Factors Associated with Sexual Intercourse, Condom-Use, and Perceived Peer Behaviors Among Adolescents in Malaysia: A School-Based Cross-Sectional Study

Abstract

High-risk sexual behavior among young adults is concerning to clinicians, public health practitioners and policy makers because it is associated with unintended health outcomes including transmission of sexually transmitted infections (STIs) and unintended pregnancy. This paper analyzes how knowledge of HIV, experience with dating behavior, and perception of peer behavior factors are associated with having sexual intercourse and use of condoms among adolescent students in Malaysia. National data from school-age adolescents who completed the Malaysian HIV/AIDS Knowledge, Attitude and Practice survey were used. Chi-square analysis and multivariate logistic regression analyses were performed. Having sexual intercourse was associated with urbaneness (p<0.001); correctly answered all UNGASS indicator (p=0.011); and perception of peer behavior having had sex (p=0.001). Condom use among those who had sexual experience was associated with males (p=0.013), believing condoms prevent HIV and STIs (p<0.002), and having friends who report having had sex (p=0.034). Equitable and effective sexual education program must be developed to promote the health of adolescents. Practical education about how condoms may prevent the transmission of STIs and HIV should be promoted.

Full text

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Factors!Associated!with!Sexual!Intercourse,!Condom-Use,!and!Perceived!Peer!
Behaviors!Among!Adolescents!in!Malaysia:!A!School-Based!Cross-Sectional!Study!
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Mohd!Hatta!Abdul!Mutalip1,!Kathryn!Mishkin2,!Faizah!Paiwai1,!Joanita!Sulaiman3,!Norzawati!Yoep1!
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Abstract!!
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High-risk sexual behavior among young adults is concerning to clinicians, public health practitioners
and policy makers because it is associated with unintended health outcomes including transmission of
sexually transmitted infections (STIs) and unintended pregnancy. This paper analyzes how knowledge
of HIV, experience with dating behavior, and perception of peer behavior factors are associated with
having sexual intercourse and use of condoms among adolescent students in Malaysia. National data
from school-age adolescents who completed the Malaysian HIV/AIDS Knowledge, Attitude and
Practice survey were used. Chi-square analysis and multivariate logistic regression analyses were
performed. Having sexual intercourse was associated with urbaneness (p<0.001); correctly answered
all UNGASS indicator (p=0.011); and perception of peer behavior having had sex (p=0.001). Condom
use among those who had sexual experience was associated with males (p=0.013), believing condoms
prevent HIV and STIs (p<0.002), and having friends who report having had sex (p=0.034). Equitable
and effective sexual education program must be developed to promote the health of adolescents.
Practical education about how condoms may prevent the transmission of STIs and HIV should be
promoted.
Key words: adolescent, condom-utilization, premarital sex
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Introduction!
In Malaysia, marriage is traditionally considered the entry into sexual activity for both genders
(Region, 2007). Since 1970, the age of marriage has increased steadily, from below 20 years in 1970 to
28 years in 2014 (Region, 2007). While marriage is typically when sexual intercourse is first
experienced, recent literature illustrates that sex among adolescents is not uncommon. Regionally
focused studies have demonstrated that as many as 12% of adolescents have engaged in sexual activity
by the age of 19 years (Anwar, Sulaiman, Ahmadi, & Khan, 2010).
Early engagement in sexual activity outside of marriage is associated with adverse health consequences
including teenage pregnancy, sexually transmitted infections (STI), and Human Immunodeficiency
Virus (HIV) infection (S. Zulkifli, Low, & Yusof, 1995). According to the World Health Organization
(WHO), more than two million adolescents are at risk of contracting HIV and 11% of all births are to
girls ages 15 to 19 worldwide (Ahmadian, Hamsan, Abdullah, Samah, & Noor, 2014; Lee, Chen, Lee,
Malaysian!Journal!of!Social!Sciences!and!Humanities!(MJ!-!SSH)!
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& Kaur, 2006). According to the Ministry of Health Malaysia, the cumulative of HIV cases accounted
2.6% of those aged 19 years and younger and the trend of infection is increasing particularly through
homosexual or bisexual contact (Malaysia, 2016). Barriers to health services impede access for health
screening, testing, counseling for adolescent’s sexual health (Ghafari, Shamsuddin, & Amiri, 2014).
One study published in 2014 found that among adolescents aged 12 to 19 years old across Peninsular
Malaysia, 50% reported having engaged in sexual behavior in the past (Farid, Rus, Dahlui, Al-Sadat, &
Aziz, 2014). Because of the potential for negative health consequences associated with unprotected
sexual activity in adolescence, it is important to understand factors associated with sexual activity
among adolescents in Malaysia. A 2012 survey in Malaysia found that adolescents who reported ever
having sex were more likely to not have a close friend, have no supportive peers, and not feel
connected to parents (Ahmad, Awaluddin, Ismail, Samad, & NikAbdRashid, 2014). A 2006 study
focusing on adolescents in Negeri Sembilan, Malaysia showed that being a boy, alcohol use, marijuana
use, cigarette smoking, and living with parents were associated with having sex in adolescence (Lee et
al., 2006).
Lack of knowledge about sexual and reproductive health is also associated with engagement in risky
sexual behavior among adolescents in Malaysia (Ohene & Akoto, 2008). Cultural and religious norms
are considered to be strong determinants of knowledge related to sexual health (Mustapa, Ismail,
Mohamad, & Ibrahim, 2015). Adolescents are frequently not aware of the opportunity for transmission
of STIs when engaging in risky sexual activity, a result, many are not aware when they have been
infected with a STI (Chandra-Mouli, McCarraher, Phillips, Williamson, & Hainsworth, 2014; Mohd,
Adibah, & Haliza, 2015). A 2017 national survey found that Malaysian adolescents’ knowledge of
sexual health, including reproductive health related to pregnancy, was limited across the country
(Mustapa et al., 2015).
While no study in Malaysia has focused on perception of peers’ behavior regarding sexual activity,
other studies have shown that this is an important factor to consider (Chiao & Yi, 2011; Jaafar,
Wibowo, & Afiatin, 2006). Early onset of sexual debut appears to be affected by perception of peer’s
engagement in early sexual activity (Romer et al., 1994). In Nigeria, 90% of unmarried students
indicated that they believed that their peers had sexual partners, and half of unmarried students
indicated they felt pressure by peers to engage in premarital sexual intercourse (Okonkwo, Fatusi, &
Ilika, 2005). The use of barrier methods to prevent STIs and pregnancy also appear to be impacted by
perception of peer behavior. Adolescents who believe that their peers use condoms indicate that they
are likely to use condoms themselves (Diclemente, 1991). Because of the importance of peer pressure
in relation to sexual activity among adolescents in low and middle-income countries, this study
analyzes the relationship between knowledge of HIV and STIs, perception of the efficacy of condoms,
and beliefs about peer sexual and risky behavior with self-reported sexual activity and use of condoms
with among school-age adolescents in Malaysia.
Methodology(
This study used data from the 2012 Malaysian HIV/AIDS Knowledge, Attitude and Practice (KAP)
survey, which collected information about sexual knowledge, sexual behavior, and HIV/AIDS
knowledge among adolescents aged 15 to 17 years who were attending selected government-run
schools in all states of Malaysia. This national school-based KAP assessment targeted public schools in
both urban and rural areas. Using a sampling frame provided by the Ministry of Education of Malaysia,
systematic sampling was used to select one government secondary school from each selected district
from each state, A total of 15 schools were selected from each district of the 15 states in Malaysia.
Data collection occurred during January and February 2012. All selected students were given a self-
administered validated questionnaire in Bahasa Malaysia (Malaysian national language). Parents and
students were informed about the purpose of this study. Parents were required to fill up informed
consent form to approve their children to participate in the study while students who agreed to
participate completed an assent form. For confidentiality, students were treated anonymously with a

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unique identification number. The questionnaire was piloted, tested for clarity and appropriateness for
the students before the study commenced in January 2012 (Bowling, 2014; Fadzilah Kamaludin, 2011).
Onsite quality control was performed to ensure all students provided valid answers.
Ethical approval was obtained from the Medical Research Ethical Committee, Ministry of Health
Malaysia (NMRR: 11-293-8562) and the Ministry of Education Ethics Committee, Malaysia.
Adolescents with assent and approved inform consent by their parents were included in this study.
Measures'and'Use'of'Variables''
The KAP survey included questions adopted from standardized and validated HIV/AIDS surveillance
indicators including the United Nations General Assembly Special Session on HIV/AIDS (UNGASS)
indicators, WHO indicators and the Ministry of Health, Malaysia indicators (Fadzilah Kamaludin,
2011). The survey captured information about socio-demographic characteristics, knowledge of
HIV/AIDS, sexual behavior and STI prevention practices, and perception of sexual education.
Students’ knowledge about HIV/AIDS was assessed through questions pertaining to general
knowledge about STIs and responses to the UNGASS indicator for HIV knowledge. The UNGASS
indicator was employed using five questions, which measured knowledge about HIV transmission and
adequate knowledge was classified for students who answered all five questions correctly. Satisfactory
knowledge about STI symptoms was indicated through students attaining or surpassing the 50th
percentile (Thanavanh, Harun-Or-Rashid, Kasuya, & Sakamoto, 2013).
Sexual experience was assessed through a categorical variable asking whether the student had ever had
sexual intercourse, in the forms of vaginal and anal intercourse. In addition, students were asked about
the type of sexual activity they had engaged in, pregnancy status and abortion experienced. They were
asked about their experience viewing pornography, masturbation and dating behavior: kissing, petting,
or both. Among students who had sex, questions about condom use and perceptions of condom use
were asked. Perception of peer sexual activity was assessed through questions about whether students
believed that their friends ever had sex, been raped, used drugs, or had contracted STIs.
Statistical'Analysis''
Data were analyzed using Stata 12 (Stata Corp) for descriptive statistics including sociodemographic
characteristics, students’ knowledge of HIV and condom use, and experience with sexual intercourse
and other sexual behaviors. Preliminary bivariate categorical analysis was performed using chi-square
statistics to examine factors associated with sexual intercourse experience. All significant independent
variables that associated with the sexual intercourse were selected for main effects in multivariate
logistic regression. Then, multivariate logistic regression was performed to assess the effect of
independent variables on participation in sexual intercourse, controlling for selected covariates.
Another multiple logistic regression model was performed to assess factors associated with condom
use among those who had sex. Diagnostic test for the goodness of fit was applied based on Hosmer &
Lemeshow to ensure the fit of logistic regression with the final model (Bewick, Cheek, & Ball, 2005).
All analyses were considered statistically significant at p< 0.05.
Results(
A total 2,769 students responded to the survey (79% response rate). More than half lived in a rural area
and were female. Just 10.3% (n=285) reported ever having had sex. Details of the participant
characteristics, stratified by those who had sex and those who never had sex are included in Table 1.

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Table 1: Characteristics of students who report ever having sex vs. Those who report never having
had sex (n=1,709)
Variable
Overall,
n=1,709
Ever had sex,
n=285
Never had sex
n=2,424
n (%)
n (%)
n (%)
Gender
Male
1,201 (44.33)
174 (14.49)
1,027 (85.51)
Female
1,242 (45.85)
101 (8.13)
1,141 (91.87)
Did not disclose
266 (9.82)
10 (3.76)
256 (96.24)
Locality
Urban
1,221 (45.07)
172 (14.09)
1,049 (85.91)
Rural
1,488 (54.93)
113 (7.59)
1,375 (92.41)
SES status (RM 1 = USD 0.251)
Did not know
858 (31.67)
96 (11.19)
762 (88.81)
< RM 1,000
879 (32.45)
92 (10.47)
787 (89.53)
RM 1,000 - 4,999
876 (32.34)
83 (9.47)
793 (90.53)
RM >= 5,000
96 (3.54)
14 (14.58)
82 (85.42)
Parent Marital Status
Married
2,433 (89.84)
249 (10.45)
2,133 (89.55)
Divorced
141 (5.21)
17 (12.14)
123 (87.86)
Widow/ Widower
134 (4.95)
12 (9.16)
119 (90.84)
Knowledge about STIs and HIV
Satisfactory knowledge about STIs
608 (22.70)
68 (11.43)
527 (88.57)
Correct UNGASS responses
135 (5.05)
6 (4.55)
126 (95.45)
Sexual behavior
Kissing
371 (15.25)
112 (30.52)
255 (69.48)
Petting
310 (12.72)
107 (34.97)
199 (65.03)
Masturbation
447 (18.63)
85 (19.50)
351 (80.50)
Watching pronography
1,175 (44.78)
185 (15.99)
972 (84.01)
Perception of peer behavior
Has friends who also had sex
716 (27.18)
134 (19.01)
571 (80.99)
Has friends who use drugs
229 (8.90)
39 (17.26)
187 (82.74)
Has friends who were raped
164 (6.40)
43 (26.38)
120 (73.62)
Has friends who have STIs
80 (3.09)
23 (29.11)
56 (70.89)
Students'who'reported'have'had'sex'
Among students who had sex, the median of first onset of sexual intercourse was 15 years old
(IQR=1.5). The majority reported having heterosexual intercourse (79%) and 70% did not use a
condom when they had sex. Nearly 50% reported not knowing that condoms could minimize the risk of
HIV and STI transmission. Among girls who had sex, 9% reported ever being pregnant, and among
those reporting a history of pregnancy, almost all reported had an abortion (Table 2).
Table 2: Characteristics of students who reported ever having had sex (n=285)
Characteristics
n (%)
Age of Sexual debut,

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Median (IQR)
15 (1.50)
25 percentile
14.00
75 percentile
15.50
Sexual experience
Heterosexual
225 (78.95)
Homosexual
36 (2.63)
Refuse to disclose
24 (8.42)
Ever use condom
Use condom
73 (25.61)
Did not used condom
188 (65.96)
Refuse to disclose
24 (8.42)
Perceived condoms could minimize contraction of HIV and
STIs
Agree
140 (49.12)
Does not agree
55 (19.30)
Don't know
84 (29.47)
Non-response
6 (2.11)
Pregnancy and abortion experience (females only), n=101
Ever been pregnant
9 (8.91)
Had abortion
8 (7.92)
Factors'associated'with'having'sex'among'adolescents'
Among all students participated in this study, 1,861 students completed all variables for multivariable
analysis. Table 3 describes factors associated with engagement in sexual activity. In unadjusted
analysis, gender (p<0.001); locality of schools (p<0.001); knowledge of HIV transmission via
UNGASS (p=0.027); experienced with kissing (p<0.001), petting (p<0.001), masturbating (p<0.001),
watching pornography (p<0.001); and perception of peers engaging in having sex (p<0.001), been
raped (p<0.001), using drugs (p<0.001), and having STIs (p<0.001) were associated with having sex.
In adjusted analyses, increased odds of sexual intercourse among adolescents were observed among
those who went school in urban areas (p<0.001), experienced kissing (p<0.001), petting (p<0.001),
believing that friends have engaged in sex (p=0.011), and believing that friends have been raped
(p=0.004), controlling for covariates. While the odds of sexual intercourse among adolescents decrease
among adolescents who had good knowledge of HIV transmission from UNGASS questions (p=0.011)
controlling for covariates.
Table 3: Factors Associated with Having Sex (n= 1,861)
Risk Behavior/ Factor
Crude OR
Adjusted OR
cOR
95% CI
p-value
aOR
95% CI
p-value
Locality
Urban
1.933
1.494, 2.500
< 0.001
2.041
1.455, 2.862
< 0.001
Rural
1
1
Gender
Male
1.786
1.369, 2.329
< 0.001
1.417
0.998, 2.012
0.052
Female
1
1
SES status
Low
1
Medium
0.916
0.653, 1.266
0.595
High
1.600
0.871, 2.940
0.130
Parent Marital Status
Married
1.320
0.683, 2.549
0.409
Divorced
1.700
0.749, 3.859
0.205

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Widow/ Widower
1
Knowledge about STIs
and HIV
Adequate knowledge about
STIs
0.815
0.606, 1.096
0.176
1.089
0.729, 1.627
0.667
Correctly answered all
UNGASS indicator
questions correctly
0.360
0.146, 0.889
0.027
0.205
0.061, 0.694
0.011
Dating and sexual
Behavior
Kissing
5.450
4.125, 7.201
< 0.001
2.289
1.471, 3.561
< 0.001
Petting
6.751
5.068, 8.995
< 0.001
3.634
2.313, 5.711
< 0.001
Experienced masturbating
2.187
1.642, 2.914
< 0.001
Experienced watching
pornography*
3.249
2.451, 4.308
< 0.001
Perception of peer
Behavior
Has friends who had sex
3.790
2.888, 4.974
< 0.001
2.159
1.467, 3.177
0.001
Has friends who have been
raped
3.933
2.689, 5.753
< 0.001
2.443
1.341, 4.451
0.004
Has friends who use drugs
2.157
1.479, 3.146
< 0.001
0.600
0.322, 1.119
0.109
Has friends who have STIs
4.305
2.601, 7.126
< 0.001
1.479
0.666, 3.287
0.336
Note: *Omitted in final model to obtain fit model based on Hosmer & Lemeshow, p-value =
0.1449
Excluded in final model: SES status, Parental status, Experienced Masturbating, Experienced
watching pornography
Factors'associated'with'condom'use'among'those'who'report'having'sex'
Among those who ever had sex (n=285), 210 students answered all questions. Responses from these
students were included in the multivariable analysis that examined condom use and its associated
factors. Table 4 describes factors associated with condom use among those who have reported having
sex. In unadjusted analysis, no significant differences were identified by locality, socioeconomic status,
parent status, knowledge about STIs and HIV, reporting having a friend who uses drugs, or reporting
having a friend who has STIs. Significant differences were identified by gender (p=0.011), believing
condoms prevent HIV and STIs (p<0.001), reporting having friends who have sex (p=0.027), and
reporting having friends who have been raped (p=0.03).
In adjusted analyses, the odds of not using condom decrease by a factor of 0.4 by males, perception
that condoms prevent HIV and STI transmission (aOR=0.4), and reporting having friends who have
sex were factors associated with using condoms (aOR=0.5), controlling for covariates.
Table 4: Factors associated with refusal of using condom among those who reported having sex
(n= 210)
Factor
Crude OR
Adjusted OR
cOR
95% CI
p-value
aOR
95% CI
p-value
Locality
Urban
0.684
0.386, 1.211
0.193
Rural
1
Gender
Male
0.447
0.241, 0.830
0.011
0.405
0.198, 0.826
0.013
Female
1
1
SES status
Low
1

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Medium
1.083
0.532, 2.204
0.826
High
0.473
0.148. 1.517
0.208
Parent Marital Status
Married
0.899
0.236, 3.429
0.877
Divorced
0.917
0.161, 5.207
0.922
Widow/ Widower
1
Knowledge about STIs and
HIV
Adequate knowledge about STIs
1.605
0.875, 2.943
0.126
Correctly answered all UNGASS
indicator questions correctly
1.477
0.162,
13.462
0.729
Agree condoms prevent HIV/STI
transmission
0.329
0.183, 0.590
< 0.001
0.355
0.185, 0.681
0.002
Perception of Peer Behavior
Has friends who had sex
0.521
0.292, 0.930
0.027
0.477
0.240, 0.947
0.034
Has friends who have been raped
0.461
0.229, 0.930
0.031
0.769
0.349, 1.694
0.515
Has friends who use drugs
0.591
0.285, 1.226
0.158
Has friends who have STIs
0.544
4
0.223, 1.327
0.181
Note: Fit model based on Hosmer & Lemeshow, p-value = 0.3119
Excluded in final model: SES status, Locality, Parental status, Knowledge on STI symptoms, UNGASS
Indicator, Perceived friends used drugs and perceived friends had STIs.
There were 210 students were included in the final model out of 276 students who claimed having had
sex.
Discussion(
This paper describes the association between sexual activity, HIV knowledge, and perception of peer
behavior among adolescents in Malaysia. In Malaysia, the majority of HIV and sexual activity-related
surveillance focuses on key populations at risk for HIV including injection drug users, men who have
sex with men (MSM), female sex workers, and transgender people (Malaysia, 2016). This paper
presents information about a group that may be at risk for HIV in the coming years adolescents.
Furthermore, this study explores factors that may be associated with adolescent sexual activity that
have not been captured in prior research. It serves as the first comprehensive presentation of national-
level findings describing adolescent sexual activity in Malaysia.
Of all adolescents in the study, 10.3% reported having had sex. Prior studies have reported a sexual
activity rate among adolescents between 5% to 20%, while the most recent nationwide school-based
survey in 2012 reporting a rate of 8.3% (Ahmad et al., 2014). Research shows that high religiosity
(Awaluddin et al., 2015) and conservative attitudes (S. N. Zulkifli & Low, 2000) are associated with
lower odds of sexual intercourse among adolescents. The sexual behavior of Malaysian adolescents is
highly influenced by the dominant Malay culture and Muslim religious beliefs. Dating and sexually
intimate behaviors among non-married people are strictly prohibited in the Malay culture. While this
study did not report ethnicity or religion, we suppose that high participation among Muslim and Malay
adolescents contributed to low prevalence of sexual activity.
When compared to national adolescent sexual activity statistics from neighboring countries, we notice
a difference. One national study following sexual activity among 1,000 adolescents in Indonesia, where
social norms surrounding sexual activity are largely similar to those in Malaysia (Holzner & Oetomo,
2004), indicated that not one reported having participated in sexual activity (Susanto et al., 2016).
Outside of Indonesia and Malaysia, rates of adolescent sexual intercourse are higher than what we
found in our study, and they may be related to social norms (Thanavanh et al., 2013),(Chiao & Yi,
2011) For example in Taiwan, where 65.8% adolescents report having accepting attitudes toward
premarital sex, 22.4% of adolescents report having had sex (Chiao & Yi, 2011). Outside of Asia,
19.2% of adolescents from 10 European countries report having had sex (Gambadauro et al., 2018).

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Interestingly, this study suggests that while the majority of students reported having had heterosexual
intercourse, 14% reporting having had homosexual intercourse. Sexual diversity is not commonly
discussed and often neglected due to difficulty to identify gay, lesbian and bisexual behavior in
adolescents (Society, 2008). In Malaysia, few studies explore or focus on sexual orientation among
adolescents in spite of the recent shift in the pattern of HIV infections in Malaysia, mainly attributable
to man having sex with man (MSM) (Malaysia, 2016). Considering that same-sex relationships are
legally, culturally, and religiously prohibited in Malaysia, it is surprising that these adolescents felt
comfortable self-reporting engagement in homosexual sex. This finding is important for the
development of equitable and effective health care promotion. It is well-documented that homosexual
adolescents are especially vulnerable to HIV because of low condom use (Saewyc et al., 2006) and that
they face stigma and discrimination when seeking health care services (Beyrer et al., 2012).
Considering that a proportion of adolescents are documented to participate in homosexual sex, this
information should be used in the development of HIV prevention programing to promote good sexual
health among both heterosexual and homosexual adolescents.
Additionally, among females who had sex, 10% reported a prior pregnancy and of those who reported a
prior pregnancy, 90% students reported having an abortion. In this region, abortion is highly
stigmatized, but having a child born out of marriage can be even more problematic for one’s social
status (Rehnström Loi, Gemzell-Danielsson, Faxelid, & Klingberg-Allvin, 2015). Unintended
pregnancy is preventable, including among adolescents, but limited access to contraceptives and
inadequate knowledge on the use contraceptives, especially in the low-middle income countries, has
become a barrier to prevent adolescent pregnancy (Chandra-Mouli et al., 2014; Mohd et al., 2015). As
is consistent with many more traditional areas of the world, among Malaysian adolescents,
contraception is rarely discussed (Mohd et al., 2015; Rehnström Loi et al., 2015). A lack of knowledge
about pregnancy prevention and appropriate antenatal care can result in high-risk pregnancies
(Najimudeen & Sachchithanantham, 2017; Omar et al., 2010). While this study specifically focused on
condom use, additional research about perceptions of other forms of birth control among adolescents
are needed.
Our findings indicate that the degree that the living location is urban, socioeconomic status, and
parent’s marital status are not significantly associated with sexual activity or condom usage. In
Malaysia, while stigma surrounding the sexual behavior of people of low socioeconomic status and
divorcees and children of divorced parents exists (Pong, 1996), these results suggest that these factors
are not associated with using condoms among adolescents. These findings are consistent with results
from other studies focusing on young people’s sexual behavior around the world (Barnes, Hoffman,
Welte, Farrell, & Dintcheff, 2007; Marston & King, 2006). Furthermore, in contrast to previous
research (Farid et al., 2014), this study found that girls were more likely to report condom usage.
Existing research about condom usage dates to 2012 and focused on adolescents aged 12 to 17 years
(Farid et al., 2014). This study focused on students aged 15 to 17 years. Perhaps a difference in ages
captured in the studies or the fact that more girls are educated about condom use now compared to in
the past have had impacts on desire to use condoms.
Finally, studies show that peer pressure is a significant predictor of sexual behavior among adolescents
(Diclemente, 1991; Jaafar et al., 2006; Okonkwo et al., 2005; Romer et al., 1994). This is consistent
with findings from Malaysia’s neighboring country, Indonesia, where 80% of adolescents admitted that
peers had an influential role in their decision to engage in sexual activity (Jaafar et al., 2006). It is well-
documented that adolescents share information about sex among friends (Jaafar et al., 2006). This
study confirms that adolescent peer influence is an important factor in the decision to engage in sexual
activity among adolescents. Appropriate STI and HIV prevention programs should include aspects of
peer influence to maximize their impact.
In contrast to prior research (Anwar et al., 2010), this study does not confirm that with increased
knowledge about STIs and HIV there is more engagement in sexual intercourse. Instead, in our study,
knowledge about HIV transmission is associated with a lower frequency of engagement in sexual
activity. Additionally, our results suggest that condom use is associated with the perception that
condoms prevent HIV and STI infection. Interestingly, our findings suggest that having high

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knowledge about STIs is not associated with use of condoms. This suggests that having knowledge
about STIs and HIV is not enough to influence condom use, but that practical education about how
condoms may prevent the transmission of STIs and HIV should be promoted among adolescents.
Study!Limitations!!
While the findings from this study are important for informing policy, there are some limitations. This
study did not employ a complex sampling analysis and therefore is not representational of the entire
population of adolescents in Malaysia. The multistage sampling design was employed for each school’s
selection from each state in Malaysia and no sampling weights were adopted in the analysis to obtain
estimates for adolescents in Malaysia. The cross-sectional design captured information at one point in
time and cannot inform a cause–effect relationship between the tested predictors and sexual
intercourse. Furthermore, this study relied on self-report to accommodate the sensitive nature of the
questions.
Conclusions(
Of all adolescents in the study, 10.3% reported having had sex. Of adolescents who had sex, 2.6%
reported having homosexual intercourse. The development of equitable and effective HIV prevention
programing is important to promote safe sexual health among both heterosexual and homosexual
adolescents. Furthermore, considering that nearly 10% of sexually active girl students reported a prior
pregnancy, additional research about perceptions and use of birth control among adolescents is needed.
Finally, our finding that condom use is highly associated with peer influence is important for informing
sexual health programs targeting adolescents in Malaysia. Practical education about how condoms may
prevent the transmission of STIs and HIV should be implemented.
Acknowledgements(
The authors thank the Director General of Health, Malaysia for allowing us to publish this manuscript.
The authors would also like to thank Dato’ Dr. Fadzilah Kamaludin, the principle investigator of the
study for Knowledge, Attitude and Practice (KAP) in HIV/AIDS and Sexually Transmitted Infections
(STI) related risk behavior of secondary school children in Malaysia for allowing us to utilize the data
for this manuscript.
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