Effects of Curriculum-Based Sexual and Reproductive health intervention on the comprehensive knowledge and attitude to condom use among first-year students in Arba Minch University: a quasi-experimental study


 Objective: To assess the effect of curriculum-based sexual and reproductive health intervention on the comprehensive knowledge and attitude to condom use among first-year students at Arba Minch University. Results: A total of 832 students participated at a baseline, and 820 students participated at posttest. This study found that there was a significant effect on changing students’ knowledge and attitude towards a condom. In the intervention group, the students’ average change of comprehensive condom knowledge score was 0.229 higher than the average score of student’ in the control group (ATE=0.229, 95% CI, 0.132 to 0.328; p < 0.001). The average change of attitude toward condom score of students’ in the intervention group was 1.834 higher than the average change score of students’ in control group (ATE=1.834, 95% CI, 1.195 to 2.772; p < 0.001).This study provides further evidence on the effect of the curriculum-based comprehensive sexual and reproductive health education effective in terms of knowledge and attitude towards a condom. Therefore, this education intervention should be strengthening the implementation of the control and prevent youths from HIV/AIDS and unintended pregnancy.


Introduction
According to the world health organization (WHO) Youth is an important population group with great potential for physical, mental, and psychological development [1]. Youths are the largest population there were 1.80 billion people between the ages of 10 and 24 years, of the 70% are concentrated in developing countries [2]. In Ethiopia from the total population, 20.04% were between 15-24 years [2,3]. Most of them are joining a higher institution for an academic program [4,5]. Higher education institutions in Ethiopia host young people aged between 19 -24 years [4,6].
According to reports shows that worldwide youths were at high risk of HIV infection, accounting for 20% of new HIV infections [7]. Seventy-nine percent of these infections occur in sub-Saharan Africa (SSA) [7]. Also, each year 7.4 million girls experienced unintended pregnancies and 3 million girls experienced unsafe abortions [8]. These problems put young people at risk for morbidity, mortality and limiting their educational and employment opportunities [8,9].
Evidence shows that higher education institutions are the best place to deal with sexual reproductive health problem including HIV/AIDS and unintended pregnancy [10]. Ethiopia started sexual and reproductive health prevention information and services accessible to higher learning institutions Since 2008 [11].Even though comprehensive sexual health education intervention is implemented in Ethiopia as one of the sexual and reproductive health-related problems prevention and control strategies among higher institution youth in Ethiopia including the study area. However, the effect of this education was not assessed previously in Ethiopia. Therefore, this study aims to assess the effect of an education intervention on knowledge and attitude towards a condom among rst-year students of Arba Minch University in 2017/18.

Study design and setting
A quasi-experimental study with pre-posttest in which students were divided into a control and intervention arm was conducted among rst-year students of Arba Minch University.

Population
All rst-year students of Arba Minch University in regular programs were the source population whereas all rst-year students in selected departments who attend regular programs and full ll inclusion criteria in both intervention and control groups were study population Inclusion and Exclusion Criterion (Eligibility Criteria) The study included all rst-year students whose age between 15-24 years, but those students who had previous exposure for compressive sexual and reproductive education and those who have unable to respond due to severe illness were excluded from the study.

Sample size sampling technique
The required sample size for the number of students needed for this study was calculated by Open Statcalc based on the following assumptions: Based on the study done in Lusaka, Zambia, the proportion of students who used condom consistently and correctly with casual partner last time among control group was 59.1% and among intervention group was 71.4% [12]. At a 95% con dence interval for a twosided test, 80% power with a minimum detectable alternative of ± 5%. Accordingly, the calculated sample size was 504 participants. Assuming a study refusal rate of 10% and a design effect of 1.5, a total minimum sample size needed for this study was 504* 0.1+ 504 = 554*1.5= 832 individuals. The total number of the sampled student was 832 (416 in the intervention group and 416 in the control group). For selecting the study participants, a multi-stage sampling method was done. Then eight departments were randomly selected from Arba Minch campus for intervention group and eight departments from Sawla campus were randomly selected for the control group. For each selected department proportional to size allocation was applied to identify the total number of students to be studied. Then after preparing the sampling frame based on the data from the registrar of the campuses, the study participants were selected using simple random sampling techniques using a computer-generated random table.

Measurement
Knowledge towards condoms was measured using four items developed after reviewing previously done literature. The scale is comprised of the following question, having heard about the male and female condom, condoms are an effective method to prevent unwanted pregnancy, HIV/AIDS and STD. The correct answers were coded "1" and wrong answers "0" [13].
Attitude towards condoms was measured using thirty Likert scale items developed after reviewing previously done literature. Respondents were presented with the following statements. Response categories included: 1 = agree, 2 = not sure and 3 = disagree.
Intention to use a condom was measured based on the study subjects responses to the question asked on regardless of their past sexual experience the students were assessed for their intention to use a condom in their next sexual encounter, using the following item: "I intend to use a condom at the next sexual intercourse." Responses were arranged from strongly agree to strongly disagree on a 5-point scale. This variable will be treated as continuous and each variable coded as "1" or Have great intention to use condoms If the study subject responded as he/she intend to use a condom at the next sexual intercourse and "0" or student don't have an intention to use condoms [3,14].
Data Collection Procedure Data were collected using a self-administered questionnaire. The questionnaire was initially adapted from the WHO knowledge, attitudes, beliefs, and practices survey instrument and further modi ed based on available literature [15][16][17][18]. At the pre-intervention stage, the baseline information for respondents was obtained from two groups (intervention and control group) one week before starting an educational intervention. The unique con dential identi cation number was assigned to each student to allow for matching their responses across time points. This was followed by intervention stage in which a series of sixteen-week education sessions for students in the intervention group which was designed to equip students with knowledge, skills, and attitudes needed to prevent from SRH problems and bring positive behavioral changes on sexual and reproductive issues. The education was delivered using brainstorming, lectures, case study, discussion and demonstrations methods. Immediately, after the last education session before the nal exam, post-intervention stage, the same questionnaire that used in the preintervention stage was administered to the same students who were selected at the pre-intervention stage in both the intervention and the control groups.

Data Quality Control
To data quality control training was given for data collectors and data clerk personnel. Intensive supervision was done by investigators during data collection. A pre-test was conducted at Arba Minch Health Science College that was equivalent to 5% of the study participants to check the accuracy and consistency of the data collection tools. All the data were cleaned double entered and cross-checked for their completeness and linkage to the unique identi cation number before analysis. The database was checked for incorrect or out of range data entry.

Data Analysis
The completeness and consistency of the data were checked, coded and double entered into Epi-data 3.1 and exported to STATA version 14.0 statistical software for further analysis. Descriptive statistics was performed. Person chi-square test was used to compare categorical outcome variables before and after intervention as well as between the intervention and control group. Furthermore, to compare continuous outcome variables before and after the intervention was tested using paired t-tests while differences between the control group and the intervention groups were tested using the independent t-test. To see the effect of intervention we used an Inverse Probability Weighted (IPW) analyses.

Results
Socio-demographic characteristics of the study participants A total of 416 questionnaires were administered to each study group and control group at the preintervention stage of the study. Among those 401 and 404 questionnaires were lled, giving the response rate of 96.75%. At post-intervention stage 411 and 409 questionnaires were administered to intervention and control group respectively. Among those 396 and 397 questionnaires were lled at this stage giving the response rate of 96.71%. Furthermore, the study and control group were properly matched such that there was no statistically signi cant difference in their socio-demographic characteristics of respondents.

Comparison of pre-test and post-test scores in both the intervention and control groups
From Paired t-test analysis, it was found out that there were signi cant differences in pre-test and posttest mean scores of comprehensive knowledge on condoms of the respondents in the intervention group with (p=0.001). While among the respondents in the control group there are no signi cant differences in the mean improvement of the scores of Comprehensive knowledge on condoms (p=0.967). Similarly, nding from Paired t-test analysis shows that, there were signi cant differences in the pre-test and posttest scores of attitude toward condoms (p=0.006) of the respondents in the intervention group compared to the control group. Also, when comparing the baseline and end-line ndings of both the intervention and control groups using Chi-square test. The proportions of study participants in the intervention group 148(36.9%) have the intention to use a condom during pre-intervention and 162(40.9%) during postintervention periods (P-value =0.001).

Comparison between of intervention and control groups after intervention
The nding of this study reveals that there is signi cant difference between intervention and control group after intervention using independent t-test shows that the mean scores between the two groups related to comprehensive knowledge of condom showed that the intervention group had higher scores than the control group with statistically signi cant differences (mean diff. = 0.221, 95%CI = 0.12 to 0.32: p=0.001). Also there is statistically signi cant differences in students' attitude to condoms (mean diff. = 2.01, 95%CI =1.06 to 2.96: p=0.001).
Effect of comprehensive sexual and reproductive health education on knowledge and attitude to condom Inverse probability weighting analysis was conducted to see the effect of the comprehensive sexual and reproductive health education on students' knowledge and attitude towards condom. All outcome variables were weighted by the baseline characteristics of study participants (sex, age, residence, religion, attendance of religious education and type of school they attended) to reduce the effect of selection bias.
In the intervention group, the student's average change of comprehensive condom knowledge score was 0.229 higher than the average score of the student's in the control group (ATE=0.229, 95% CI, 0.132 to 0.328; p < 0.001). The average change of attitude toward condom score of the student's in the intervention group was 1.834 higher than the average change score of student's in control group (ATE=1.834, 95% CI, 1.195 to 2.772; p < 0.001). (Table 2).

Discussion
Results from the current study found that there is a signi cant difference between intervention and control group after intervention on student's comprehensive knowledge and attitude towards condom. This nding was in line with study conducted in Los Angeles and Northern Ghana [19,20]. This study also supported the 2030 Agenda speci c all learners acquire knowledge and skills needed to promote sustainable development [21].
With regard to intention to use condom, the nding of this study that there were signi cant differences in the changing students' intention to condom use between the intervention and control groups after intervention. This nding was supported study conducted in Tanzania, Los Angeles, Zambian and USA [12,19,22,23]. This might inducted that availing condom around school compound may reduce students from practicing risky sexual behavior that may help the Fight against HIV and to Ending the AIDS Epidemic by 2030 [21] Furthermore, the nding of this study shows that there was no signi cant difference between intervention and control group in the consistent and correct use of condom after the intervention. This nding was supported by study conduct in Zambian secondary schools which reveal that there was no change in condom use practice after the intervention [24].

Conclusions
In conclusion, this study found that the curriculum-based comprehensive sexual and reproductive health education improve the students' knowledge and had impact on their attitude and intentions towards condom use. However, the ndings of this study did not show a signi cant effect on students' consistent and correct use of a condom because this may require time to practice. Therefore, strengthen the implementation of this intervention should be are necessary for the control and prevention of STI including HIV/AIDS and unintended pregnancy.

Limitation of study:
This study may have some of limitation. First, the campuses were not randomly assigned to intervention and control groups. Although, we tried to match some confounding factors such as social-demographic characters, there may be some unknown factors in uencing the effect of intervention, which might increase or decrease the real effect of intervention. Second, the intervention period 6 months this may not show long term impact of this program.

Declarations
Ethics approval and consent to participate The letter of ethical approval was obtained from the institutional review board of College of Medicine and Health Sciences in Arba Minch University with reference number CMHS/11833/11. Written consents from all participants were obtained after being fully informed about the objectives and procedures of the study for in both groups. The con dentiality and privacy of participants were actively protected. All participants were assigned a unique identi cation number. Every effort was made to emphasize the voluntariness of this study and decisions to stop or discontinue in the study was respected and did not affect the regular attendance of education in any way.

Consent for publication: Not applicable
Availability of data and materials: The data used to support the ndings of this study are available from the corresponding author upon request.
Competing interests: The authors declare that there is no con ict of interest regarding the publication of this paper Funding: Arba Minch University supports this research nancially. The university has no role in the design of the study, collection, analysis, and interpretation of the data and in writing the manuscript.
Authors' contributions NB, SH and MS conceived and designed the study. NB and SH coordinated the running of the study. NB, TS, SS, SA, EZ, ND and ZT conducted data collection. NB, SH, WG, WG and EZ were participated in data analysis. NB and SH drafted the manuscript. NB, SH, MS, SS, TS, EZ,WG,SA, WG, ND and ZT contributed to the interpretation of the analysis and critically revised the manuscript. All authors read and approved the nal manuscript.