Factors Associated With Attitude Toward Premarital ...

Asia-Pacific Journal of Public Health http://aph.sagepub.com/

Factors Associated With Attitude Toward Premarital Sexual Activities Among School-Going Adolescents in Kelantan, Malaysia Azriani Abdul Rahman, Razlina Abdul Rahman, Shaiful Bahari Ismail, Mohd Ismail Ibrahim, Siti Hawa Ali, Halim Salleh and Wan Abdul Manan Wan Muda Asia Pac J Public Health published online 29 June 2012 DOI: 10.1177/1010539512449856 The online version of this article can be found at: http://aph.sagepub.com/content/early/2012/06/28/1010539512449856

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449856 alAsia-Pacific Journal of Public Health

APHXXX10.1177/1010539512449856Azriani et

Factors Associated With Attitude Toward Premarital Sexual Activities Among School-Going Adolescents in Kelantan, Malaysia

Asia-Pacific Journal of Public Health XX(X) 1–8 © 2012 APJPH Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539512449856 http://aph.sagepub.com

Azriani Abdul Rahman, MD, MCommMed1, Razlina Abdul Rahman, MBBS1, Shaiful Bahari Ismail, MBBS, MMed Fam Med1, Mohd Ismail Ibrahim, MD, MCommMed1, Siti Hawa Ali, CQSW (UK)1, Halim Salleh, PhD1, and Wan Abdul Manan Wan Muda, EdD1

Abstract The objective of this cross-sectional study was to determine the factors associated with the attitudes toward premarital sexual activities among school-going adolescents in Kelantan, Malaysia. It was conducted among 1032 secondary school students using a self-administered validated questionnaire. Multiple logistic regression revealed that the risk factors for having permissive attitudes toward practice of premarital sexual activities were male students (odds ratio [OR] = 1.83; 95% confidence interval [CI] = 1.34-2.48), being less religious (OR = 2.02; 95% CI = 1.49-2.73), and younger age group of students (13 to 14 years old; OR = 1.42; 95% CI = 1.05-1.92). Having good knowledge on sexual and reproductive health was a protective factor against permissive sexual attitude (OR = 0.27; 95% CI = 0.20-0.36). In conclusion, male and young adolescents were at risk of having permissive attitudes toward sexual behaviors, but good knowledge on sexual and reproductive health and being more religious may protect them from it. Keywords adolescent health, social determinants of health, psychological/behavioral medicine, health education, child health

Introduction Sexual health is the complete physical, emotional, mental, and social well-being of individuals’ sexual life.1 Adolescence is a stage in life when individuals go through a period of transition to sexual maturity.2 Due to the widening age gap between menarche and marriage, there is a growing 1

Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

Corresponding Author: Azriani Abdul Rahman, Department of Community Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia Email: [email protected]


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incidence of premarital sexual activities that threatens sexual and reproductive health of adolescents.3 It has been noted that adolescents today are facing the danger of sexually transmitted diseases (STDs), unwanted pregnancies, and unsafe abortions.4 Although premarital sex is less common in Asia than in some developed regions, it is clearly on the rise.3 The attitude of adolescents toward sexual behaviors has been shown to be a strong influence on their sexual activities.1,5 It is determined by various factors such as age, sex, knowledge on sexual and reproductive health, religiosity, relationship with parents, and high-risk behaviors.6-13 In Malaysia, the prevalence of premarital sexual activity has been increasing over the years.14 Several studies have been conducted to determine the factors influencing the practice.5,15-17 However, to our knowledge, the information on the determinants of attitudes toward sexual behavior is very limited. For this reason, there is an immediate need for a set of data to initiate and support early identification and intervention on adolescents with risky attitudes so that the actual practice of premarital sexual activities may be prevented and controlled. Furthermore, it is also very important to identify the protective aspects of the risky attitudes so that preventive health care services for adolescents, particularly health education and promotion, may be improved and strengthened. The objective of this study was to determine the factors associated with the attitudes toward premarital sexual activities among school-going adolescents in Kelantan, Malaysia. The hypothesis to be tested was that the age, sex, knowledge on sexual and reproductive health, religiosity, relationship with parents, and high-risk behaviors of the adolescents are associated with risky attitudes toward premarital sexual activities.

Methods This study was conducted in Kelantan, Malaysia, a state along the northeastern coast of Peninsular Malaysia facing the South China Sea. The state covers a land area of 14 922 km2 and is populated mainly by the Malay ethnic group. This cross-sectional study was carried out in April 2009 at 7 secondary schools in one of the districts in Kelantan, among adolescents in secondary 1 to secondary 5. Sample size calculation was done using PS Software (version 1.0.13). A total of 686 students was required for the study based on the following considerations: significance level of .05, study power of 80%, P0 of 54.0% (proportion of male adolescents, obtained from a pilot study conducted among 56 secondary school students in a district other than the current study), P1 of 65.0% (the expected proportion of male adolescents having permissive attitudes toward premarital sexual behaviors), and a ratio of those having permissive and nonpermissive attitudes toward premarital sexual behaviors of 1, a 20% nonresponse rate, and multiplication by 2 for the design effect. Classrooms in secondary 1 to secondary 5 were selected randomly. All students from each selected classroom were included in the study. Written consent was obtained from the students and their parents prior to data collection. The students were assessed through a self-administered, anonymous questionnaire but they were guided to answer the questions. The questionnaire consists of sociodemographic information, including personal and family background, attitudes toward premarital sexual behaviors (18 items), and knowledge (23 items).The attitude items included (a) “Having sexual intercourse before marriage is not wrong,” (b) “Having sexual intercourse with the same gender (homosexuals) is not wrong,” (c) “You are interested to have sexual intercourse before marriage,” (d) “It is not wrong if you only kiss your boyfriend/girlfriend,” (e) “Sending pornographic SMS/MMS is not wrong,” (f) “Adolescents who have never involved in sexual intercourse before marriage are old-fashioned,” (g) “It is not wrong if you just hug your boyfriend/girlfriend,” (h) “Sending pornographic SMS/MMS is exciting,” (i) “Touching another person’s body parts with sexual


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excitement is not wrong,” (j) “Adolescents who have never involved in sexual intercourse before marriage are dull or not attractive,” (k) “Kissing/necking without having sexual intercourse is not wrong,” (l) “Holding hands with your girlfriend while experiencing sexual excitement in secluded or public places is not wrong,” (m) “Sex education in schools is needed,” (n) “Abandonment of babies is cruel/inhumane,” (o) “Sexual intercourse is only permissible after marriage,” (p) “People who have sexual intercourse before marriage are those without morals,” (q) “If you have a boyfriend/girlfriend, you have to protect/ safeguard his/her honor,” and (r) “If you have a boyfriend/girlfriend, you have to respect him/her. To assess the knowledge, the items included are knowledge on human reproductive organs, pregnancy, contraception, HIV and STDs, and abortions. The questions for the attitude components were put forward in both acceptable and unacceptable statements. An ordinal response for an acceptable item (“Strongly Agree,” “Agree,” “Not Sure,” “Not Agree,” and “Strongly Not Agree”) scores “4,” “3,” “2,” “1,” and “0,” respectively, and vice versa. Based on the median score of 56.0 (interquartile range [IQR] = 13), the students were categorized as having permissive and nonpermissive attitude toward premarital sexual behaviors. Permissive attitude was defined as the attitudes toward accepting the practice of premarital sexual behaviors (score