The long-term effect of sexual and reproductive health education on college students' sexual behavior
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Arifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
The long-term effect of sexual and reproductive health education on
college students' sexual behavior
Izzatul Arifah1*, Rizky Larasati1, Titin Kurniawati1
1
Public Health Program Study, Health Science Faculty, Universitas Muhammadiyah
Surakarta
*Corresponding author:
Izzatul Arifah
Gatak, Pabelan, Kartasura, Sukoharjo Regency, Central Java 57169
Phone numbers: 081227151421
E-mail address: ia523@ums.ac.id
Abstract
Background: The short-term benefits of Sexual and Reproductive Health (SRH) education on
adolescents' sexual behavior have beenwell identified. However,the effects of the educational program
on young adults’sexual behavior have not much been investigated yet. Aims: This study measured
the long-term effects of adolescent’s SRH education on college students’ sexual behavior at a
university in Sukoharjo. Settings and Design: This study was a cross-sectional study conducted from
January- April 2020. Methods: With a proportionate random sampling technique, the sample was
chosen from 12,764 college students aged 20-24 at a university in Sukoharjo district, Indonesia.
Finally, 491 unmaried college students participated in this study and filled an online survey. Statistical
analysis used: This study performed multi logistic regression test to model the risk of students' sexual
behavior. Results: Of 491 students, eighteen students (3.7%) reported sexual intercourse during
college. Learning SRH from Adolescent’s Counselling and Informational Center (ACIC) could reduce
the likelihood to engage in risky sexual behavior (50% reduction in risks among the students who
learned SRH from ACIC compared to those who had not (p-valueArifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
How to cite this article: Arifah I, Larasati R, Kurniawati T (2021): The long-term effect of sexual and
reproductive health education on college students’ sexual behavior, Ann Trop Med & Public Health;
22(S01): SP24134. DOI: http://doi.org/10.36295/ASRO.2021.24134
Introduction
Indonesian youth still poses sexuality and reproductive health issues which can be an
interesting yet challenging topic at the same time. While the sexual issues remain taboo to the
Indonesian community, actions are required to solve the sexual and health issues among Indonesian
youth due to the growing number of premarital sex, which also can affect the future adolescents’
health, in the last decades (1). Nowadays, modern young adults have had greater control over sexual
content exposure to information media than the older generation, and thus it results in more significant
chances of having sexual behavior (2). Even though permissive attitude towards sexual behavior
remains insignificant, trends in premarital sex have increased over the year. Data from a national
survey and some studies on adolescents' sexual behavior show that most adolescents thought that
premarital sex was not allowed (3–5).
While the survey showed a contrast tendency of the trends of sexual behavior. The incidence of
premarital sex increased over the past two decades. Data from the 2017 Indonesian Demographic and
Health Survey (IDHS) show that 8% of single males and 2% of single females aged 15–24 years
reported their sexual intercourse. The percentage was much bigger compared to data from the 2003
and 2007 IDHS, around 5% and 6.4% among single males aged 15-24 years in 2003 and 2007,
respectively. However, the percentage of females who had a sexual intercourse over the years
remained constant (6,7). Other studies in several big cities have found a higher number of premarital
sex. In Jakarta, 22% of adolescents’ had premarital sex and pregnancy (1). Another study on 1000
young people in Central Java found that 18% of males and 6 % of females ever engaged in a
premarital sexual intercourse (8).
This statistic raises concerns for adolescent reproductive health in their future developmental
stage, especially for a chance of unintended pregnancy and Sexually Transmitted Disease (STD). The
2017 Indonesian Demographic and Health Survey (IDHS) suggests that less than half of youth who
had sexual intercourse used a condom during their last sexual activities (4). Additionally, 12% of the
female youth reported unintended pregnancy (4). Unprotected sexual intercourses increase the risk of
STD infection. The Indonesian Ministry of Health reports an increasing trend of new HIV infection
among youth. In 2017, the percentage of HIV-infected youth aged 20-24 was higher (16%) than youth
aged 15-19 (4%)(9). Youth who get infected by HIV will have suboptimal reproductive health outcome
in the future.
Adolescent sexual behavior appears due to a complex array of individual factors and external
factors. Individual factors, such as age, education, knowledge, mental health, self-efficacy,
competence, and confidence, affect adolescent sexual behavior(10–12). External factors, including
social connectedness, parental support, peer support and Sexual and Reproductive Health (SRH)
educational program influenced sexual behavior(10,13–17). Evidence from some SRH education
interventions to reduce poor reproductive health outcomes shows positive results. Some systematic
Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2021.24134Arifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
reviews of effectiveness of sex education program in developing countries and low-middle income
countries have shown school-based sexuality education and curriculum-based sexuality education
interventions reduced the risks of sexual behaviors in adolescents (18–20). One of the systematic
review measures the outcome of the intervension within the short-term and long-term periods. Both
systematic reviews suggest that the positive effect of curriculum or school-based sexuality education
accompanied by adults or peers lasted longer to improve young adults sexual behavior (18). Another
study also has pointed out the long-term effect of school-based sexuality education programs on
adolescent effectively reduced unprotected sex and STD infection in early adulthood (17).
The Indonesian government has run some SRH education programs, namely Adolescent’s
Counselling and Informational Center(ACIC) or Pusat Informasi dan Konseling Remaja (PIK R) and
Adolescent Friendly Health Service (AFHS) or Pelayanan Kesehatan Peduli Remaja (PKPR). The
ACIC was a peer-led sexuality education by using apreventive and promotive approach to improve
adolescent reproductive health, while the AFHS also uses a curative, rehabilitative approach and
support by health professionals. Despite the limited evidence about both programs’ effectiveness on
reproductive knowledge and behavior at the national level, some studies in several cities in Indonesia
have figured outthe positive impact of sex education that the ACIC could give. A study about the
program evaluation of reproductive health negative behavior (pornography access) in Bekasi city has
shown a lower prevalence of negative behavior in students who utilized the ACIC programs than those
who did not (21). Another study in six cities in West Java province also has revealed that students who
participated in the ACIC program had a better attitude and knowledge about sexuality compared to
those who did not participate(22). Both studies have evaluated the impact of ACIC program on high
school students in a short-term period since the program become an extracurricular activity. The
studies only take into account measuring knowledge and attitude towards sexuality. However, the
long-term effects of SRH educational programs for adolescents has received little attention and is not
fully understood.
Therefore, this study measured the long-term effects of SRH education for adolescents on
young adults, especially college students. This group are mostly unmarried, educated but have greater
access to information media, which effects on their sexuality were questioned(23).Some studies in
Indonesia have documented the growth of sexualization of local and imported information media
increased liberal attitudes towards sex among Indonesian adolescents(24,25). In selecting the
population, this study was conducted in one of universities in Sukoharjo near Surakarta, the second-
largest city in Central Java. Previous studies about adolescent sexual behavior have been done in
several big cities in Indonesia, including Jakarta (Jakarta province) and Semarang (Central Java
province). Focusing in Sukoharjo near Surakarta gave new insights into college students' sexual
behavior in semi-urban areas.
Subjects and Methods
This cross-sectional study was conducted from January to April 2020. The population was
12,764 college students aged 20-24 at one of the universities in Sukoharjo Regency, near Surakarta,
Central Java, Indonesia. Of the population, 491 unmarried college students were willing to participate
Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2021.24134Arifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
in this study. They were chosen with a proportionate random sampling technique (proportional in
faculty level). The minimum sample size according to Lemeshow’s formula was 411 respondents.
Before the data collection, this study has obtained an ethical appoval from the Health Research
Ethics Committee, Faculty of Medicine, Muhammadiyah Surakarta University. Data were collected by
online questionnaires (Google Form). The link of the online questionnaire distributed through
WhatsApp to the intended respondents. A maximum of three WhatsApp messages was sent daily as a
reminder. The respondents were asked to fill consent form for their participation since this study asked
their personal information. One hundred ninety-three respondents refused to participate in the study.
Information collected from the questionnaires included sexual behavior, exposure to Sexual
Reproductive Health (SRH) education, parental support, pornography access on social media, and
sociodemographic characteristics. All questionnaires were self-designed, and its validity and reliability
had been tested with the value of 0.886.
Respondents were asked about exposure to SRH educational programs delivered by four
different sources, such as teachers through school subjects, SRH program provided by the ACIC,
health professional, or other parties (NGOs or researchers). The sexual behavior questionnaire
consisted of 10 questions asking whether or not respondents ever engaged in shared sexual activities,
such as Kissing, Necking, Petting, and Intercourse (KNPI), during college. The respondents who had
done KNPI would be categorized as having risky sexual behavior. Parental support was measured
from 11 questions about parents’ role for providing SRH information or discussion, acting as a
supervisor, source of advice, and controlling their children sexual behavior. The respondents would be
categorized as having parental support if the total parental support score was above the median score
of the total respondents (score 4).
Additionally, 13 questions measuring peer support involved peer as a source of sexual
information, peer perspective, peer behavior, and peer pressure on sexual behavior. The respondents
would be categorized as having peer support if the score was above the median score of the total
respondents (score 4). A multi logistic regression was used to model the risk of educational program
factors controlled by other variables of sexual behavior in a 95% Confidence Interval.
Results
Table 1 shows the respondents’ age, sex, residence, faculty, sexual activity, and exposure to
the Sexual Reproductive Health education program. The number of females were slightly higher than
males. The majority of the respondents was 21 years old and had studied at the faculty of education.
Most of them learned SRH issues from their teachers during high school. It can be noted that 3.7% of
the respondents who ever had sexual intercourse during college.
Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2021.24134Arifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
Table 1: Respondents’ Characteristics
Variable Frequency Percentage (%)
Sex
Male 209 42.6
Female 282 57.4
Age
20 108 22.0
21 213 43.4
22 146 29.7
23 22 4.5
24 2 0.4
Residence
Parents’House 222 45.2
Boarding House 241 49.1
Dormitory 9 1.8
Relative’s House 16 3.3
Others 3 0.6
Faculty
Health Science 52 10.6
Medicine 10 2.0
Dentistry 5 1.0
Education Science 142 28.9
Economy and Business 84 17.1
Law 23 4.7
Engineering 82 16.7
Geography 24 4.9
Psychology 19 3.9
Islam Religion 40 8.2
Communication and information 10 2.0
Exposure to SRH educational program for
adolescents
Learning SRH from teachers during a school lesson 404 82.3
Learning SRH from the ACIC 75 15.3
Learning SRH from health professionals 109 22.2
Learning SRH from other sources of information at 112 22.8
school
Sexual activity
Kissing 88 17.9
Necking 27 5.5
Petting 24 4.9
Intercourse 18 3.7
Table 2 explains the bivariable analysis of affecting factors on sexual behavior. Parental
support, peer support, pornography access, and gender significantly affected sexual behavior in
college students. Peer supporthad a higher OR value than other variables in predicting risky sexual
behavior, OR value 7.4 with 95% CI (3.6-15.1). Interestingly, there was no significant association
between four source SRH program and college students’ sexual behavior.
Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2021.24134Arifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
Table 2: Bivariable analysis of independent variables on college students’ sexual behavior in
Sukoharjo regency
Variables Sexual Behavior OR OR 95%CI
Risky Safe
N(%) N(%)
Learning SRH from a teacher during a
school lesson
Yes ref 76(18.8) 328(81.9) 1
No 2023) 67(77) 1.28 0.7-2.3
Learning SRH from the ACIC
Yes ref 10(13.3) 65(86.7) 1
No 86(20.7) 330(79.3) 1.69 0.8-3.4
Learning SRH from health professionals
Yes 25(22.9) 84(77.1) 1.3 0.7-2.2
No ref 71(18.6) 311(81.4) 1
Learning SRH from other sources
Yes 24(21.4) 88(78.6) 1.16 0.7-1.9
No ref 72(19) 307(81) 1
Parental support
Yes ref 20(10) 181(90.1) 1
No 76(26.2) 214(73.8) 3.2* 1.9-5.5
Peer support
Yes ref 9(5) 171 (95) 1
No 87(28) 224(72) 7.4* 3.6-15.1
Pornography Access
Yes 56(24.5) 173(75.6) 1.79* 1.1-2.8
Noref 40(15.2) 222(84.7) 1
Residence
Parents’ House ref 42(18.9) 180(81.1) 1 1
Relative House 4(25) 12(75) 1.42 0.4-4.6
Boarding House 47(19.5) 194(80.1) 1.03 0.7-1.6
Dormitory 2(22.2) 7(77.8) 1.22 0.2-6.1
Others 1(33.3) 2(66.7) 2.14 0.2-24.2
Sex
Male 64(30.6) 145(69.4) 3.4* 2.2-5.5
Female ref 32(11.4) 250(88.7) 1
Note: *p-valueArifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
Table 3: Multivariable model using a logistic regression analysis of factors affecting college
students’ sexual behavior
Variables OR(Adjusted) OR 95% CI
Learning SRH from ateacher during a school
lesson 1
Yes ref 0.6-2.1
No 1.12
Learning SRH from the ACIC
Yes ref 1
No 2a 0.9-4.3
Learning SRH from health professionals
Yes 1.39 0.7-2.5
No ref 1
Learning SRH from other sources
Yes 1.4 0.7-2.5
No ref 1
Parental Support
Yes ref 1
No 2.1b 1.2—3.7
Peer support
Yes ref 1
No 5.8c 2.6-12.6
Gender
Male 2.1c 1.3-3.6
ref
Female 1
Residence
Parents’ House 1.3 0.2-7.1
Relative House 1.8 0.2-13.8
Boarding House 1.5 0.2-8.2
Dormitory ref 1 1
Others 11.5 0.5-243
AIC:436,8; BIC: 487,2; Pseudo R2: 14,9%
Note: ap-valueArifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
Discussion
This study's main finding suggests that learning SRH from the ACIC may have meaningful
results to reduce the probability of risky sexual behavior amongcollege students despite its
insignificant result. Exposure to other SRH education programs either from teachers, health
professionals, or other sources did not relate to sexual behavior. In contrast, evidence supported that
having supportive peer was a vital predictors of college students’ sexual behavior. Besides, having
supportive parents could reducethe likelihood of engaging in risky sexual behavior, suggesting that
parents' bounding and parental education play an important role for college students' sexual health. In
terms of gender, males and females had different probabilities of risky sexual behavior. Males had a
higher risk of engaging in risky sexual behavior.
This study suggests that exposure to SRH educational programs may have long-term effects on
sexual behavior in early adulthood. A previous study about along-term effect of school-based sexuality
education at British University has found positive outcomes. Students exposed to a school-based
sexuality education in adolescence reported lower risky sexual activities and STDs in early
adulthood(17). Other systematic reviews also have the same evidence that sexuality education could
provide long-term effects. One study in Tanzania has found that knowledge remained significant after
three-year post-intervention, but lack sustained effect on behavior(20).
Regarding the unimplemented school-based sex education in Indonesia, this study evaluates
other efforts of the sexuality education program, for example SRH information provided by teacher,
school’s extra curricula activity namely ACIC, health professional or other party (NGO or researcher).
Among all of the four, the ACIC educational programs show the most promising effect on students'
sexual health. Even though it was not statistically significant, the 50% reduction in risky sexual
behavior was meaningful for those who learn SRH information from the ACIC. This means that the
ACIC, a peer-led sexuality education program, had a possible long-term effect on early adulthood’s
sexual and reproductive health. Even though the peer-led sex education was questioned to result in
an intended behavioral change and information sharing effectively, this intervention had the potential
in some situations (18,26). A systematic review of the sexuality education program in a developing
country suggests that some peer-led interventions positively impacted behavioral change. That
systematic review concludes that there was no single type of effective programs; most of the
interventions were useful in certain situations (18). A previous study about along-term effect of
sexuality education has shown that learning about sex from peers led to a reduction in STDs risks,
and this risk reduction also could be obtained by learning from a school-based sex education.
Emphasizing that learning from peer as essential as learning school-based sex education.(17). Most
of Indonesian schools do not provide a school-based sexuality education, and thus peer-sharing
programs may significantly benefit students.
Despite the benefits of learning SRH from the ACIC, this study had some limitations that can
influence how to interprete these results. The national-scale implementation of the ACIC program
results in a non-uniformity of the program quality at every school (21,22). This study did not ask the
respondents about SRH topics they learned, who taught them, the frequency and duration of the
program session, and kind of activities provided by the ACIC in details. Hence, the respondents might
Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2021.24134Arifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
learn various topics in different frequency and duration. These considerations may contribute to the
insignificant results of the ACIC program's effect on sexual health. Given the limitations, a future study
needs to add some improvements, especially in controlling variation of education program
implementation by the ACIC.
Other distinguished results of this study have proven that peer was vitally influential on college
students' sexual behavior. Peer perspective, peer sexual behavior, and peer pressure affected one's
sexual behavior, especially in adolescents whose peer norms were still important to their behavior
(27). Some previous studies suggest the same results. A previous study in a rural area has pointed
out significantly stronger peer influence on adolescents to engage in sexual behavior (14). Another
systematic review of longitudinal and experimental studies about risk factors of HIV-related sexual
behavior proves that peer norms influenced one's sexual behavior (10). Furthermore, peer close
relationship, defined as feelings of connectedness and support by friends, also influenced adolescent
sexual reproductive health outcomes. A systematic review has revealed peer close relationship could
be either supportive or not for sexual and reproductive health outcomes. Two studies in African
American females have found the more someone spent time with friends, the better the peer relation.
As a result, they were more likely to initiate sex intercourse before mature age (risk association). This
means that peer support would be the key for individuals to engage in sexual-risk behavior (13).
Interestingly, this study has revealed about 10.1% of the respondents experienced peer pressure to
watch a pornography video and engage in prostitution. To counter this persuasion, adolescents need
to have self-determination. Another systematic review has summarized that self-determination was a
protective factor of SRH outcome (12). Furthermore, there were an intervention that effectively
improved self-determination was namely Positive Youth Development. This intervention program
included youth training through competence-building curriculum, including cognitive, social,
behavioral, emotionional and moral aspects (12,28). The same competence-building training could be
conducted in college extracurricular activities or during the orientation to help youth achieve social
competence to reduce the likelihood of sexual activity during college.
Another important finding of this present study is parental support where parents act as a
source of SRH information and discussion, supervisor, advisor, and control, reduce the likelihood of
engaging in risky sexual behavior. This evidence suggests that parental bounding and parental
education are vital for college students' sexual health as well(17). Other previous studies also support
this finding (10,14,17,29,30). A systematic review of parental bounding factor to Adolescent Sexual
and Reproductive Health outcome has suggested that parental bounding and parental monitoring
could protect adolescent sexual health (13). Other systematic reviews state that enhanced parents-
child communication was related to increased sexual abstinence, decreased sexual initiation and
frequency of intercourse, and condom usage in adolescents (29). Besides, parents find barriers to
communicate about sexual health with their children since they lackknowlwedge about sexual health
andconsider this topic taboo(29). Many interventions to increase parents' self-efficacy in
communicating with their children have been done in many countries and been proven to positively
enhance parent-child communication (29). Further research that designs a similar intervention is
required by considering Indonesian culture and social norms.
Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2021.24134Arifah et al (2021): Long-term effect of SRH education Jan 2021 Vol. 24 Issue 01
Moreover, gender also contributed to the risk of risky sexualbehavior. Males had a higher risk of
sexual behavior than females. Previous studies support this finding as well (1,31,32). The sexual script
theory asserts the acceptability of sexual behavior can differ based on times, place, and certain
conditions that create social condition in which sexual expression is more acceptable. According to
this theory, males are more acceptable to engage in risky sexual behavior than females. A study in the
US has proven that risky sexual behavior among males was more acceptable by their peers than girls
(33). Another factor that may contribute to this difference is sexual communication between parents
and children. Sexual communication is commonly available by mothers’ guidance. Hence, the
protective effect of such communication on sexual behavior is more noticeable for girls than boys (30).
Besides, a study on the communication model between boys in Indonesia has discovered that boys
did not communicate about health, particularly sexual health issues. They chose to look at information
online rather than discuss it with their peers (34). A special approach is necessary to educate boys
using means of communication to respond to this finding.
All in all, this study samples were representatives of college students' population at a semi-
urban university where most of the community was Islam and the proportion of female students was
slightly larger as the general proportion of Indonesian college students. Regarding the use of an online
survey about taboo personal life experience, there was a high probability of under-reported sexual
behavior. Moreover, this limitation should be examined further in future research.
Overall, learning about SRH from the Adolescent’s Counselling and Informational Center during
high school could reduce risky sexual behavior in college students. Other factors that influenced
college students' sexual behavior involved peer support, parental support, and gender. Further
research is required to confirm the long-term effect of SRH education on adolescent reproductive
health in the next developmental stage.
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