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Knowledge of Sexual and RepRoductive HealtH among adoleScentS
Vol 42 No. 3 May 2011 717
Correspondence: Dr Azriani Ab Rahman, De-
partment of Community Medicine, School of
Medical Sciences, Health Campus, Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelan-
tan, Malaysia.
Fax: 609-767 6654
E-mail: azriani@kb.usm.my
individuals reach sexual maturity and is
a period of transition to maturity (United
Nations, 1997). Sexual and reproductive
health among adolescents has emerged
as an important issue in Asia. Sexually
transmitted diseases (STDs), unwanted
pregnancies, and unsafe abortions are
the main sexual and reproductive health
issues facing adolescents today (Low,
2006).
KNOWLEDGE OF SEXUAL AND REPRODUCTIVE
HEALTH AMONG ADOLESCENTS ATTENDING
SCHOOL IN KELANTAN, MALAYSIA
Azriani Ab Rahman2, Razlina Ab Rahman1, Mohd Ismail Ibrahim2, Halim Salleh2,
Shaiful Bahri Ismail1, Siti Hawa Ali3, Wan Manan Wan Muda3, Maizun Ishak4
and Amaluddin Ahmad1
1Department of Family Medicine, 2Department of Community Medicine,
3School of Health Sciences, 4Department of Obstetrics and Gynecology,
School of Medical Sciences, Health Campus, Universiti Sains Malaysia,
Kubang Kerian, Kelantan, Malaysia
Abstract. The objectives of this study were to describe the knowledge of sexual and
reproductive health among adolescents attending school and to compare the levels
of knowledge between males and females and between older and younger groups
of adolescents. A cross-sectional study was conducted among 1,034 secondary school
students using a self administered validated questionnaire. The items with the fewest
correct responses included: whether one can get pregnant after a single act of sexual
intercourse (30.4%), whether sexual intercourse causes sexually transmitted diseases
(STDs) (12.4%) and whether washing the vagina after sexual intercourse prevents
pregnancy (17.0%). Their main source of sexual information was friends (64.4%). An
independent t-test revealed the mean knowledge score was signicantly higher among
females than males on items assessing whether the genitalia may be touched freely by
family members, females having attained menarche may become pregnant if having
sex, whether pregnancy will occur if there is penetration of the penis into the vagina,
whether premarital sexual intercourse causes pregnancy and if there is a relationship
between abandoned babies and premarital pregnancies. The mean knowledge score
assessing whether pregnancy can be prevented using condoms was higher among
males than females. The mean knowledge scores were signicantly higher among
form four and form ve students than forms one, two and three students. Lack of
knowledge regarding important aspects of sexual and reproductive health warrant
the need to strengthen sexual and reproductive health education.
Keywords: knowledge, sexual and reproductive health, school going adolescents
INTRODUCTION
Adolescence is a stage in life when
SoutHeaSt aSian J tRop med public HealtH
718 Vol 42 No. 3 May 2011
Due to the widening age gap between
menarche and marriage, there is a grow-
ing incidence of premarital sexual acti-
vity among adolescents (Ann et al, 2001).
Although premarital sex is less common
in Asia than in some developed regions, it
is clearly on the rise (Low, 2009). Adoles-
cents are vulnerable to this phenomenon
because they lack information and skills
in negotiating sexual relationships (Low,
2009). This is particularly the case when
reproductive and sexual health issues are
still considered taboo subjects in many
countries, thus preventing adolescents
from obtaining adequate knowledge,
guidance and services regarding repro-
ductive and sexual health, particularly at
the school level (Smith et al, 2000). It has
been reported most young adolescents
in South and Southeast Asia have little
information about their bodies and issues
surrounding sexual and reproductive
health (IHWC, 2007).
In Malaysia, the phenomenon of pre-
marital sexual activity has been increas-
ing over the years (IPH, 2008). The mean
age of first sexual intercourse among
Malaysian adolescents has been reported
to be fifteen years old (Kamarudin et
al, unpublished; Lee at al, 2006). At this
young age, adolescents are naive about
the implications of their behavior both
at that time and in the future, and they
have a limited knowledge of sexual and
reproductive health in general. Several
studies have shown knowledge regarding
sexual and reproductive health among
adolecesnts varies by locality, sex and age
(WHO, 2005). This has occurred in spite
of the fact sex education was integrated
into the secondary school curriculum in
1989 through the Physical and Health
Education, Science, Additional Science,
Biology, Moral and Islamic Education
package called Family Health Education
(FHE). Since 1994, elements of FHE have
also been introduced to primary school
children through Physical and Health
Education. Muslim students are exposed
to sexual and reproductive health issues
through Islamic Education as a compul-
sory subject (Low, 2009). It is apparent
sex education in primary and secondary
schools in Malaysia has been rather inef-
fective.
There are only a limited number of
studies in Malaysia assessing knowledge
about sexual and reproductive health
among adolescents attending school.
The few available support the need for
a more organized, systematic delivery of
sexual and reproductive health education
to school age children to improve their
knowledge and help them make better,
healthier decisions regarding sexual be-
haviors (Kamarudin et al, unpublished;
WHO, 2005).
The objectives of this study were to
describe the knowledge of sexual and
reproductive health among adolescents
attending school in Kelantan and to
compare the level of knowledge between
male and female adolescents and older
and younger age groups of adolescents.
It was hypothesised there is a signicant
difference in the level of knowledge be-
tween male and female adolescents and
between older and younger adolescents.
MATERIALS AND METHODS
This study was conducted in Kelan-
tan, Malaysia, a state along the northeast-
ern 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 car-
ried out in April 2009 at seven secondary
Knowledge of Sexual and RepRoductive HealtH among adoleScentS
Vol 42 No. 3 May 2011 719
schools in Kelantan, among adolescents
in secondary one to secondary ve. The
sample size was calculated using a single
proportion formula. A total of 862 stu-
dents was required for the study based on
the following considerations: precision
level of 0.05, a value of standard normal
distribution of 1.96, a percentage of ado-
lescents with a correct response to using
condoms as a contraceptive method of
63.3% (WHO, 2005), a 20% non-response
rate and multiplication by 2 for the de-
sign effect. Students were selected from
classrooms at random at each level of
education from secondary one to second-
ary ve. All students from each selected
classrooms were included in the study.
The students were assessed through
a self administered, anonymous question-
naire but were guided in answering the
questions. Written consent was obtained
from the students and their parents
prior to data collection. The question-
naire consisted of sociodemographic
information, including personal and fam-
ily background, knowledge (23 items) of
human reproductive organs, pregnancy,
contraception, HIV and sexually trans-
mitted diseases (STDs), abortions and
their sources of sexual and reproductive
health information. Categorical responses
(True/False/Don’t know) were assigned
for the knowledge components. A correct
response was given a scores of 2, an incor-
rect response was given a score of 0, and
an answer of don’t know was given a score
of 1. The questionnaire was validated by
fty-six secondary school students in a
district other than the current study. Item
analysis for the questionnaire was good:
the Cronbach’s alpha score was above 0.7
(Razlina et al, 2009).
Sociodemographic information and
and data regarding knowledge of the re-
spondents were tabulated for descriptive
statistics. An independent t-test was used
to compare mean knowledge scores be-
tween boys and girls, and between older
and younger age groups of adolescents.
Data entry and statistical analysis were
carried out using SPSS version 12.
Ethical approval was obtained from
the Research and Ethics Committee, Uni-
versiti Sains Malaysia on 23 December
2008.
RESULTS
A total of 1,034 students were includ-
ed in the study. The majority of students
were females (56.4%) and Malays (100.0%)
who came from households with a mean
total monthly income of less than RM
500 (44.9%). Households with a monthly
income <RM 720 are considered below
the current national poverty level. The
mean age was 15 years old (SD of 1.42).
A large proportion of their fathers (57.9%)
and mothers (62.7%) had a formal educa-
tion level up to secondary school level
(Table 1).
The knowledge items with the lowest
percentages of correct responses from the
students were those that assessed the fol-
lowing issues: one may get pregnant after
a single act of sexual intercourse (30.4%),
sexual intercourse is a cause of STDs
(12.4%), washing the vagina after sexual
intercourse can prevent against pregnancy
(17.0%), and having a hot shower after
sexual intercourse prevents pregnancy
(16.7%). The majority of students (79.8%)
knew sexual abstinence is the best method
to prevent pregnancy (Table 2). Their main
source of sexual information was friends
(64.4%) (Table 3).
Th e me an knowledge scores for
several items were signicantly higher
among females than males (Table 4). These
included items that assessed whether the
SoutHeaSt aSian J tRop med public HealtH
720 Vol 42 No. 3 May 2011
uterus is the organ where a fetus stays,
whether the genitalia may be touched
freely by family members, whether a
female who has reached menarche may
become pregnant after sexual intercourse,
whether pregnancy can occur if there is
penetration of the penis into the vagina,
whether premarital sexual intercourse
may cause pregnancy, and whether there
is a relationship between abandoned ba-
bies and premarital pregnancy. The mean
knowledge score on the item that assessed
n (%)
Sex
Male 451 (43.6)
Female 583 (56.4)
Race
Malay 1,034 (100.0)
Non Malay 0 (0.0)
Age (years) 15 (1.42)a
13 202 (19.5)
14 212 (20.5)
15 194 (18.7)
16 216 (20.9)
17 210 (20.3)
Mathernal education level
Never have formal education 48 (4.7)
Primary school 155 (15.0)
Secondary school 646 (62.7)
College/university 182 (17.7)
Paternal education level
Never have formal education 36 (3.5)
Primary school 163 (15.8)
Secondary school 596 (57.9)
College/university 235 (22.8)
Total household monthly income (RM)
Less than 500 464 (44.9)
500 to 1,000 269 (26.0)
1,001 to 2,000 111 (10.7)
More than 2,000 189 (18.3)
Table 1
Sociodemographic characteristics of
study subjects.
a mean (SD)
whether pregnancy may be prevented
using condoms during sexual intercourse
was higher among males than females.
The mean knowledge scores were sig-
nicantly (p<0.001) higher among second-
ary four and ve students than secondary
one, two and three students (Table 5).
DISCUSSION
Our study ndings are in line with
other reports showing knowledge levels
among school age adolescents regarding
sexual and reproductive health vary by
location, age and sex (WHO, 2005); the
inadequate knowledge found here about a
number of important aspects of this issue
warrants immediate attention. Many stu-
dents responded wrongly that girls could
not become pregnant if they had sexual
intercourse only once or if they washed
their vagina or showered after sexual
intercourse. This misunderstanding can
create complacence and the feeling sex-
ual intercourse is a small matter because
they can simply perform these preven-
tive measures at the time of sex without
consequences. Fortunately, the majority
of students knew sexual abstinence is
the best method to prevent pregnancy.
Various contraceptive methods are easily
available; adolescents should be educated
abstinence from sexual intercourse is the
most effective method to prevent preg-
nancy, HIV and STDs. This is especially
important since the majority of students
did not know that sexual intercourse is
a cause of STDs although many of them
knew about HIV. One reason for this out-
come is the extensive and constant media
coverage of HIV (WHO, 2005), similar to
the ndings noted by another study on
the subject (NPFDB, 1998).
Interestingly, girls had a better know-
ledge than boys about sexual health in
Knowledge of Sexual and RepRoductive HealtH among adoleScentS
Vol 42 No. 3 May 2011 721
the majority of locations studied, which
is in contrast to the ndings of a previ-
ous study of secondary school students
in Kelantan nine years ago (Kamarudin
et al, unpublished). However, more boys
than girls knew a condom was a method
of contraception, consistent with another
previous study (NPFDB, 1998). There is a
need to improve knowledge among boys
because premarital sexual activity is more
prevalent among males than females (Ann
et al, 2001; Lee et al, 2006).
Knowledge among older students
was better than younger students. Earlier
exposure to sexual and reproductive
Items n %
The vagina is the organ for sexual intercourse. 496 37.7
The vagina is the organ for delivery of babies. 510 49.5
The uterus is the organ where a fetus stays. 572 55.3
The genitalia may be touched freely by family members. 820 79.2
Ejaculation and passing urine are functions of the penis. 597 57.7
The testis produce sperm. 473 45.7
Penile discharge during ejaculation contains sperm. 599 57.9
Females who reach menarche can become pregnant if they have sex. 734 70.9
Pregnancy may occur if there is penetration of the vagina by the penis. 597 57.7
Pregnancy occurs when there is fertilization by the ovum with sperm. 720 69.6
One may become pregnant after one act of sexual intercourse. 314 30.4
Pregnancy may not occur if having sexual intercourse with only one partner. 526 50.9
Premarital sexual intercourse may cause pregnancy. 755 73.1
Sexual intercourse is a cause of STDs. 127 12.4
HIV is transmitted via sexual intercourse. 858 83.0
There is a relationship between abandoned babies and premarital pregnancies. 869 84.1
Illegal abortions cause severe bleeding. 552 53.3
Illegal abortions cause infections. 160 15.5
Illegal abortions cause maternal death. 410 39.7
Pregnancy is prevented using condoms. 618 59.8
Vaginal washing after sexual intercourse prevents pregnancy. 176 17.0
Sexual abstinence is the best method to prevent pregnancy. 825 79.8
Having a hot shower after sexual intercourse prevents pregnancy. 172 16.7
Table 2
Correct responses to questions about reproductive and sexual health among study
subjects in Kelantan, Malaysia.
n (%)
Parents 67 6.5
Siblings 57 5.5
Friends 666 64.3
Teachers 178 17.2
Lovers 111 10.7
Mass media 623 60.2
Television, internet, 555 53.6
compact discs.
Table 3
Sources of sexual and reproductive
health information among
adolescents attending school in
Kelantan, Malaysia.
SoutHeaSt aSian J tRop med public HealtH
722 Vol 42 No. 3 May 2011
Items Mean (SD) Mean (SD) Mean difference p-valuea
Male Female (95% CI)
The vagina is the organ for sexual intercourse. 1.44 (0.59) 1.40 (0.71) 0.034 (-0.200,-0.037) 0.375
The vagina is the organ for delivery of babies. 1.26 (0.62) 1.32 (0.60) 0.058 (-0.041,-0.108) 0.129
The uterus is the organ where a fetus stays. 1.38 (0.64) 1.59 (0.57) 0.029 (-0.283,-0.136) <0.001
The genitalia may be touched freely by family members. 1.67 (0.54) 1.84 (0.41) 0.175 (-0.233,-0.136) <0.001
Ejaculation and passing urine are functions of the penis. 1.67 (0.52) 1.46 (0.69) 0.213 (-0.136,-0.289) <0.001
Testis produce sperm. 1.44 (0.57) 1.39 (0.59) 0.051 (-0.020,-0.123) 0.158
Penile discharge during ejaculation contains sperm. 1.66 (0.52) 1.44 (0.59) 0.220 (-0.290,-0.289) <0.001
Females who reach menarche can become pregnant if having sex. 1.50 (0.62) 1.80 (0.49) 0.295 (-0.362,-0.228) <0.001
Pregnancy may occur if there is penetration of the vagina by the penis. 1.43 (0.69) 1.58 (0.55) 0.156 (-0.232.-0.081) <0.001
Pregnancy occurs when there is fertilization of the ovum by sperm. 1.65 (0.50) 1.71 (0.50) 0.058 (-0.120,-0.003) 0.064
One may become pregnant after one act of sexual intercourse. 1.27 (0.56) 1.26 (0.50) 0.009 (-0.056,-0.074) 0.780
Pregnancy may not occur if having sexual intercourse with only one partner. 1.45 (0.58) 1.50 (0.53) 0.051 (-0.119,-0.017) 0.141
Premarital sexual intercourse causes pregnancy. 1.63 (0.58) 1.75 (0.48) 0.115 (-0.180,-0.050) 0.001
Sexual intercourse is a cause of STDs. 1.00 (0.49) 1.06 (0.44) 0.053 (-0.110,-0.004) 0.071
HIV is transmitted via sexual intercourse. 1.80 (0.45) 1.83 (0.40) 0.036 (-0.087,-0.016) 0.184
There is a relationship between abandoned babies and premarital pregnancies. 1.78 (0.45) 1.87 (0.36) 0.091 (-0.140,-0.042) <0.001
Illegal abortions cause severe bleeding. 1.48 (0.55) 1.54 (0.53) 0.060 (-0.126,-0.007) 0.078
Illegal abortions cause infections. 1.12 (0.47) 1.09 (0.42) 0.029 (-0.026,-0.083) 0.306
Illegal abortions causes maternal death. 1.32 (0.55) 1.38 (0.56) 0.056 (-0.125,-0.013) 0.109
Pregnancy is prevented using condoms. 1.66 (0.52) 1.50 (0.56) 0.157 (-0.091,-0.224) <0.001
Washing the vagina after sexual intercourse is a prevention against pregnancy. 1.13 (0.49) 1.13 (0.41) 0.005 (-0.049,-0.060) 0.850
Sexual abstinence is the best method to prevent pregnancy. 1.76 (0.50) 1.78 (0.48) 0.022 (-0.082,-0.038) 0.468
Having a hot shower after sexual intercourse prevents pregnancy. 1.17 (0.44) 1.15 (0.37) 0.019 (-0.030,-0.069) 0.453
Table 4
Mean knowledge scores (scores of each item) between male and female school-going adolescents in Kelantan.
a Independent t-test
Knowledge of Sexual and RepRoductive HealtH among adoleScentS
Vol 42 No. 3 May 2011 723
health information may provide students
with better information to make choices
since the age of rst sexual intercourse
for both male and female Malaysian ado-
lescents has been reported to be as young
as nine years old (FFPAM, 2002). This
supports the need to begin sexual and
reproductive health education earlier in
primary schools (WHO, 2005).
The fact that peers were the most
common source of sexual and reproduc-
tive health information in this study is
consistent with other studies (Kaiser et al,
2003; Kamarudin et al, unpublished). The
majority of students reported they had
heard about sexual and reproductive
health through the mass media, such as
in magazines, on television and on the
internet. Few students obtained informa-
tion about sexual health from their teach-
ers or parents. There is a need to balance
the information obtained from the media
with that obtained from teachers and
parents because there is always a danger
unltered information given by the media
may promote sexual intercourse rather
than educating regarding sexual and re-
productive health.
Parents also play an important role
in educating their children about sexual
and reproductive health. However, some
parents may be inhibited about educat-
ing their children in this area. Parents
may assume their children are unlikely
to engage in sexual relations or are not
mature enough to be educated regard-
ing this subject; parents may also believe
this information is better given at school
(Ann et al, 2001). However, some studies
have suggested that the preferred source
of information about sexuality especially
among young females, is the parents, par-
ticularly mothers. Unfortunately, parents
are often not prepared to respond to this
need satisfactorily (Ann et al, 2001).
Lack of knowledge about sexual
and reproductive health among school
age adolescents warrants the need to
strengthen sexual and reproductive health
education programs in schools. Studies
have shown that education regarding
sexual and reproductive health does not
increase sexual activity. Instead, it may
help to delay the rst sexual intercourse,
thus reducing the frequency of sexual ac-
tivity, pregnancy, abortion and unwanted
birth rates. It may also increase condom
use among sexually active youths, pro-
tecting them from STI, including HIV
and pregnancy (UNAIDS, 1997). Schools
are important for providing sexual and
reproductive health education because
they reach a large number of children and
adolescents (Ann et al, 2001). Monitoring
school efforts has shown teachers either
shy away from the subject or do not have
the skills to teach the subject (Low, 2009).
Medical and health personnel appear
to be better able to deliver the message.
Alternatively, teachers may be trained
Age group (years) Mean (SD) Mean difference (95% CI) p-valuea
13 to 15 31.80 (5.32) -4.75 (-5.35, -4.14) <0.001
16 to 17 36.54 (4.35)
a Independent t-test
Table 5
Mean sex knowledge scores (total score) by age group among subjects.
SoutHeaSt aSian J tRop med public HealtH
724 Vol 42 No. 3 May 2011
by health care personnel using sexual
education modules. Sexual education is
still a taboo subject and thus embarrass-
ing for some to discuss openly. It may be
helpful if the health education sessions
in schools are conducted separately for
boys and girls so that both sexes are more
free to discuss the subject. It would also
be better for health educators to reach
out to students of the same sex. Outreach
programs by nongovernment organiza-
tions and government health agencies are
also essential for targeting out-of-school
adolescents (Zulkii and Low, 2000).
A major limitation of our study was
it included only adolescents attending
school who are ethnic Malays.
In conclusion, there is an immediate
need to increase the level of sexual and
reproductive health knowledge among
school age adolescents in Kelantan, Ma-
laysia. Parents, schools and health care
providers are challenged with the task
of providing adolescents with accessible
sexual and reproductive health informa-
tion to promote healthy sexual and repro-
ductive lives.
ACKNOWLEDGEMENTS
We would like to express our appre-
ciation to the Universiti Sains Malaysia
for the university research grant and to
the adolescents who participated in this
study.
REFERRENCES
Ann DB, Shireen JJ, Iqbal S, Kathryn MY. De-
velopment and research training in hu-
man reproduction sexual relations among
young people in developing countries:
evidence from WHO case studies. New
York: UNDP/UNFPA/WHO/World Bank
Special Programme of Research, 2001.
Federation of Family Planning Associations of
Malaysia (FFPAM). Annual report. Kuala
Lumpur: FFPAM, 2002.
Institute for Public Health (IPH). The third
National Health Morbidity Survey (NHMS
III) 2006, Vol 2. Kuala Lumpur: Ministry of
Health, Malaysia, 2008.
International Women’s Health Coalition
(IWHC). Young adolescents’ sexual and
reproductive health and rights: South and
Southeast Asia. [Cited 2010 May 2]. Avail-
able from: URL: www.IWHC.org
Kaiser HJ, Hoff T, Green L, Davis J. National
survey of adolescents and young adults:
sexual health knowledge, attitudes and
experiences. Menlo Pork, CA: Henry J.
Kaiser Family Foundation, 2003.
Lee LK, Chen CY, Lee KK, Kaur J. Premarital
sexual intercourse among adolescents
in Malaysia: a cross-sectional Malaysian
school survey. Singapore Med J 2006; 47:
476-81.
Low WY. Adolescent health: what are the issues
and are we doing enough? Singapore Med
J 2006; 47: 453-5.
Low WY. Malaysian youth sexuality: Issues and
challenges. JUMMEC 2009; 12: 3-14.
Ministry of Education (MOE) Malaysia.
Huraian sukatan pelajaran.Kurikulum
Bersepadu Sekolah Menengah. National
Health Morbidity Survey (NHMS) Report,
2009. Kuala Lumpur: MOE.
National Population and Family Development
Board(NPFDB). Report of the national
study on reproductive health and sexuality
1994/1995. Kuala Lumpur: NPFDB, 1998.
Razlina AR, Azriani AR, Mohd Ismail I, et al.
Validation of questionnaire on premarital
sexual activities among secondary school
students [Abstract]. Kuala Lumpur: 9th
IAAH World Congress. 28 -30 October
2009: 76 pp.
Smith G, Kippax S, Aggleton P. HIV and sexual
health education in primary and second-
ary schools ndings from selected Asia
Pacific countries. Monograph 10/2000.
Knowledge of Sexual and RepRoductive HealtH among adoleScentS
Vol 42 No. 3 May 2011 725
Sydney, Australia: National Centre in HIV
Social Research, 2000. [Cited 2010 Feb 2].
Available from: URL: www.dgroups.org/
groups/LSNet/docs/ACF472A.pdf?ois=no
United Nations (UN). World population moni-
toring 1996: selected aspects of reproduc-
tive rights and reproductive health. New
York: UN, 1997.
UNAIDS. Impact of HIV and sexual health edu-
cation on the sexual behaviour of young
people: a review update. 1997. [Cited 2010
Mar 2]. Available from: URL: http://www.
unaids.org/publications/documents/chil-
dren/schools/grunskme.pdf
World Health Organization (WHO). Sexual and
reproductive health of adolescents and
youths in Malaysia. A review of literature
and projects. Geneva: WHO, 2005: 24-5.
Zulkii SN, Low WY. Sexual practices in Ma-
laysia: Determinants of sexual intercourse
among unmarried youths. J Adolesc Health
2000; 27: 276-80.
