather than biomedical [5,6]. Sexual practices among young have been reported to be on the increase worldwide [7]. Studies have shown that sexually active young people are at high risk of sexually transmitted infections (STIs) as they engage in risky sexual behaviors and, therefore, sexual behaviors among young people need more attention [1,2,8].
University students are at high risk of risky sexual behaviors such as sexual coercion, having multiple sexual partners and sexual practices without condom with non-regular partners. These in turn, expose them to negative consequences like STIs, unwanted pregnancy and abortion, and failure in academic achievement [8][9][10]. Peer pressures, lack facilities for sexual and reproductive health services, lack of parental control, prior expectation about the university, being in the young age category, living out-off campus, substance use, campus and outside environment, and low income level were identified as predisposing factors for risky sexual behaviors [9][10][11].
Young people use a unique language when talking among peers on sexual matters [12]. Communication about sexual matters is more important now than previous time [5]. It has been noted that sexual communication is predictive of condom use, and reported as a means to self-efficacy among heterosexuals [13,14]. Sexual behaviors of the young people is shaped and influenced by conversations and interactions with peers [1,2,11,[14][15][16][17][18]. Young people are more likely to talk openly with close friends. Both males and females chose their friends whom they can trust to talk about sexual matters and who will take the issue seriously [11,15,19]. In general, sexual communication among the young requires basic reproductive health information and services, and negotiation skills in sexual relationships [14,17,20].
Previous studies elsewhere have shown that young people engaged in risky sexual behaviors [7,9,11,13,20,21], but little has been explored about among Debre Berhan University students. As to our knowledge, lexicons of words used during communication about sexual matters were not investigated. Thus, this study was aimed to explore sexual behaviors and lexicons of words used to talk about sexual issues among Debra Berhan University students. The result can be useful to guide communication strategies like behavior change communication, sexual counseling, peer-to-peer sex education and training to enhance the sexual life of young people.

Study setting and participants
A qualitative study was conducted to explore sexual behaviors and lexicons of words used to communicate on sexual matters among Debra Berhan University students in 2014. The University is located in Debra Berhan town, Amhara Regional State which is 130 Kms from Addis Ababa. There were 10,006 regular students in the University, of which 6,596 were male, during our study period [22].
The study participants were selected from regular students to gather primary data. The inclusion criteria were being aged 18 years or older, unmarried, registered as a regular student and consenting to participate. Those students who are critically sick during the data collection period were excluded from the study.

Sample size and sampling technique
Sample size was determined by saturation of data and categories, based on iteration level and constant comparative analysis (CCA). Accordingly, eight focus group discussions (FGDs) comprised of 7 to 11 participant were conducted. The FGDs were structured by sex (37 male and 32 female) and year of study. Criterion purposive sampling technique was used to select study participants.

Data collection methods and tools
The data was collected through FGDs and participant observation. The sampling process was flexible and continued until theoretical saturation. The moderator and the participant observer were the investigators. Assistant moderators were gender matched to participants for all FGDs. The discussions were pre-scheduled and took place in class rooms which guaranteed optimum privacy. Each FGD was lasted 60 to 80 minutes to conduct.
Data collection tools were FGD guide and observation checklist.
The FGD guide was flexible and semi-structured open-ended questions. This guide was emerged from the study objectives and adapted from literatures [12,19,[23][24][25][26]. Each English version FGD guide was translated into Amharic, which is the common language of the students, and translated back to English. Voice recorder was used to record FDGs in addition to note taken during discussions. The observation checklist was used to capture terms used to talk about sexual issues. Participants were observed in different places in the campus to identify terms they use to talk about sexual issues with their peers or sexual partners. The researcher attended and participated in the activities that the young perform and socialized with them for a total of 20 days.

Data management and analyses
Data obtained from FGDs and observations were transcribed verbatim. All audio taped and field notes of the discussions were transcribed to Amharic then translated into English language. Data were reduced through summarization and categorization. Patterns and themes in the data were identified during analysis using constant comparison approach as in previous studies [27][28][29][30][31][32]. ATLAS.ti 7 software was used to manage the overall coding and memo developing process.
The codes were assigned to the data obtained from FGDs. These codes then compared in relation to their underlying meanings, patterns, occurrences and similarities. Codes were emerged to families (categories) and super-families (themes). Categories were formed by clustering similar codes and giving them name. Two major themes, i.e. Sexual behaviors and Lexicons of words used while communicating about sexual matters were identified. Quotes of participants were used to illustrate these themes.
Different criterion was applied to maintain the rigor and trustworthiness of the study. Credibility of the finding were maintained through prolonged engagement (i.e., developing an early familiarity with culture of participants to build trust and rapport), reflexivity (through field journal and log book/diary), audio recording, and participant validation (the researcher gets back to participants to see whether the transcribed data correctly represent their points of views for member checking), and thick and rich (dense) description.
In addition, the use of purposive sampling and dense description is maintained transferability of the study. Dependability of the result is also ensured through dense description of the research methods and by the contrast of interpretations among participants (through coderecode procedure). FGD findings were supported by findings from participant observation (triangulation of methods).

Ethical consideration
Ethical clearance was obtained from the Research and Ethical Committee of the college of Public Health and Medical Sciences, Jimma University. A formal support letters were obtained from the department of Health Education and Behavioral Sciences and Debra Berhan University. All participants were given detail information about the purpose of the study. Moreover, personal identifiers were not used to report the findings, and verbal informed consent was obtained from all participants for their willingness to participate in the study.

Results
A total of 69 students were participated in the study. More than half of the participants (53.6%) were males.

Sexual behaviors
According to the information obtained from the FGD discussants, sexual behaviors among Debre Berhan University students were risky. A 23 years old 4 th year female student expressed it as "I think the sexual behavior or sexual life of students in this campus is risky, because many students engage in different forms of unsafe sexual practice during their stay. " Students call "Over mawutat" in Amharic language, to refer the activities related to sexual practice outside the campus i.e. going to hotels, bars or night clubs for drinking, dancing and sexual practice. These activities were commonly practiced during evening and on weekends. A 22 years old 3 rd year female student described that "There is unhealthy sexual practice or sexual relationship. There are drinking, dancing, and sexual practices by going out of the campus. " Students leave the responsibility of contraceptive use for one another. For instance, female and male students say "Let He use it" and "Let She use it" concerning the use of contraceptives respectively. A 19 years old 2 nd year female student expressed the sexual behavior of students as: "Many of the students practice unsafe sex and do not use any form of contraceptives. As a result, unwanted pregnancy and abortion are frequently observed among our University students. "

Predisposing, reinforcing and enabling factors (PRE) of sexual behaviors
This study revealed that the most common reasons or motivators for sexual practice were low awareness regarding STIs and sexual behaviors, globalization, peer pressure, substance abuse, and financial constraint ( Table 2). Students consider sexual films disseminated through internet, and social media like face book posts as modern sexual practice, and try to practice accordingly.

Reinforcing Factors
Enabling Factors  Negative peer influence was identified as one of the most influencing factors for the initiation and engagement of sexual intercourse. A 19 years old 1 st year male student expressed it "Now a days, students consider those students who didn`t initiate sex and who do not have sexual partner(s) were considered as foolish or unwise. On the other hand, having sex and sexual partner(s) during campus life is considered as modernity. " Similarly, 24 years old 4 th year male student expressed negative peer pressure as: "Apart from their own sexual practice, students even help their friends to be engaged in same practice. Mostly, those students who practice sex enhance other students to have sexual partner(s) and initiate them to have sex by covering the costs needed. "

Lexicons of words used by students to talk on sexual issues
This study explored terms that were used by young people when they talk about sexual issues with their peer and sexual partners. Students use different terminologies which were not commonly known by the external community (Appendix 1). They consider these terminologies as modern languages to refer the use of condom, going for sex out of the campus, sexual relationship, pregnancy and abortion.
They use words or phrases like 'with bald' , 'with bare' , 'barefoot' and 'non-fasting' to refer having sex without condom while 'with sock' , 'with fast' and 'with glove' were used to refer having sex using condom.
Students also use 'let us go out' to describe going out of the campus for drinking alcohol, dancing and having sex. 'Quatralech' and 'asfenaterachew' were used in Amharic (local language) to mean experienced pregnancy and abortion respectively. It was recognized that young people commonly use unique terms related to their sexual practices than formal language.

Discussion
This study showed that sexual behaviors among Debre Berhan University students were risky and influenced by several factors. Several students engage in unprotected sexual practices during their campus life. Having multiple sexual partners and sexual practices without condom were among the risky sexual behaviors described by most of the FGD discussants in the current study. Similarly, risky sexual practice is prevalent, 32.3% in male and 43.5% in female, among Jimma University students, Ethiopia [7]. Having multiple sexual partners and inconsistent condom use with new partner were very common among Jimma and Ugandan University students [7,10,21].
Our study also found that students push responsibility to one partner rather than negotiating for safe sex. For instance, female students leave decision to use condom for their male partner saying "Let he use it. " The same is true for male students saying "Let she Use it. " As a result, unintended pregnancy and abortion were frequently observed among University students as reported by FGD participants. Consistent findings were reported from previous studies [1,7,10]. In University of Cape Town, decision to use or not to use condom was left to men [33].
Negative peer pressure, going to night clubs, subsequent substance abuse, globalization, lack of awareness, having multiple sexual partners, lack of parental monitoring and cultural diffusion were among the factors that influence sexual behaviors. This finding is similar with what have been reported by other studies conducted in similar settings [7,10,18,21,33]. Having sex and multiple sexual partners during campus life are considered as modernity in our study area. In South Africa, maintaining relationships with more than one sexual partner was also viewed as a modern practice [33].
The current study showed that the influence of globalization through cultural diffusion was considerable. This finding is similar with the findings of other studies. Globalization, Internet and international youth media trigger global youth culture [1,24,26,33].
Students communicate on sexual issues using their own terminologies which are not known by external communities. The words or phrases they use to talk on sexual issues have relation with their sexual practices. This finding is in line with the study conducted in England, South Africa and Kenya [3,12,19,23,33].
This study is not free from limitations. Since the study is qualitative in nature, findings are not generalizable to all young people. In addition, as the students may not recall all the terminologies they used to talk on sexual issues, terminologies are not all inclusive.
In conclusion, sexual behaviors among the students were risky. They do not take responsibility in negotiating for safer sex. Peer pressure, substance abuse, globalization, lack of awareness, having multiple sexual partners, and lack of parental monitoring were among the factors that influence sexual behaviors. Students usually use unique terms related to their sexual practices than formal language. The use of these terminologies influences their (students) sexual behaviors.
Therefore, strategies that bring behavioral change should be considered and strengthened targeting university students. Strengthening promotion of condom use, peer education and life skill training are useful for university students to reduce risky sexual behaviors. Furthermore, encouraging students to openly discuss sexual issues, providing education about risk factors for sexual behaviors, and communication and negotiation skills are all necessary steps to reinforce behavior.

Supporting Information
Appendix 1 Lexicons of words used (DOCX).