Sexual risk-taking behavior amongst emerging adults in a tertiary institution of learning in Coastal Kenya: A qualitative study of stakeholders’ perspectives using causal loop mapping

Background It is known from previous studies that university students in sub-Saharan Africa (sSA) engage in sexual risk-taking behaviour (SRTB). However, there is paucity of data on correlates of SRTB among university students (emerging adults {EmA}) at the Kenyan Coast thus hindering intervention planning. This study seeks to provide an in-depth qualitative understanding of correlates of SRTB and their interconnectedness among university students at the Kenyan coast combining qualitative research with a systems thinking approach. Methods Using the ecological model, and employing in-depth interviews, we explored the perceptions of twenty-one EmA and five other stakeholders on what constitutes and influences SRTB among EmA at a tertiary institution of learning in Coastal Kenya. Data were analysed using a thematic framework approach. A causal loop diagram (CLD) was developed to map the interconnectedness of the correlates of SRTB. Results Our findings show that unprotected sex, transactional sex, cross-generational sex, multiple sex partnerships, gender-based violence, sex under influence of alcohol/drugs, early sex debut, and sharing sex toys were common SRTBs. Based on the ecological model and CLD, most of the reported risk factors were interconnected and operated at the individual level followed by those that operate at social level. Conclusion Our study shows that EmA are mostly engaging in unprotected sex. Enhancing sexuality education programs for students in Kenyan universities and strengthening support systems including counselling for those using alcohol/drugs may help reduce SRTB among EmA in universities in Kenya. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was partially funded by the Medical Research Council [Grant number MR/M025454/1] to AA. This award is jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under MRC/DFID concordant agreement and is also part of the EDCTP2 program supported by the European Union. The authors are also grateful for the support of the Sub-Saharan African Network for TB/HIV-1 Research Excellence (SANTHE), a DELTAS Africa Initiative [grant number DEL-15–006] to AH. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [grant number 107752/Z/15/Z] and the UK government. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Prior to recruitment, a written informed consent was obtained from all potential participants. Ethical clearance was granted by Pwani University Institutional Scientific and Ethics Review Committee (ERC/PhD/003/2019) and the Kenya Medical Research Institute Scientific and Ethics Review Unit (KEMRI/SERU/CGMR-C/166/3925). Additionally, administrative approvals were granted by the National Council for Science Technology and Innovation (NACOSTI/P/19/1142) and Pwani university (Ref: PU/DVCRE/RSCH/VOL.1/37). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data underlying the results presented in the study are readily available upon request from the corresponding author (cheastevenson@gmail.com) upon request because it contains potentially identifying information