Risky sexual behavior refers to sexual behavior that renders a person vulnerable to sexuality-related and reproductive health issues such as Sexually Transmitted Disease (STDs), human immune deficiency virus (HIV), unwanted and unplanned pregnancy, abortion and psychological distress [1]. Youth are at high risk because they get involved in risky sexual behaviours due to lack of knowledge and guidance about reproductive health, family planning and the risk of sexually transmitted infections. Most of the youth throughout the world engage in sexual intercourse by age of 20, irrespective of the marital status [2]. 

Risky sexual behavior can include the initiation of first sex at the early age of 18 years, sexual activity under the influence of alcohol, anal intercourse, sexual abuse and transactional sex and paid sex [3]. Those who practice sex may involve in changing sexual partners frequently and have multi-partner in the same time period or involve in unprotected sex [4,5].

UNAIDS global report on AIDS epidemic shows that risky sexual behavior like decrease in use of condoms and multiple sexual partner have increased in several countries in sub-Saharan Africa [6-8]. A meta-analysis report showed that out of 19148 male, 75.2 percent reported of having practice of high risk sex [9,10]. In USA revealed that among high school student nationwide 34.2 percent were sexually active out of which 38.9 percent did not use condom during last sexual intercourse [11].

In Nepal, like other Asian countries, the problem of sexuality still remains a taboo. However, young people are taught about health and population at school levels but they are poorly informed about risky sexual behaviours [12]. Men have average 2.4 sexual partners in their life time and 40 percent of men used condom during their last sex [13]. Over a quarter of the respondents were sexually active before marriage, boys five times more compared to girls and involved in multiple sexual relations, of which peers were the most common (71.1 percent) sexual partners. Overall, three out of every four sexually active school youths were found to have practiced risky sexual behavior like initiating multiple sexual relations and pre-marital sexual relations. The use of condom was found declining in subsequent sexual contacts [14,15].

Quantitative cross-sectional study design was conducted on allied health science college students in Kathmandu valley. The duration of the study was from May 1 to November 31, 2019. The students of Allied Health Science Colleges made up the sample of this study. There was no similar study conducted in Nepal, therefore 50 percent prevalence was taken for the study, the sample size was calculated. With p = 0.5, q = 0.5 and z = 1.96, we estimated a sample of at least 384 students to be observed. Though, with the availability of sample unit 430 participants were enrolled in the study. Random sampling technique was used to select the colleges preparing list of colleges using the sampling frame. Data was collected from all eligible university health science students present on the day of data collection and available in two follow up sessions.

The semi-structured self-administered questionnaire was used to collect the data. This questionnaire comprised of socio-demographic information, risky sexual behavior and attitude scales. The questionnaire was translated from English to Nepali for better understanding and pretesting of the tool was done with 10% of the population to check the reliability and validity of the tools.

Data were entered into Epi Data version 3.1 and analyzed using SPSS 20 version. Data was present on frequency, percentage and table. Chi-square test was conducted to determine the association between the risky sexual behaviors and factors associated with it.

The ethical approval for the research was acquired from the ethical board of Nepal Health Research Council. Initially, the permission was taken from the college administration and informed verbal and written consent was taken from the participants before collecting data assuring the confidentiality of the information and for study purpose only.

Out of 430 Participants more than half, 58.4% were female respondent and 41.6% were male respondent. Majority of participants 89.3% were Hindu, followed by Buddhist 5.3%, Christian 2.6% and Muslim 2.8%. Nearly half of participants 58.6% were Brahmin/Chhetri. Similarly, others were janjati 34.4%, Dalit 6.7% and Muslim 0.2%. More than half 68.6% had nuclear family and 31.4% had joint/extended family. One third of the participants, 71.9% were living with family and others with friends 13.3%, hostel 6% and only 8.8% of participants were found to be living alone. The median age of the respondent was 22, minimum age was 18 and maximum age as 30. In terms of education level of father, 29.1% had received the Secondary level education. Similarly, 10% had received lower secondary education, higher secondary 28.1% had received higher secondary education, 30% had received bachelor and above education and 2.8% were illiterate. Similarly, over one fourth of participants' mother (35.1%) had received the secondary level education and others had primary (20.5%), higher secondary (16.0%), bachelor or above (10%) and 17.7% were Illiterate (Table 1-2).

Table 1: Socio-Demographic Characteristics n = 430

Table 2: Frequency Distribution of Participant by Individual Factors

Nearly half of the respondents 49.3% were from bachelor third year, similarly 38.8% were from second year, 10% were from first year and 1.9% were from First Year. In addition, 50.9% were from BPH faculty. Most of the respondents, 72.6% were single. Similarly, 18.8% were in relationship with GF/BF and 8.6% were married. 

Out of the 430 respondent 81.2% of respondent have heard about risky sexual behavior and 18.8% respondents have not heard about risky sexual behavior. The first source of information on risky sexual behavior of 22.8% respondents was internet, 19.5% of said books and teachers, 18.8% said TV/radio, 11.9% said friends, 4% said family and 4.2% said health clinics.

Out of 430 participants 46.3% have had sexual intercourse while 53.7% haven't had any kind of sexual intercourse. Out of them 56.28% had their first sexual intercourse in higher secondary level, 37.18% in university level and 6.53% in secondary level. The median age of sexual debut was 19 years, with minimum age of sexual debut 15 and maximum age 27. 59.29% of those who had sexual intercourse said that the main reason of sexual debut was desire of experiment, 16.08% said their reason was peer pressure, 1.50% said influence of alcohol and 23.11% said they did not know the reason. Similarly, 78.39% said that their first sexual intercourse was voluntary while 21.60% said that their first sexual intercourse was not voluntary. 98.99% said that their first sexual intercourse was vaginal, 0.50% said anal while 0.5% said oral. Similarly, 46.73% have experienced oral sex and 13.56% have experienced anal sex. 2.51% said they mostly get peer pressure for risky sexual behavior, 24.12% said they get peer pressure sometimes and 73.36% said they have never been pressurized for risky sexual behavior.

86.39% have experienced sexual intercourse in past 12 month, while 13.06% have not had sexual intercourse in past 12 month. Similarly, 72.83% had only one sexual partner in past 12month, 27.16% had two or more sexual partner in past 12 month. 12.1% agreed of having sexual intercourse with casual partners in past 12 months. Among those who agreed, 34.61% had one casual sexual partner and 71.15% had two or more casual sexual partner. Similarly, 4.59% have had sexual intercourse with commercial sex workers once, 7.47% twice, 10.34% had thrice or more while 77.58% never had sexual intercourse with commercial sex workers.

Almost all the respondents (99.49%) who have had sexual intercourse have used condom while 0.50% have never used condom. Out of them 13.13% said that they always use condoms, 59.59% said that they use condoms rarely and 27.27% said they use condoms occasionally.

Table 3 shows the association of prevalence of sexual intercourse with casual sexual partner with the socio-demographic variables. It was found that gender (p-value = 0.0001).

Table 3: Factor Associated with Sexual Intercourse with Causal Sexual Partner

Relationship status (p-value = 0.0073), engaged in job (p-value = 0.006), going to cinema hall (p-value = 0.030), substance use (p-value = 0.0287), visiting night club (p-value = 0.00002) and pocket money (p-value = 0.0111) were associated with the prevalence of sexual intercourse with casual sexual partner.

Also show association of number of casual sexual partner with socio demographic variables. It was found that only gender (p-value = 0.004) was associated with prevalence of number of casual sexual partner.

Table shows the factor associated with prevalence of exchanging sex for gifts or money. The factors like sex (<0.000001), family type (0.014814), relationship status (<0.000001), visiting cinema halls (0.007775), substance use (<0.000001) and visiting night clubs (0.001473) were associated with the prevalence of exchanging sex for gifts or money.

Also shows the factors associated with prevalence of sexual intercourse with commercial sex workers. It was found that sex of participants, engaged in job; visiting  cinema halls, visiting night clubs and education of father were associated with prevalence of sexual intercourse with commercial sex workers.

This study assesses the risky sexual behaviors and associated factors among University level students in Kathmandu valley.

Despite strong social and cultural taboos, the participants are not only involved in premarital sex but also in risky sexual behavior. This study shows among 430 participants 46.3% had sexual intercourse and out of them, 86.94% were involved in sexual activities in past 12 month of which 80.9% respondents first sexual involvement was before their fifteenth birthday. Out of those who had sexual intercourse, 22.4% had sexual intercourse with commercial sex worker. Only, 29.14 respondents had used condom during first sex experience. These findings were different from the study conducted in Amhara region, Ethiopia which illustrated that 16% of respondents had sex prior to the data collection period and more than half 56.3% respondents who start sex had their sexual intercourse was before their eighteenth birthday. Only 16.7% respondents used condom at first sex whereas and few 6.3% had sex with commercial sex workers. Among the participants, more than half 58.3% had sexual intercourse in the past 12 months [1].

Present study 86.66% of participants were used alcohol during sexual intercourse. Similar study conducted in South West Ethiopia. In 2011/12 showed that Thirty-four percent of the male and 27.7% of the female students consumed alcohol, 45% of the male and 27.3% of the female students watched pornographic movies in the last six months [16]. Another study conducted in Kathmandu Nepal students exposed to pornography was more likely to engage in sexual risk behavior than those who were never exposed [12].

Present study 35.25% respondents had ever use substance during sexual intercourse rest (68.75) were not. Similar study conducted in combodia showed that substance use was one of the most powerful predictors of risky sexual behavior among both boys and girls in this study. This is also dependable with findings from previous research in developing countries, which has linked illicit drug or alcohol use with adolescent premarital sex and non-use of condoms [17].

In our study regarding this question the main Reason to start sexual intercourse for first time just 1.50% were from influence of alcohol 59.29 were Desire to sexual experiment, 16.08% were from pear pressure. One Contract study conducted in 2014 in Jiga woreda, West Gojjam, Amhara, Ethiopia. Another Contract study conducted in 2014 in Ethiopia showed 28.6% were influence from alcohol [1]. This study showed 26.63% of participants face Peer pressure for risky sexual behavior. One contract study conducted in Northern Ethiopia showed that Students not facing peer pressure are 64% less likely practices risky sexual behavior [18].

Current study found peer pressure for risky sexual behavior most of 73.36% were never, 24.12% were sometimes and 2.51% were mostly One study conducted in Cambodia that defined the structure of peer pressure has been used to explain these associations. Peer pressure is defined as pressure from peers to “do something or to keep from doing something else, no matter if you personally want to or not” [19].

In this study Sexual behavior in past 12 months 86.93% were yes and rest were no.

In our study regarding number of sexual partners in past 12 month 72.83% were one and two or more were 27.16%. One similar study conducted in 2014 in Ethiopia revealed that 70.8% were had one sexual partner and rest were two or more sexual partner [18].

In this study almost 99.49% respondents were used condom during intercourse. One contract study conducted in Ethiopia reviled that only 60.4% respondent used condom during intercourse rest 39.6% were not [18].

Present study out of 430 participants 67% were watched porn movies. 

One study conducted in Southwest Ethiopia study an attempt was made to assess the proportion of risky sexual behaviors and its associated factors. The study revealed that 35% of the study participants were engaged in at least one of the risky sexual behaviors [16].

In the present study 7% urban participants and 5.5% rural participants were involved to anal sex. Anal sex was significantly associated with risky sexual behavior (p = 0.040).

Prevalence of male 12.1% and female 1.5% were involved of anal sex. That was statistically association with risky sexual behavior (p = 0.000). 

One study conducted in Southern Brazil anal sex practice were not associated with risky sexual behavior [20].

Present study visited night club was significantly associated with risky sexual behavior (p = 0.008).

Our study visited night club is significantly association with oral sex (p = 0.031).

Present study going to cinema hall is significantly association with intercourse last 12 month (p = 0.016).

Also show association of number of casual sexual partner with socio demographic variables. It was found that only gender (p value = 0.004) was associated with prevalence of number of casual sexual partner.

Present study shows the factor associated with prevalence of exchanging sex for gifts or money. The factors like sex (<0.000001), substance use (<0.000001) and visiting night clubs (0.001473) were associated with the prevalence of exchanging sex for gifts or money.

One study conducted in combodia showed that Substance use was one of the most powerful predictors of risky sexual behavior among both boys and girls [19].

Our finding shows the factors associated with prevalence of sexual intercourse with commercial sex workers. It was found that sex of participants, engaged in job; visiting cinema halls, visiting night clubs and education of father were associated with prevalence of sexual intercourse with commercial sex workers.

One study conducted in Northern Ethiopia in 2018 showed that Students having sex with commercial sex workers are eighteen times more likely to practice risky sexual behavior [18].

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