Abstract
ABSTRACT
Objectives
To assess the prevalence of risky sexual behaviour (RSB) and its associated factors among Nepalese undergraduates residing in hostels of Kathmandu Metropolitan City, Nepal.
Design
Cross-sectional study
Setting
Hostels operating inside Kathmandu Metropolitan City were taken as the study setting.
Participant
A total of 361 undergraduate students residing in hostels in the Metropolitan City
Outcome measures
RSB was the outcome measure assessed using nine questions able to trace any risky sexual practice practiced by the participants within the past year prior to data collection. The question included participants’ engagement in sexual activity before the age of consent, having unprotected vaginal sex even when pregnancy is not intended, engaging in vaginal sex with strangers without a condom, risky oral sex with a stranger and/or intimate partner, risky condom use, having multiple sex partners, having sex under the influence of alcohol and having sex with commercial sex workers. A positive response to any of these nine questions was considered indicative of RSB. Pearson’s χ2 test and multivariable logistic regression analysis were performed to determine factors associated with RSB at the 5% level of significance.
Results
The prevalence of RSB was found to be 35.7% (95% CI: 30.2 to 40.2). RSB was found to be associated with higher age (≥25 years) (aOR: 3.938; 95% CI: 1.707 to 8.673), male gender (aOR: 3.233; 95% CI: 1.623 to 6.439), being in relationships in the past/current (aOR: 3.914, 95% CI: 2.099 to 7.012), lower education of mother (aOR: 3.655; 95% CI: 1.189 to 9.237) and peer pressure to have a sexual relationship (aOR: 2.356; 95% CI: 1.260 to 4.349). Notably, bivariate analysis illustrated problematic pornographic consumption to have a statistical relation with RSB, which was weakened and became non-significant after accounting for other factors in the adjusted model (aOR:1.213, 95% CI: 0.331 to 4.442).
Conclusion
RSB is a concerning behaviour among undergraduate students and is linked with age, gender, relationship status, parental education and peer pressure. There is a need for comprehensive sex education programmes that equip students with the knowledge and skills needed to navigate healthy relationships, make safe choices and embrace responsible sexual practices.
Keywords: Behavior, Public health, REPRODUCTIVE MEDICINE, Risk Factors, Cross-Sectional Studies, Nepal
Strengths and limitations of this study.
This is one of the few studies that has assessed the prevalence of risky sexual behaviour and its associated factors among undergraduate students in developing nations such as Nepal.
The study was conducted in the National Capital, aiming to cover undergraduate students with diverse sociodemographic characteristics.
Although we tried to make the data collection session as private and confidential as possible, the sensitive nature of the research topic and self-reported approach may have been slightly influenced by social desirability bias.
Introduction
Risky sexual behaviour (RSB) is an act of engaging in unsafe sexual practices such as unprotected sexual intercourse, sex with multiple partners and sex under substance abuse, making an individual vulnerable to reproductive health problems.1 2 These RSB are often related to a wide range of negative health events, such as sexually transmitted infections (STIs), unintended pregnancy, sexual and psychological violence and poor mental health, as well as other reproductive health problems and severe health outcomes.2,4 Globally, an estimated one million people encounter STIs, predominantly due to RSB.5 Since the start of the HIV epidemic, AIDS-related illnesses have claimed 40.4 million lives, with unsafe sexual practices recognised as a significant contributor to HIV & AIDS.5 6
Nepal is a signatory to the International Convention on Population and Development (ICPD) and has demonstrated its commitment to adolescent health by incorporating Adolescent Sexual and Reproductive Health (ASRH) into the National Reproductive Health Strategy since 1998.7 Despite the commitment, the utilisation of sexual and reproductive health (SRH) services remain unsatisfactory among adolescents and youth, mostly due to inadequate information about reproductive health.8 9 A past study executed among adolescents attending a tertiary-level hospital revealed that 58.0% of the adolescents demonstrated only a moderate level of knowledge about SRH.10 Moreover, past studies have consistently highlighted the inadequate knowledge among Nepalese adolescents and youth regarding SRH practices.11,13 The poor knowledge of SRH during adolescence can make them vulnerable to unsafe sex and develop RSB in adulthood.
The Nepal Demographic and Health Survey of 2022 reported that only 16% of young women and 27% of young men possess a thorough knowledge of HIV prevention methods.14 Similarly, a study conducted in rural Nepal revealed that nearly two-thirds (73.2%) of school-going adolescents aged 15–24 years were engaged in various forms of RSB.15 Undergraduates are individuals typically aged between 18 and 29, who are at a crucial phase of life, making significant decisions and transitioning from adolescence to adulthood. This period is particularly vulnerable to the initiation of different lifestyle habits.16 Understanding the prevalence and contributing factors of RSB among this vulnerable population is crucial to inform public health interventions and educational programmes that promote safe and healthy sexual practices.
Method
Study design and setting
This was a cross-sectional study conducted among undergraduate students residing in the hostels of the Kathmandu Metropolitan, Nepal, between July and October 2023. In Nepal, similar to many Asian countries, undergraduates who are away from their homes for education often choose hostels for their accommodation. Hostels can be either private housing specifically designated for student accommodation or university or college-run dormitories. These hostels offer shared living spaces and amenities along with some basic necessities such as meals, furniture, laundry services and bedding, all of which are included in rental fees, and are more affordable options for students in comparison to private apartments. These hostel residents are a distinctive group of students living away from their homes for educational purposes, who can experience reduced parental guidance, increasing their susceptibility to engage in risky behaviours, including RSB. Given the limited knowledge of the prevalence and nature of RSB among Nepalese youths, this study aimed to assess the magnitude of this issue and its associated factors among Nepalese undergraduates. Kathmandu Metropolitan City is the capital and eldest metropolitan city of Nepal. It is the most populated city of Nepal, housing 20% of the urban population in an area of 50.67 km2.17 It attracts a large student population from various regions of the country seeking higher education opportunities. Due to the limited availability of on-campus housing, many undergraduate students rely on private hostels for accommodation. A total of 272 hostels registered in the Nepal Hostel Association (NeHA) are functioning inside Kathmandu Metropolitan City.
Participants
Undergraduate students residing in the sampled hostels for at least 6 months before data collection were eligible participants for the study. No exclusions were made based on age, gender, ethnicity, academic discipline or other characteristics.
Sample size determination and sampling technique
The sample size was determined using Cochran’s formula (n=z2pq/d2), where p referred to the past prevalence of RSB (73%) observed among school-going students of rural Nepal aged 15–24 years,15 q=1−p, and d is the allowable error (5%). Considering a 95% CI, the sample size was initially estimated to be 301, which was optimised to 373 after adjusting for a finite population of 6060 hostellers, and a 30% non-response rate, considering the sensitivity of the research problem.
Initially, a total of 272 hostels within Kathmandu Metropolitan City registered under the NeHA were contacted for research permission, of which 196 hostels agreed to support. From these, 20 hostels were randomly selected using STATS V.2.0, and the undergraduate students accommodated in these hostels were chosen randomly using the lottery method.
Data collection
The data were collected using a self-administered questionnaire and were distributed and collected from participants in a closed envelope to protect their anonymity. All the students were oriented about the questions presented in the questionnaire for clarification, and written informed consent was acquired from them before handing them the enclosed questionnaire. Male participants were approached by a male researcher, and female participants were approached by a female researcher. The questionnaire consisted of four sections. The first section consisted of questions related to participants’ sociodemographic characteristics, followed by the second section focusing on their lifestyle-related attributes. The third section consisted of questions regarding their sexual behaviour followed by fourth section consisting of the Problematic Pornography Consumption Scale (PPCS),18 to assess participants’ level of pornography exposure at PPCS score>75 considered to be problematic. Additionally, based on the nature of our data, a PPCS score of 50–74 was used to identify those at risk of problematic consumption.
Outcome variable
The outcome variable for this study was RSB, which was assessed using a pretested tool prepared by the research team. This tool was developed after an extensive literature review and in consultation with SRH experts. The tool for assessing RSB in the past year consisted of nine questions. Based on the participant’s response, if the participant’s response indicated engagement in any of the risky behaviours, then s/he was considered to have RSB while sharing safer practices in each of the nine questions was considered non-risky behaviour. The nine items consisted of questions such as engaging in sex before the age of consent, having vaginal sex with intimate partner without using contraceptives even with no intention of pregnancy, engaging in vaginal sex with strangers without using a condom, having oral sex with strangers or intimate partner even while sensing a risk of infection, not checking expiry date and/or damage of condoms, having multiple sex partners, having sex under the influence of alcohol and having sex with commercial sex worker in past one year. If a participant reflected engagement in more than one risky behaviour, each instance was recorded, but the participant was counted only once in the prevalence estimate as practicing RSB. The tool used for assessing RSB is provided in online supplemental document 1.
Data processing, management and analysis
The collected data were carefully reviewed for accuracy and completeness. The data were entered in EpiData software V.3.1. A total of 10% of the randomly selected data were manually rechecked for accuracy in data entry, and all data were exported to Statistical Package for the Social Sciences V.20 for statistical analysis. The data were summarised in terms of frequency, percentage, mean and SD. The χ2 test and unadjusted odds ratio (uOR) were calculated at a 5% level of significance to identify the factors associated with RSB. The factors found to have statistical significance (p<0.05) in the χ2 test were subjected to the final model of multivariable logistic regressions for adjusted odds ratio (aOR). Before performing multivariable analysis, the multicollinearity among selected independent variables was tested using the variance inflation factor (VIF), where a VIF greater than five was taken as an indication of multicollinearity between the independent variables.
Patient and public involvement
None.
Results
A total of 373 undergraduate hostellers were approached for this study, of which 361 provided their complete responses to all questions. Thus, a response rate of 96.78% for all questions was acquired, and 361 samples were analysed. The overall prevalence of RSB among the undergraduates was 35.7% (95% CI: 30.2 to 40.2). Out of 361 students, nearly one-third (37.7%) reported that they were sexually active in the past year prior to data collection. In regards to the sexually active undergraduates, 94.8% were found to have RSB. Of the 129 participants engaging in RSB, 13 (10.1%) reported engagement in a single RSB, 28 (21.6%) reported engagement in two, 32 (24.8%) in three, 30 (23.3%) in four, 18 (14.0%) in five, 3 (2.3%) in six and 5 (3.9%) in seven RSB. Among them, more than a quarter (28.7%) reported engaging in vaginal sex without contraceptives, even with no intent to become pregnant. Similarly, nearly one-third (33.1%) of the participants reported practicing oral sex with strangers without protection. Nearly a quarter (28%) reported having multiple sex partners, while nearly one-third (36%) reported engaging with commercial sex workers in the past year. (table 1).
Table 1. Sexual behavioural practices among undergraduate students (n=361).
| Characteristics | n | % (95% CI) |
| Sexual engagement | ||
| No | 225 | 62.3 (57.6 to 67.3) |
| Yes | 136 | 37.7 (32.7 to 42.4) |
| Age at first sexual intercourse (n=136) | ||
| ≥18 years | 113 | 83.1 (76.5 to 89.7) |
| ≤17 years | 23 | 16.9 (10.3 to 23.5) |
| Vaginal sex without contraceptives (n=136) | ||
| Yes | 97 | 71.3 (62.8 to 78.3) |
| No | 39 | 28.7 (21.7 to 37.2) |
| Oral sex without protection (n=136) | ||
| Yes | 45 | 33.1 (25.3 to 40.8) |
| No | 91 | 66.9 (59.2 to 74.7) |
| Vaginal sex with a stranger without a condom (n=136) | ||
| Never | 59 | 43.4 (36.0 to 53.7) |
| Sometimes | 66 | 48.5 (39.7 to 57.8) |
| Often | 11 | 8.1 (4.0 to 13.2) |
| Check expiry dates and/or damage of condom (n=136) | ||
| Never | 60 | 44.1 (35.6 to 52.9) |
| Sometimes | 27 | 19.9 (14.7 to 26.5) |
| Often | 49 | 36.0 (27.9 to 43.4) |
| Number of sex partners (n=136) | ||
| Single partner | 98 | 72.0 (63.9 to 78.7) |
| More than one partner | 38 | 28.0 (8.8 to 31.3) |
| Engaged in sex under the influence of alcohol (n=136) | ||
| Never | 79 | 58.1 (50.3 to 65.8) |
| Sometimes | 49 | 36.0 (27.9 to 45.3) |
| Often | 8 | 5.9 (2.2 to 9.6) |
| Sex with commercial sex workers (n=136) | ||
| Never | 87 | 64.0 (55.5 to 72.5) |
| Once | 21 | 15.4 (8.4 to 21.3) |
| Twice | 17 | 12.5 (8.1 to 18.8) |
| Three or more times | 11 | 8.1 (3.7 to 12.5) |
| Overall sexual practice | ||
| Non-risky | 232 | 64.3 (59.8 to 69.8) |
| Risky | 129 | 35.7 (30.2 to 40.2) |
The age of the participants ranged from 18 to 32 years, with a mean age of 21.7±2.72 years. Among the 361 participants, the largest group of participants (29.9%) were enrolled in the management stream, followed by health sciences (28.8%), education/humanities (21.1%), engineering (11.6%) and basic sciences (8.6%). Slightly more than half (57.1%) of the participants were male. Nearly half (55.7%) reported being in a relationship currently or within 1 year preceding data collection. In bivariate analysis, sociodemographic factors such as participants’ age, gender, relationship status and educational level of both parents were found to be associated with RSB (table 2)
Table 2. Association of RSB with sociodemographic characteristics (n=361).
| Characteristics | n (%) | RSB | χ2 | p value | |
| Presence, n (%) | Absence, n (%) | ||||
| Age | |||||
| <20 years | 133 (36.8) | 34 (25.6) | 99 (74.4) | 18.489 | <0.001* |
| 20–25 years | 178 (49.3) | 65 (36.5) | 113 (63.5) | ||
| ≥25 years | 50 (13.9) | 30 (60.0) | 20 (40.0) | ||
| Gender | |||||
| Male | 206 (57.1) | 104 (50.5) | 102 (49.5) | 45.462 | <0.001* |
| Female | 155 (42.9) | 25 (16.1) | 130 (83.9) | ||
| Family type | |||||
| Nuclear | 213 (59.0) | 69 (32.4) | 144 (67.6) | 2.523 | 0.112 |
| Joint/extended | 148 (41.0) | 60 (40.5) | 88 (59.5) | ||
| Relationship status | |||||
| Never been in a relationship | 160 (44.3) | 30 (18.8) | 130 (81.3) | 36.095 | <0.001* |
| Been in a relationship (past/current) | 201 (55.7) | 99 (49.3) | 102 (50.7) | ||
| Education status of the father | |||||
| Illiterate | 17 (4.7) | 11 (64.7) | 6 (35.3) | 9.659 | 0.022* |
| Literate with informal education | 20 (5.5) | 8 (40.0) | 12 (60.0) | ||
| Up to secondary level (1–10 grade) | 134 (37.1) | 53 (39.6) | 81 (60.4) | ||
| Higher education | 190 (52.7) | 57 (30.0) | 133 (70.0) | ||
| Education status of the mother | |||||
| Illiterate | 38 (10.5) | 21 (55.3) | 17 (44.7) | 8.652 | 0.034* |
| Literate with informal education | 52 (14.4) | 21 (40.4) | 31 (59.6) | ||
| Up to secondary level (1–10 grade) | 156 (43.2) | 53 (34.0) | 103 (66.0) | ||
| Higher education | 115 (31.9) | 34 (29.6) | 81 (70.4) | ||
| Current academic status | |||||
| Health science | 104 (28.8) | 30 (28.8) | 74 (71.2) | 6.435 | 0.169 |
| BSc science | 31 (8.6) | 16 (51.6) | 15 (48.4) | ||
| Management | 108 (29.9) | 40 (37.0) | 68 (63.0) | ||
| Engineering | 42 (11.6) | 13 (31.0) | 29 (69.0) | ||
| Education/humanity | 76 (21.1) | 30 (39.5) | 46 (60.5) | ||
| Academic year | |||||
| First year | 128 (35.5) | 38 (29.7) | 90 (70.3) | 6.023 | 0.110 |
| Second year | 93 (25.8) | 38 (40.9) | 55 (59.1) | ||
| Third year | 65 (18.0) | 20 (30.8) | 45 (69.2) | ||
| Fourth year | 75 (20.8) | 33 (44.0) | 42 (56.0) | ||
Significance at pp<0.05.
RSBrisky sexual behaviour
Out of 361 participants, nearly one-fifth (19.4%) reported belonging to a rural community. Approximately one-third (29.6%) of the participants experienced peer pressure to engage in a sexual relationship. Assessment using the PPCS revealed that 12.7% of the participants exhibited behaviours suggesting a risk of problematic pornography consumption, scoring between 50 and 75 in the PPCS, while 4.4% met the criteria for problematic consumption with a PPCS score>75. Bivariate analysis indicated that RSB has a statistically significant relationship with peer pressure for sexual relationships, smoking status and pornography consumption (table 3)
Table 3. Association of RSB and lifestyle and psychological factors (n=361).
| Variables | n (%) | RSB | χ2 | p value | |
| Presence n (%) | Absence n (%) | ||||
| Home town | |||||
| Urban | 291 (80.6) | 104 (35.7) | 187 (64.3) | 0.000 | 0.997 |
| Rural | 70 (19.4) | 25 (35.7) | 45 (64.3) | ||
| Peer pressure for a sexual relationship | |||||
| Absence | 254 (70.4) | 61 (24.0) | 193 (76.0) | 51.242 | <0.001* |
| Presence | 107 (29.6) | 68 (63.6) | 39 (36.4) | ||
| Smoking status | |||||
| No smoking | 299 (82.8) | 88 (29.4) | 211 (70.6) | 30.114 | <0.001* |
| Smoking | 62 (17.2) | 41 (66.1) | 21 (33.9) | ||
| Survivors of sexual abuse | |||||
| No | 330 (91.4) | 123 (37.3) | 207 (62.7) | 3.962 | 0.050 |
| Yes | 31 (8.6) | 6 (19.4) | 25 (80.6) | ||
| Status of pornography consumption | |||||
| Non-problematic consumption | 299 (82.8) | 97 (32.4) | 202 (67.6) | 8.968 | 0.011* |
| At the risk of problematic consumption | 46 (12.7) | 22 (47.8) | 24 (52.2) | ||
| Problematic consumption | 16 (4.4) | 10 (62.5) | 6 (37.5) | ||
Significance at pp<0.05.
RSBrisky sexual behaviour
For multivariable analysis, the VIF test was performed among the independent variables that were found to have a statistically significant relationship with RSB in bivariate analysis. The highest reported VIF was 1.749, confirming that there was no issue of multicollinearity. It was observed that, compared with undergraduates under 20 years of age, those above 24 years were thrice more at odds (aOR: 3.938; 95% CI: 1.707 to 8.673) of practicing RSB. Similarly, males were observed to have three times higher odds (aOR: 3.233; 95% CI: 1.623 to 6.439) of engaging in RSB as compared with females. Individuals who were in a relationship in the past or are currently in relationships had a threefold increase in odds (aOR: 3.914, 95% CI: 2.099 to 7.012) of practicing RSB as compared with those who were never in a relationship. Participants whose mothers had low educational attainment had higher odds of engaging in RSB (aOR: 3.655; 95% CI: 1.189 to 9.237). It was observed that experiencing peer pressure to have a sexual relationship could double the odds of engaging in RSB (aOR: 2.356; 95% CI: 1.260 to 4.349). Notably, bivariate analysis illustrated that participants with problematic pornographic consumption were three times more at odds of practicing RSB. However, this association weakened and became non-significant after accounting for other factors in the adjusted model (aOR: 1.213, 95% CI: 0.331 to 4.442) (table 4).
Table 4. Factors associated with RSB practice (n=361).
| Variables | RSB | |||
| uOR (95% CI) | p value | aOR (95% CI) | p value | |
| Age | ||||
| <20 years | Ref | Ref | ||
| 20–25 years | 1.675 (1.021 to 2.747) | 0.041* | 1.561 (0.824 to 2.956) | 0.172 |
| ≥25 years | 4.368 (2.197 to 8.681) | <0.001* | 3.938 (1.707 to 8.673) | 0.001* |
| Gender | ||||
| Female | Ref | Ref | ||
| Male | 5.302 (3.191 to 8.809) | <0.001* | 3.233 (1.623 to 6.439) | 0.001* |
| Relationship status | ||||
| Never been in a relationship | Ref | Ref | ||
| Been in a relationship (past/current) | 4.206 (2.593 to 6.823) | <0.001* | 3.914 (2.099 to 7.012) | <0.001* |
| Education status of the father | ||||
| Illiterate | 4.278 (1.509 to 12.127) | 0.006* | 2.381 (0.601 to 10.043) | 0.206 |
| Literate with informal education | 1.556 (0.603 to 4.010) | 0.360 | 1.291 (0.344 to 5.013) | 0.688 |
| Up to secondary level (1–10) | 1.527 (0.959 to 2.430) | 0.074 | 1.544 (0.824 to 2.937) | 0.171 |
| Higher education | Ref | Ref | ||
| Education status of the mother | ||||
| Illiterate | 2.943 (1.384 to 6.258) | 0.005* | 3.655 (1.189 to 9.237) | 0.024* |
| Literate with informal education | 1.614 (0.815 to 3.197) | 0.170 | 0.994 (0.356 to 2.447) | 0.825 |
| Up to secondary level (1–10) | 1.226 (0.729 to 2.062) | 0.443 | 0.776 (0.382 to 1.576) | 0.435 |
| Higher education | Ref | Ref | ||
| Peer pressure for a sexual relationship | ||||
| Absence | Ref | Ref | ||
| Presence | 5.517 (3.387 to 8.984) | <0.001* | 2.356 (1.260 to 4.349) | 0.008* |
| Smoking status | ||||
| No smoking | Ref | Ref | ||
| Smoking | 4.681 (2.616 to 8.376) | <0.001* | 0.923 (0.408 to 2.087) | 0.847 |
| Status of pornography consumption | ||||
| Non-problematic consumption | Ref | Ref | ||
| At the risk of problematic consumption | 1.909 (1.020 to 3.574) | 0.043* | 1.409 (0.609 to 3.175) | 0.423 |
| Problematic consumption | 3.471 (1.226 to 9.826) | 0.019* | 1.213 (0.331 to 4.442) | 0.771 |
Significance at pp<0.05.
aORadjusted ORRSBrisky sexual behaviouruORunadjusted OR
Discussion
The findings of this study contribute significantly to addressing the identified gap in the literature by providing novel insights into the assessment of RSB and its associated factors among undergraduate students in Nepal. It was noted that over one-third of the total participants (35.7%) were engaged in RSB. In context to those who were sexually active, 94.8% were found to engage in RSB. A comprehensive literature review revealed no existing studies assessing RSB among this population subgroup. However, a study conducted among school-going youth revealed the prevalence of RSB among sexually active youth was 73.2%,15 which is lower than our observation. Another study focusing on RSB among young men in Nepal reported that 20% of sexually active single men and 9% of married men were engaged in RSB.19 The practice of RSB has been reported among undergraduates throughout the world from different countries such as Sri Lanka, Ethiopia and Rwanda where the RSB among undergraduates was observed to be between 12.1% and 64.0%.20,22 Similarly, a meta-analysis based on 18 studies from Ethiopia estimated the pooled prevalence of RSB among college and university students to be 41.62%.23 The variation in the prevalence of RSB might be attributable to the difference in sample size and study setting as well as the variation in the case definition of RSB in these studies. Despite the variations, these observed rates of RSB indicate that risky sexual practice among youth is a concerning public health issue.
The data revealed that multiple RSBs are prevalent among the participants as 10.1% reported engaging in a single RSB, while nearly half (46.4%) reported engaging in two to three RSBs, and over two-fifths (43.5%) reported instances of engagement in more than three RSBs. Among the various RSBs, prominent issues include engaging in sexual activity before reaching legal age, practicing unprotected vaginal and oral sex, having multiple sexual partners, neglecting condom quality checks and sexual engagement with commercial sex workers. In line with this observation, a study based on adolescent students from Pokhara Metropolitan, Nepal revealed that 85.09% of the students had their sexual experience between the ages of 15 and 19 years, while 10.56% were sexually active before the age of 15 and 13.33% of the adolescents had unprotected sex.24 Similarly, the initiation of sexual engagement before the age of 18 and unprotected sex has been reported by multiple studies from Nepal.25 26 Likewise, a study from rural Nepal reported that 28.2% of the sexually active youth were engaged with multiple sexual partners.15 Engagement with multiple sexual partners has been reported by other studies as well.24 25 Similarly, nearly two-thirds (36%) of the undergraduates had sex with commercial sex workers, even though commercial sex work has been considered as an act of trafficking in Nepal and is punishable under the Human Trafficking and Transportation (Control) Act 2008, penalising those involved directly or indirectly in prostitution, which is also endorsed by National Penal Code, 2074.27 The sexual engagement of students with commercial sex workers has also been reported by numerous studies from Nepal where it is expected to range between 8.5% and 48.9%.1524,26 28 Despite the presence of laws and programmes aimed to prevent minors’ engagement in sexual activities to protect them from sexual abuse, as well as regulations controlling commercial sex work and various initiatives focusing on adolescent SRH, these risky behaviours persist. This underscores the urgent necessity for more effective and comprehensive sexual education interventions among Nepalese adolescents and youth. It is crucial to enhance their understanding of SRH and reduce the risk of STIs within this vulnerable group.
It was observed that the odds of RSB increased with the increase in age. This is in line with a study from Ethiopia where students above the age of 24 years were found to be twice more likely to engage in RSB as compared with younger students.21 This finding aligns with several cross-sectional studies that have observed the complex relationship between age and sexual behaviour and observed that age may play a crucial role in influencing individuals’ likelihood of engaging in RSB.23 25 29 30 A plausible explanation for this association could be that the older students may be more inclined to be involved in relationships, exhibit greater confidence in making independent decisions and enjoy improved financial options compared with their younger counterparts.
Males were thrice more likely to engage in RSB than females. This finding is in line with other studies from Nepal, where males were reported to express more sexual engagements and higher risk of sexual behaviour.15 25 Globally, studies have reported a higher proportion of RSB among males as compared with females.22 23 30 Studies noted that males tend to report higher sexual exposure than females,20 which might be the case in our study as well. The difference in RSB across genders could be attributed to many factors such as social desirability biases and sexual double standards such as women are expected to be virgins until marriage, and male masculinity is associated with sexual engagement. This might also explain why males are more likely to engage with commercial sex workers, have multiple partners and express their sexual escapades more as compared with females.25 Similarly, students whose mothers had lower education were found to have a threefold increase in odds of engaging in RSB. Studies have suggested that family environment and parental education could play a significant role in influencing sexual behaviour later in life.25 30 These observations suggest that addressing gender-specific social norms and enhancing parental education may prove effective in mitigating RSB among youth.
Participants who were in relationships were thrice more likely to engage in RSB. Past studies have shared that the first sexual partner in most cases is often a boyfriend or girlfriend.20 28 Additionally, it has been observed that students who are in a relationship are more likely to be engaged in a premarital sexual relationship,25 thereby increasing their risk of RSB. A study based on African college students partially supported the hypothesis that students in long-term relationships are more likely to engage in RSB.31 Likewise, it was also observed that students experiencing peer pressure to have sexual relationships were twice more likely to experience RSB. This finding is in line with a study based in Kathmandu, which suggested that peers play an important role in influencing the views, attitudes and sexual behaviour of individuals.28 Peer pressure has been observed to be one of the important factors for RSB among students in many counties.22 Thus, enhancing comprehensive sex education programmes is crucial for promoting safer sexual practices among this vulnerable group and addressing the influence of peers and peer pressure on RSB.
Bivariate analysis revealed that participants with problematic pornographic consumption were three times more likely to engage in RSB, which is in line with past observations,23 where pornographic exposure has been thought to increase the motivation of sexual desire. It has been highlighted that exposure to sexually explicit media content including pornography in early adolescence can be a predictor for RSB such as early sexual engagement, unsafe sex and multiple sexual partners.32 However, in this study, this association weakened and became non-significant after accounting for other factors in the adjusted model. This is in line with another observation which suggests that early exposure to sexually explicit material could be an additive risk factor for sexual risk-taking but pornography might not completely contribute to sexual risk-taking among young adults.29 These findings suggested that while problematic pornography consumption might be linked to RSB, other factors play a more crucial role which should also be taken into consideration while making any assumptions.
Despite being one of the few studies exploring the RSB and its associated factors among undergraduates in Nepal, it is crucial to acknowledge its inherent limitations, and the findings should be interpreted based on these limitations. Although we tried to make the data collection session as private and confidential as possible, due to the sensitive nature of the research topic and self-reported approach, there may be a slight possibility of social desirability bias as some students could have deliberately hidden some information about unacceptable behaviour. Despite Kathmandu being the national capital housing diverse Nepali citizens from all demographic backgrounds and our effort to include students from various academic streams for improved generalisability, it is important to note that Nepal, being a small yet culturally rich and diverse nation, the study area may not fully encompass all aspects of the nation’s cultural, racial and ethnic diversity. Thus, a larger community-based survey covering these factors might provide additional insights.
Conclusion
The study underscores significant prevalence of RSB among undergraduate students, revealing concerning trends such as early sexual engagement, unprotected sex, multiple partners and engagement in commercial sex work. The findings highlight the urgent need for comprehensive sexual education interventions tailored to the specific needs of Nepalese adolescents and youth, focusing on social norms, gender-specific education and parental involvement, emphasising the importance of reducing risks associated with STIs within this vulnerable group.
supplementary material
Acknowledgements
The authors would like to thank all the undergraduate students who participated in this study and provided their valuable time and information. Without their support, this study would not have been possible. The authors would also like to extend their gratitude to the Nepal Hostel Association and selected hostels for their approval and constant support during data collection.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-084160).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants. Ethical approval for this study was obtained from the institutional review committee of CiST College (Ref no. 47/080/081). Participants gave informed consent to participate in the study before taking part.
Data availability free text: The data set generated and analysed during the current study is available from the corresponding author upon reasonable request.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Contributor Information
Ram Kumar Chaudhary, Email: ramkumarchaudhary372@gmail.com.
Anisha Chalise, Email: anisha.chalise90@gmail.com.
Saloni Pandey, Email: salonipandey2010@gmail.com.
Shishir Paudel, Email: shishirpaudel11@gmail.com.
Data availability statement
Data are available upon reasonable request.
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