Risky Sexual Behavior Practice and Associated Factors Among Street Adolescents in Jimma Town, Southwest of Ethiopia, 2023

Background: Adolescents living on the streets are more exposed to the practice of risky sexual behavior and its consequences than other adolescents of the same age are. Yet, the majority of research on this subject has been done on adolescents and young people attending schools and universities. Therefore, ignoring the sexual and reproductive health needs of this vulnerable segment of the population could have long-term negative effects on both society and the economy. 

Objective: Assessing the practice of risky sexual behavior and associated factors among street adolescents in Jimma town, southwest of Ethiopia.

Methods: This study used a mixed explanatory, community-based cross-sectional study design. Both quantitative and qualitative data were used to support the findings. The study period was from June 20-30/2023. Among descriptive analysis, frequency distribution, Mean, SD, and Median, as well as cross-tabulation were employed. To calculate the likelihood of engaging in Risky Sexual Behavior, Bivariate and Multivariate logistic regression analysis with COR and AOR were used and level of significance declared at p-value < 0.05. Additionally, for qualitative data thematic analysis was done.

Results: According to this study, 45.3% of the street-dwelling adolescents in Jimma town engage in risky sexual behavior. At about 64.3% of respondents who engaged in risky sexual behavior reported having multiple sexual partners. Additionally, the study found that more than three fourth of street-dwelling adolescents did not believe that risky sexual behavior would have serious consequences. Being male, aged 15-19, drinking alcohol, chewing khat, having peer pressure, and having a low perception of the severity and susceptibility, these variables were also found to be strong predictors of RSB practice among street adolescents in Jimma Town.

Conclusion and Recommendation: Nearly half of street adolescents were engaged in risky sexual behavior. And factors like; Gender, Age, Peer pressure, Frequency of religious visits, drinking alcohol, chewing khat, and perceived (susceptibility, and severity) were significantly associated with the practice of RSB. As well as the majority of IDI participants agreed that engaging in safe sexual behavior is difficult. A number of narratives, including males’ expectations to engage in aggressive or obligated sex, ignorance brought on by high levels of sexual derived (feeling), excessive drug and alcohol use, and the need for money and material benefits in order to survive life on the streets, explained these barriers. Based on the findings this study has been recommended that, programs for risk reduction that are aimed at these vulnerable groups should have to focus on strengthening sexual and reproductive health education and behavioral change in order to address the underlying causes of risky sexual behavior practice.

The World Health Organization defines "adolescence" as the age range between 10 and 19 years old, and it is regarded as a transitional stage between childhood and adulthood. Additionally, a time of rapid development, inquiry, and risk-taking [1]. They can test their skills and abilities and find their identity by taking risks. Moreover, they typically take risks by using drugs, drinking alcohols, and engaging in risky sexual behavior.

In addition, their health and well-being may suffer negative long-term consequences because of this risk-taking behavior. The nature of street life exposes street dwellers particularly adolescents to a wide range of reproductive health problems caused by the practice of risky sexual behavior, such as having multiple sexual partners at the same time, initiating sexual activity at too early an age, using condoms inconsistently or unprotected sex, and engaging in commercial sex work or street-based sex [2,3].

Adolescent is important stage during which values are formed. In this life span, many adolescents people sexually active and begin to develop patterns of sexual behavior. Compared to adolescents living with families or guardians, those who live on the streets depict risk-taking behavior at higher rates 5. They are among the high risk and insecure groups and vulnerable to various forms of exploitation and abuses. However, in general, adolescents have limited access to reproductive health services focused on their specific needs, particularly for those living on the street the problem is very serious [1].

According to studies carried out in various countries, including Ethiopia, most adolescents and young adults engaged in risky sexual behavior when they were younger8. For instance, studies conducted in several Ethiopian towns, including Harar, Jimma, and Dilla, showed that, respectively, 59.3%, 79.5%, and 36.1% of children, adolescents, and young people living on the streets were involved in risky sexual behavior [4-6]. Furthermore, in similar manner research carried out in Africa reveals that most people living on the streets have participated in unsafe sexual activities. For example, a Ugandans study shows that, about 70% of street teenagers had sex before the age of fifteen. According to this study, one of the young individuals had more than three daily sexual companions on average [7]. Additionally, 78.5% of adolescent street girls in the DRC rely on prostitution as their primary source of income [8]. These in general give an idea of how serious the issue is and how much action needed to curtail the factors affecting sexual risky behavior and long-lasting impact in the sexuality issues that street adolescents face. Therefore, to fully comprehend the factors those contribute to adolescents engaging in risky sexual behavior, particularly the perceptions that motivate this behavior. Therefore, this research attempted to provide information on the findings of this study would aid in generating hypotheses and hints about the scope of the issue. It also anticipated providing trustworthy information to public health administrators about how to address adolescence issues that are contributing to the state of reproductive health as it stands today. Additionally, the findings of this study will offer pertinent data that can assist national and international organizations that assist those who live on the streets.

Study Area and Period

The period for this study was from June 20-30/2023, Jimma town, southwest Ethiopia. This study was conducted in Jimma town, one of the oldest and most historic towns in southwest Ethiopia. It has a total area of 431 square kilometers, divided into 17 kebeles. According to projections from the 2007 population survey conducted by the Ethiopian Central Statistics Agency, the city has a total population of 207,573 in 2022, of which 103,330 are male and 104,243 are female. Due to the nature of their existence, it is difficult to accurately estimate the number of street adolescents in the town. Despite the discrepancy of the data obtained from different sectors, the number of street children and adolescents indicate that around 1,065.

Study Design

A community-based cross-sectional mixed explanatory study design was used to conduct this study.

Source Population

The population source for this study consisted of all street adolescents residing on Jimma town's streets between the ages of 10-19 years old. In addition, governmental and non-governmental organization those working on street dwellers.

Sample Size Determination

The sample size was calculated by using EPI Info version 7.2.5.0 by considering different assumptions. To determine the prevalence of violence against housemaids, the sample size was determined by assuming a 50% prevalence of risky sexual behavior among street teenagers in Addis Ababa, which is 71.6% [9], a 95% confidence interval, a 5% margin of error, and a 10% nonresponse rate 343.

For the qualitative part of the study, based on information saturation and idea diversity among key informants, the sample size was selected. Data saturation was regarded as sampling until redundancy was achieved and no new information could be found. Consequently, twelve key informants in various fields were interviewed, including adolescent living on the streets.

Measurements

Street adolescents: In this study, the term “street adolescents” was defined as those who are in the age group of between 10 to 19 years old and who are living on the streets of the town during this study period.

Risky Sexual Behavior: In this study, it is defined as, either never using condom or using infrequently, having multiple sexual partners in the past 12 months, beginning sex before the age of 18, or engaging in commercial sex workers.

Data Collection Tool, Personnel, and Procedure

An interviewer-administered structured questionnaire was adapted and modified after reviewing different related literatures as appropriate to address the study objectives [5,7,9-12]. The questionnaire included questions about socio-demographic backgrounds, living environmental related factors, past and present sexual histories, and Health belief model components, perceived (susceptibility, severity, barriers and benefits), as well as it consisted self-efficacy and cues to action towards the practice of risky sexual behavior and its consequences. Six female diploma nurses who could speak the local languages and two supervisors who were qualified with BSc nurses were recruited. One supervisor and two highly experienced data collectors were assigned. Additionally, supervisors and data collectors received one-day training on the objective of the study, the questionnaire's questions, and the methods for collecting data. Quantitative survey, an unstructured open-ended interview guide was adapted from the reviews of different literatures. In-depth interviews focused on the following of important variables, including knowledge about sexual behavior, perceptions toward risky sexual behavior and its effects, the extent of vulnerability to risky sexual behavior, and obstacles to preventing risky sexual behavior.

Data Quality Management

To ensure data quality, emphasis was given to designing the data collection instruments, which were then translated to the Afaan Oromo and Amharic languages by language experts, after which they were translated to English by another person to check consistency. Before the actual data collection, a pretest was conducted on 5% of the sample of the sample on the same subjects with these study participants in neighboring towns before the start of the actual survey. Supervisor and experienced data collectors with prior experience were assigned. The principal investigator then gave those designated as data collectors and supervisor one-day training on the purpose of the study, the data collection methodology, and questionnaire content. After that, the study's objectives were explained to the participants, and confidentiality was guaranteed by not recording personal identifiers on the questionnaire in place of names using code numbers. Both quantitative and qualitative data were used to triangulate the results of the study. Triangulating respondent data across research investigators, theories, and methods can help reduce research bias. Addresses the same topic using a range of tools, which further improves validity. Gives you a complete understanding of the research problem, which further increases credibility [13].

Data Analysis Procedures

Data was entered into Epi-data V 3.1, exported to SPSS v 20. The results were described using descriptive statistics like frequencies, percentages. In addition, Hosmer- Lemeshow test of the data was used to assess the model's fit. A reliability analysis was conducted on a total of 47 items used to assess the dependent variables, and their combined Cronbach's alpha result was 0.84. All explanatory variables that show an association with the outcome variable at a p-value of less than 0.20 were chosen as candidates for multivariable analysis. Subsequently, a multivariable analysis was conducted utilizing the backward stepwise selection method to account for potential confounding variables and establish the existence of a statistically significant association between explanatory variables and the outcome variable at P value less than 0.05. The degree of association between independent variables and the outcome variable was measured using an Adjusted Odd Ratio, with 95% confidence interval. For the qualitative, thematic analysis of the qualitative data involved manual compilation and summarization.

Declarations

Ethical Consideration

The study was approved by the institutional review board (Ref. No: JUIH/IRB/441/23) of the institute of health, Jimma University. An official letter of permission was obtained from Jimma town Health office. The purpose of the study was explained to each study participant and written informed consent was obtained from each participant aged 18 years and older. For those under 18 years, verbal informed consent was obtained from their parent after describing the purpose and benefits of the study. The interviews were performed in private and secure places.

Socio-Demographic Characteristics

A total of 298 self-reported places of residency street-dwelling adolescents in the streets of Jimma town, 274 provided complete responses and yielding a 92% response rate. Majority of 234(85.6%) the respondents were males, and the remaining 40(14.4%) were females. The study's overall mean and median age of street adolescents was 15.2 (SD1.8) and 15 years old respectively. Also, over two-thirds (68.2%) of study participants were street adolescents with the age of between 15-19 years old. educational attainment, 211(77%), respondents, had completed at least primary school grades (1-8). Regarding residency area before joining street life, the majority 215(78.5%) of study participants joined street life of Jimma town by coming from rural areas. 172(62.8%) spent more than three years. One hundred forty-nine (54.4%) respondents were reported having an average daily income of more than 50 ETB. Concerning to religious facilities visits, nearly three-quarters of respondents 202(73.7%) said they had never been visited religious facilities (Table 1).

Table 1: Shows the distribution of Socio-demographic characteristics of street adolescents in Jimma town, southwest of Ethiopia in 2023.

Living Environment Related Factors

The study participants were also asked about watching pornographic films, and the results indicate that more than half of them 59.9 percentage admitted to having watch pornographic films. Additionally, the analysis finding indicates that almost over two-thirds 187(68.2%) of respondents responded that they had peer pressure in terms of the practice of risky sexual behavior. Regarding to the place where street adolescents sleep overnight the study revealed that, majority 175(63.9%) of respondents were sleep overnight on the street. Regarding to substance use, the study revealed that over three fourth (77.4%) of respondents were drink alcohol. Out of the study participants 62.4% of respondents had an experience of smoking cigarette, 73% of respondents had an experience of sniffing Mastish/glue, and (73.7%) of respondents had an experience of chewing khat. This quantitative finding also supported by the majority of in-depth interviews participants (Table 2).

The IDI participants stated in their statement, "I don't tell you that these adolescents can get drinks like beer, draft, and other drinks because they cannot afford. Rather, they have easier access the locally brewed alcoholic drinks and drugs made with leaf locally called ‘Hadha Faris’, which may increase their desire to engage in risky sexual behavior. Because there are so many people there who want to have sex with them.

Living on the streets and being exposed to drug use go hand in hand. The consensus was that living on the streets is miserable. Additionally, they claimed that street adolescents occasionally experience depression, lack of sleep, anxiety, and loneliness, as well as a sense of hopelessness and a bleak outlook on the future. By taking substances, they enjoy the temporary pleasure of it and forget the disgustful life they are facing on the street increasing their exposure to the practice of risky sexual behavior.

Table 2: Shows the distribution of factors related with living environment among street adolescents in Jimma town, southwest Ethiopia 2023.

Perception of Street Adolescents Towards the Practice of RSB

Regarding to the perception of street adolescents towards the practice and consequences of risky sexual behavior, thirty-two assessment questions were used. These include how street adolescents perceive their exposure and the severity of its consequences caused by their sexual behavior (Table 3).

Perceived Susceptibility

The result indicates that 207(75.5%) of street adolescents were had low perception towards the susceptibility of consequences caused by the practice of risky sexual behavior.

This quantitative result supported by IDI conducted with a 45-year-old female employee of the women and child office. According to this IDI participant witness, “Children and Adolescents living on the streets do not think or know that their sexual behavior will have consequences such as; STIs, including HIV, syphilis, and others, as well as unwanted pregnancies and abortions.

Perceived Severity

About 213(77.7%) street adolescents were had low perception towards the severity of these problems. This quantitative data also IDI health extension workers when girls get pregnant on the streets, "…. Some of them go to medical facilities for abortions. However, most of them are in pain and suffering with bleeding. Sometimes even newborns are found right where they mainly reside. And she also said that, they don’t know how much they are suffering with these problems.” (29 Years old, Female HEW).

Perceived Barrier

According to the study findings, 200(73%) of street adolescents were had a low perception of the barriers to engaging in safe sexual behavior. The in-depth interview that was conducted with street adolescents also supports these findings as well.

According to the witness of an 18-year-old street male adolescent who participated in this IDI, “We don't listen to anyone, we do what we want. In addition, he believes that there will be stigma and discrimination if they do not act like their friend’s act. Moreover, they have a fear of ignorance by their friends. As well as this IDI participant also revealed that, as they dislike condom, because most of them agreed that, condom decreases sexual satisfaction.

Perceived Benefits

In total, 172(62.8%) of street adolescents gave the perceived benefits of engaging in risky sexual behavior high ratings. according to this IDI participant, "most children and adolescents who live on the streets think they won't be treated equally with other people if they don't act in the same way toward other friends. They also worry that they won't be viewed as strong enough if they don’t act as their friends.

Self-Efficacy

The findings revealed that about 201(73.4%) of street adolescents had low self-efficacy scores in relation to the suggested measures to stop the practice of risky sexual behavior.

The IDI findings indicate, street adolescents did not use condoms during sexual activity. According to those interviewees, using condoms depends on the partners. Most people prefer having sex without a condom, especially with strangers.

Cues to Action

Out of the total study participants, one hundred ninety-three (70.4%) of respondents had high score towards the cues/remainder factors influencing to the practice of risky sexual behavior. “IDI conducted with this staff’s belief, there are many factors that motivate street adolescents to engage in risky sexual behavior. Factors such as the place where they spend the night because males and female street dwellers spend the night together in the same place. Also, they take different kinds of drugs to protect them self from fear and cold weather.

Table 3: Shows the theoretical variables/perception of street adolescents towards the consequences caused by the practice of Risky Sexual Behavior in Jimma town in 2023GC. (N=274).

Factors Associated with The Practice of RSB Among Street Adolescents

In binary logistic regression analysis independent variables such as; (Gender, Age, Frequency of religious facility visits, Average daily income, Previous residence area, duration of years spent living on the street, peer pressure, watching porn movies, drinking alcohol, chewing khat, and perception such as perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and Cues to action were factors significantly associated with the practice of risky sexual behavior among street adolescents. In multivariate logistic regression analysis after confounding variables controlled; being male, age group of 15-19 years, not visiting religious facility, having peer pressure, chewing khat, alcoholic, and having low perception towards the susceptibility and severity of consequences caused by the practice of risky sexual behavior were significantly associated factors with the Risky sexual behavior among street adolescents in Jimma town (Table 4).

According to the analysis, male respondents were 3.4 times more likely to engage in risky sexual behavior than female respondents [AOR=3.4(1.2,9.3)]. Respondents who are in the age group of between 15-19 years old were more than 12 times more likely to engage in risky sexual behavior as compared to respondents in the age group of 10-14 years old [AOR=12(5.3, 27.5)]. Regarding the frequency of religious facility visits, respondents who didn’t visit religious facilities were 2.7 times more likely to engage in risky sexual behavior than those respondents who visited religious facilities at least once a year [AOR=2.7(1.2,6.3)].

As well as the analysis revealed that, having peer pressure also determine street adolescents’ sexual behavior. Respondents who had peer pressure were 2.7 times more likely to engage in risky sexual behavior as compared to those respondents who did not have peer pressure [AOR=2.7(1.2,6.1)]. Regarding substance use, the analysis shows, respondents who drank alcohol were 5 times more likely engaged in the practice of risky sexual behavior than those who didn't drink alcohol [AOR=5(1.7,14.9)]. Additionally, respondents who chewed khat were 3.4 times more likely to engage in risky sexual behavior than those who did not chew khat [AOR=3.4(1.3,8.5)].

Concerning to the perception of street adolescents, analysis revealed that, respondents who had low perceived susceptibility towards the potential complications caused by the practice of risky sexual behavior were six times more likely to engage in the practice of risky sexual behavior as compared to those had high score of perceived susceptibility [AOR=6(2.4, 16.3)]. As well as the analysis also indicates that respondents with low perceived severity towards the potential complications/consequences caused by the practice of risky sexual behavior were 3.5 times more likely to engage in risky sexual behavior than those with high perceived severity [AOR=3.5(1.5, 8.4)].

Table 4: Distribution of Multivariate and bivariate logistic regression analysis shows the independent variables significantly associated with the practice of risky sexual behavior among street adolescents in Jimma town 2023.

1, Indicate for reference group, COR=Crude Odds Ratio, AOR=Adjusted Odds Ratio, CI=Confidence Interval, *=pv less than 0.01, and **=pv less than 0.05.

This study, has been viewed comprehensively with both quantitative and qualitative information, aimed to provide pertinent data on risky sexual behavior determinants among adolescents living on the streets. Also, used the constructs of the health belief model to determine the intention to engage in risky sexual behavior among street adolescents aged 10 to 19 years old in Jimma town. The prevalence of risky sexual behavior practice among street adolescents in Jimma town southwest of Ethiopia found to be 45.3% [95% CI: (39.3-51.4%)]. Even so, the geographical and the age range covered between studies were different, the result of this study is similar to the results of studies conducted in Addis Abeba (43%) and Wonago (43.5%) on street children between the age of (10-18) [11,14]. The result of this study lower than the finding of the studies conducted on street youth in Dila town, Addis Abeba, and Gonder city [9,12,15]. This discrepancy might be have arisen from differences in the age groups of the study participants; the age range covered by this study was 10-19 years old, whereas the age range covered by those studies was 10-24 years old. The discrepancies in the results could also be attributed to geographic differences and respondents' over- or underreporting of their responses. Additionally, the prevalence of sexually active study participants (61.7%) in Gondar, compared to 56.2% in this study, and the age differences between the two studies for example the age of 15-19 years old study participants in this study was 68.2%, while in Gondar (51.4%) these factors might be the possible reasons of discrepancy in findings. In addition, the result of this study was much lower than the study conducted in Brazil. The discrepancy of the result might be socio-demographic variations in the two study areas, such as differences in income, and years spent living on the streets (half of the participants in the Brazil study had been homeless for at least four years) [16], while in this study area only 10% lived for more than 4 years.

In addition, as compared to studies conducted in southern Ethiopia (31.6%) [16] and Gondar zone (27.5%) [17]. The finding of this study is higher. The variation in study variables used to assess the risk of sexual practice could be the cause of this discrepancy. For instance, when assessing risky sexual behavior, the study conducted in southern Ethiopia did not take into account the participant's age at their first sex. Furthermore, the main reasons of these results discrepancy might be the difference in study participants, for example the study participants of the current study focused was only street adolescents aged between 10-19 years, whereas the study conducted in southern Ethiopia examined all individuals who are living on the street. The discrepancy of results between Gondar and this study might be, attributed to a number of factors, including early sexual activity, a higher prevalence of substance abuse, and a lack of information, and the variations in the geographical location could be contributing factors. However, the measure-contributing factor for this discrepancy the study conducted in Gondar zone was among adolescents living with their families, whereas this focus on only street dwelling adolescents. This demonstrated that street adolescents engaged in more risky sexual behavior than their non-street counterparts did.

The odds of practicing risky sexual behavior were higher among street adolescents in age group of 15-19 years, being male, never visiting religious facility, having peer pressure, alcohol intake, chawing khat, and having low perception towards the susceptibility and severity of the potential consequences caused by the practice of risky sexual behavior. These factors confirmed by similar studies conducted in various towns of Ethiopia such as, Jimma, Addis Abeba, Harar, Dilla, Gondar, and Mekelle [4–6,18]. In addition, the studies conducted in different countries such DRC, Ghana, Uganda, Iran, Brazil, USA, and China also confirmed these factors as a predictor of risky sexual behavior practice among street dwellers [19-21]. According to this study male street adolescents were greater than three times practice risky sexual behavior as compared to female’s street adolescents [AOR=3.4(1.2,9.3)]. This implies that being maleness exposes to the practice of risky sexual behavior. This finding also in line with studies conducted in Ethiopia towns [7,22,23]. For instance, the study conducted in SNNPRS revealed that, male respondents were about 3 times at more likely engaged in the practice of risky sexual behavior than females [24]. This might be because male respondents had a more likelihood of engaging in multiple sexual partners than female respondents. However, this finding opposed with the finding of study conducted in Uganda Kapala the finding was females were more likely engaged in risky sexual behavior as compared to males [7]. Living on the streets without assistance can generally make it easier to obtain and use cheap alcohol and drugs, which can eventually weaken self-control and raise the chance of engaging in risky sexual behavior without the use of condoms.

This also evidenced by IDI participants in an attempt to emphasize the problem as well as to provide conclusive remarks on the views of many females about places of they spent time participants said:

A street girl who was 19 years IDI participant said, "…There would always be drunken boys in the night, and when they found females sleeping on the street, they would have even team and odd sex.” According to the witness of street adolescents who participated in this IDI, “…We don't listen to anyone; we do what we want to do. In addition, he believes that, there will be stigma and discrimination if we do not act like our friends. Because if we don't do what our friends do, they will completely ignore us.”  (An 18-year-old street male dweller).

Among the study participants, more than two third (68.2%) of respondents were found in the age group of 15-19 years old. Also, being in this age group significantly associated with the practice of risky sexual behavior. Street adolescents who are in the age group of 15-19 years old were twelve times more likely engaged in the practice of risky sexual behavior as compared to those in age group of 10-14 years old [AOR=12(5.3, 27.5)]. This indicates that adolescents near the late adolescence age are more likely to engage in risky sexual behavior than early adolescence age groups. It also, implies that as age increase the likelihood of practicing risky sexual behavior increased studies from Southern Ethiopia [6,25]. Gondar [26] and Sri Lanka [27] reported similar findings. There are many reasons for the strong association between these ages and risky sexual behavior. As children get older, they are more likely to associate with peers who engage in risky sexual behavior, perhaps they do not use drugs while older adolescents do, and other factors at play may make older adolescents more likely to engage in risky sexual behaviors.

This also evidenced by IDI participants in an attempt to emphasize the problem as well as to provide conclusive remarks on the views of many females about places of they spent time participants said:

The majority of IDI participants of this study asserted that… “Boys particularly those in-between the ages of 15-19 do not obey our advice. For instance, when you start advising them to use condoms and other preventative measures, they begin laughing at you”.

In this study, respondents who did not visit a religious facility were 2.7 times more likely engaged in risky sexual behavior practice than those who visited a religious facility [AOR=2.7(1.2,6.3)]. This finding is in line with finding of study conducted in Jimma zone on students living away their families. A related study carried out in Harare, Zimbabwe, also verified that among street dwellers, having a negative religious belief is a predictor of engaging in risky sexual behavior. According to this study, street children's and adolescent' negative religious and spiritual self-images have a significant detrimental impact on their social interactions, moral behavior, and psychological well-being [28]. In a similar manner, an Australian study finds that respondents who classified as highly religious think that having sex before marriage or early in life is always immoral and that going to religious places shields them from having risky sex. This lends credence to the idea that a person's religious beliefs and their perspective on sexual behavior are related.

In addition, this study found that street adolescents who have peer pressure were 2.8 times more likely practice sexual behaviors in risky ways as compared to their counterparts [AOR=2.7(1.2,6.1)]. This finding is further supported by the studies carried out in Bahir Dar city, Nekemte town, and Woldia town [23,29,30]. This may be because people who live on the streets want safety and a sense of belonging in order to survive, which is why peer pressure may have an impact on sexual behavior.

According to the witness the majority IDI study participants street dwellers in Jimma town particularly children and adolescents are dependent on Khat, Alcohol, Cigarettes, Mastish/glue, Benzene, Shisha, as well as Ganja. Even some of them were interviewed while they are chewing khat and smoking Cigarettes as well Mastish/glue. Also, the analysis result of this study shows that, using khat and alcohol increases the likelihood of engaging in risky sexual behavior by greater than 3 and five times with [AOR=3.4(1.3, 8.5)] and [AOR=5(1.7, 14.9)] respectively. According studies suggestion, alcohol and drugs often go along with the practice of risky sexual behavior among street adolescents. In addition, a worldwide, measures of correlation have revealed the significant associations between substance use and risky sexual behaviors [31]. And also revealed as a predictor of sexual behavior among street children and adolescents by a study conducted in Jimma town and Addis Ababa substance users have the risk of taking sexual risks is three to five times higher than who do not use substances [5,32]. As well as it supported by a study conducted by the CDC on substance use, which concluded that the least likely to be sexually risky were adolescents who reported no drug or alcohol use [33].

In addition, the expectancy theory as well, supports this finding. This theory largely emphasizes the significance of internalized cultural and societal expectations regarding the impact of substances on the sexual behavior. According to this theory, a person's expectation that using drugs will reduce their sexual inhibitions and/or boost their sexual pleasure moderates the relationship between drugs and sexual behavior, making it more likely and dangerous as their anticipation rises. Having sex under the influence of alcohol exacerbates the situation and can compromise use of condoms and heighten sexual risks unwanted pregnancy, abortion, and including HIV/AIDS among street adolescents. Especially those who do not have adult supervision and live in very harsh environmental conditions and in areas where they tend to use substances such as khat, tobacco, ganja, shisha, and benzene. This raises the chance of having unprotected sex [34]. Early sexual encounters regularly associated with substance use, particularly in boys [34,35].

Despite the general perception of the susceptibility and severity of the consequences of risky sexual behavior, the study also found that majority of street adolescents were had low perceptions towards the (barriers and self-efficacy), as well as high perception towards the benefits and cues/remainders to engaging in risky sexual behavior to the practice of safe sexual behavior and risky sexual behavior. In addition to the results of this study, the theory of health belief model contends that people are more likely to engage in risky sexual behavior if they believe the benefits of doing so outweigh the disadvantages of doing so [36].

The odds of engaging in risky sexual behavior associated with the perception of street adolescents towards the consequences caused by the of risky sexual behavior. Street adolescents who had low perception towards the susceptibility of consequences were more likely to engage in risky sexual behavior than street adolescents with high perceived susceptibility to the negative effects of risky sexual behavior, by a factor of more than 6.3 time [AOR=6(2.4,16.3)]. And Street adolescents who perceived the complications and worthiness of the consequences of risky sexual behavior as having low severity were 3.5 times more likely to engage in risky sexual behavior than those who perceived the complications as having high severity [AOR=3.5(1.5,8.4)]. A Study conducted in Ethiopia has noted that respondents with low perceptions towards the exposure of consequences caused by their behavior were more likely engaged on those particular risky behaviors. For instance, in a study conducted in Ethiopia shows that, the majority of study participants believed they posed no risk of contracting any diseases despite the high prevalence of consequences associated with risky behavior [37]. A Tanzanian study also revealed the association of low perception towards the risks caused by someone behavior. According to this study conclusion, people with low-risk perception tend to underestimate their own risks, which they attempt to offset through their behavior [38]. This result is further corroborated by the optimistic bias or cognitive bias theory, which explains why people underestimate their risk in comparison to the actual risk because they think they are less likely to encounter a negative event for themselves.

By this study, the nearly half of sexually active street adolescents were engaged in Risky Sexual Behavior in the previous 12 months. In addition, more than three-quarters of street adolescents were started having sexual relations before turning 18 years old. According to this study, factors such as being male, being between the ages of 15-19, not having ever visited a religious institution, being under peer pressure, and using substances, particularly khat and alcohol. Also, the theoretical variables or perceptions like, having low score of perceptions towards the susceptibility, severity, and barrier of preventive and consequences caused by the practice of risky sexual behavior were found to be strong predictor of risky sexual behavior among street adolescents. The IDI participants also confirmed that there is very little cross-sector service integration in Jimma town to mitigate the negative effects of street adolescents engaging in risky sexual behavior. Therefore, integrated interventions risk reduction programs aimed at these vulnerable populations must seriously address underlying causes like substance use, especially the use of khat and alcohol, as well as perceptions of the risks connected to risky sexual behavior. As a result, in order to encourage behavioral change, all responsible bodies need to be to require implementing interventions while taking the aforementioned factors into account.

Abbreviations

HBM: Health Belief Model

IDI: In-Depth Interview

RSB: Risky Sexual Behavior

NGO: Nongovernmental Organization

Data Sharing Statement

The dataset for the current study is available from the corresponding authors upon reasonable request.

Ethics Approval and Consent to Participate

The study was approved by the institutional review board (Ref. No: JUIH/IRB/441/23) of the institute of health, Jimma University. An official letter of permission was obtained from Jimma town Health office. The purpose of the study was explained to each study participant and written informed consent was obtained from each participant aged 18 years and older. For those under 18 years, verbal informed consent was obtained from their parent after describing the purpose and benefits of the study. The interviews were performed in private and secure places.

Availability of Data and Materials

All data generated or analyzed during this study are included in this manuscript.

Acknowledgments

We express our genuine thanks to all individuals who contributed to the study respondents, the data collectors, and Jimma University.

Author Contributions

GK, HA began the concept; GK, HA, MT and AN developed the proposal; GK and HA participated in data collection, transcription, and translation. GK and HA was involved in data coding, analysis, and writing the draft manuscript GK, HA, MT and AN reviewed the last version manuscript has analyzed the data. All authors read, agreed, and approved the last version of the manuscript.

Funding

The research work was funded by Jimma University. The funders had no role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript.

Availability of Data and Materials

The dataset for the current study is available from the corresponding authors upon reasonable request.

Disclosure

The authors declare no competing interests in this work.

Consent for Publication

Not applicable. 

Competing Interests

The authors declare that they have no competing interests.

Supplementary Information

Additional file: Questionnaire used for data collection.