The Open Public Health Journal




ISSN: 1874-9445 ― Volume 13, 2020
RESEARCH ARTICLE

The Correlation between Perceived Peer Norms in Attitude and Self-Efficacy Premarital Sexual Behavior



Katayon Vakilian1, *Afsaneh Keramat2
1 Reproductive Health, Medical School, University of Medical Sciences, Arak, Iran
2 Reproductive Health Nursing Midwifery School, Shahroud University of Medical Sciences, Shahroud, Iran

Abstract

Background and Aims:

Adolescence is a period of life in which high-risk behaviors, including sexual behaviors, put the adolescents at risk for sexually transmitted diseases, including AIDS. This research aimed at studying the relationship between peers' perception of sexual behavior and adolescents' attitudes and self-efficacy.

Materials and Methods:

This cross-sectional study used a multi-stage method to examine 1500 subjects in the universities of Shahroud, Iran. The questionnaires were consisted of sexual abstinence attitude, abstinence self-efficacy and peer subjective norms. To ensure the confidentiality of information, the questionnaire was distributed among 1500 students in six universities anonymously, and students҆ field of study was not mentioned. The collected data was analyzed with descriptive (Mean, Percent) and inferential tests (independent t-test, chi2, and Spearman test) using SPSS 18 software.

Results:

The mean age of the females was 20.26±1.49, and that of males was 20.32±1.575. 59.3% of male students and 86.8% of female students had poor sexual abstinence to sex before marriage. Moreover, the sexual abstinence self-efficacy of 29% of male students and 13.1% of female students, regarding the sexual abstinence before marriage, was strong. Findings showed that the more one believes in his/her abilities in sexual abstinence, the more they believe that their friends will not be involved in sex

Conclusion:

It is required to provide the opportunities to learn and correct the socio-emotional skills required for physical and sexual health in relationships through social interactions with peers. In this context, the reproductive health programs need to be prioritized in the youth health programs and schools

Keywords: Public health, Reproductive health, Self-Efficiency, Sexual health, Peer subjective norms, Sexual abstinence.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 13
First Page: 555
Last Page: 558
Publisher Id: TOPHJ-13-555
DOI: 10.2174/1874944502013010555

Article History:

Received Date: 30/5/2020
Revision Received Date: 26/8/2020
Acceptance Date: 05/9/2020
Electronic publication date: 26/10/2020
Collection year: 2020

© 2020 Vakilian & Keramat.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Reproductive Health, Medical School, Sardasht rejoin, Basij square, Arak University of Medical Sciences Arak, Iran; Tel:098-86-34173505; dr.kvakilian@arakmu.ac.it





1. INTRODUCTION

Adolescence is a period of life in which high-risk behaviors, including sexual behaviors, put the adolescents at risk for sexually transmitted diseases, including AIDS [1Vakilian K, Mousavi SA, Keramat A. Estimation of sexual behavior in the 18-to-24-years-old Iranian youth based on a crosswise model study. BMC Res Notes 2014; 7: 28.
[http://dx.doi.org/10.1186/1756-0500-7-28] [PMID: 24410965]
, 2Mousavi A, Keramat A, Vakilian K, Esmaeili Vardanjani SA. Development and adaptation of Iranian youth reproductive health questionnaire. ISRN obstetrics and gynecology 2013; 2013
[http://dx.doi.org/10.1155/2013/950278]
]. It is estimated that 55% of male and female adolescents have sex by the age of 18; 42% of female adolescents at the age range of 15-19 years old, and 44% of male adolescents [3WHO. Countries [Internet] 2017.cited 16 April 2017 http://who.int/ countries/irn/en/, 4Sexual Activity and Contraceptive Use Among Teenagers in the United States: 2011-2015 is available athttps://www.cdc. gov/nchs/data/nhsr/nhsr104]. Various factors such as low knowledge about sexually transmitted diseases and reproductive health, passing a long time from the age of puberty to marriage, peer pressure, lack of life skill training, transition from traditional to modern society, access to new technologies put adolescents at risk of high-risk sexual behavior [5Keramat A, Vakilian K, Mousavi S. Barriers to youths’ use of reproductive health services in Iran. Life Sci J 2013; 10: 943-9., 6Mousavi SA, Keramat A, Vakilian K, Chaman R. Interpretation of opposite-sex friendship based on social ecology model in Iranian females. Iran J Psychiatry Behav Sci 2012; 6(2): 69-78.
[PMID: 24644485]
]. A study conducted in Iran on youth reproductive health indicators showed that young people had low knowledge about HIV, and only 26% of males and 19% of females had heard of sexually transmitted diseases [7Vakilian K, Keramat A, Seyyed Abbas M. The necessity of developing AIDS and reproductive health indicators for Iranian adolescents in the national health system; The evaluation of indicators among 18-24 year old university students of shahroud, Iran: A cross-sectional study. Open Public Health J 2018; 11.
[http://dx.doi.org/10.2174/1874944501811010339]
]. In addition, the studies in Iran indicated that 19.8-41% of the young people in the age range of 18-24 years old had sex for at least once before marriage [1Vakilian K, Mousavi SA, Keramat A. Estimation of sexual behavior in the 18-to-24-years-old Iranian youth based on a crosswise model study. BMC Res Notes 2014; 7: 28.
[http://dx.doi.org/10.1186/1756-0500-7-28] [PMID: 24410965]
, 8Shokoohi M, Karamouzian M, Mirzazadeh A, et al. HIV knowledge, attitudes, and practices of young people in Iran: findings of a National Population-Based Survey in 2013. PLoS One 2016; 11(9)e0161849
[http://dx.doi.org/10.1371/journal.pone.0161849] [PMID: 27626638]
]. The use of condoms at this age range among the females and males was 16 and 27%, respectively [9Vakilian K, Abbas Mousavi S, Keramat A, Chaman R. Knowledge, attitude, self-efficacy and estimation of frequency of condom use among Iranian students based on a crosswise model. Int J Adolesc Med Health 2016; 30(1): 30.
[http://dx.doi.org/10.1515/ijamh-2016-0010] [PMID: 27176740]
]. Lack of sexual training puts adolescents at risk for sexually transmitted diseases, HIV, unwanted pregnancies, unsafe and illegal abortions [10Jonas K, Crutzen R, van den Borne B, Reddy P. Healthcare workers’ behaviors and personal determinants associated with providing adequate sexual and reproductive healthcare services in sub-Saharan Africa: a systematic review. BMC Pregnancy Childbirth 2017; 17(1): 86.
[http://dx.doi.org/10.1186/s12884-017-1268-x] [PMID: 28288565]
]. The 2015- 2020 Adolescents Health Strategy emphasized the improvement of health literacy from childhood to adolescence as a strategic target to improve the conscious decision-making development in the developing countries. This strategy is in line with the effects of social norms of peers, family, and school, which “may put the adolescents at risk or protect them” [11Tekliuk RV, Serheta IV, Serebrennikova OA. Healh-related behaviour in adolescents who have received basic instruction in health promotion 2019.]. The model of human ecology shows that the microsystems of friends and family play a key role in directing adolescents towards the high risk behaviors including sexual behaviors. Furthermore, according to the theory of social norms, peers have an effective role in the involvement of adolescents in high-risk behaviors. This effect is rooted in adolescents' beliefs about norms that are common among peers. Such norms may influence the way adolescents dress and behave, as well as their use of media [12Sasson H, Mesch G. Parental mediation, peer norms and risky online behavior among adolescents. Comput Human Behav 2014; 33: 32-8.
[http://dx.doi.org/10.1016/j.chb.2013.12.025]
]. This study aimed at studying the relationship between peers' perception of sexual behavior and adolescents' attitudes and self-efficacy.

2. METHODOLOGY

This study was analytical cross-sectional research. It was conducted on 1500 students in the age range of 17-24 years old in the universities of Shahrud city between 2010 and 2011 in Iran. Multi-stage sampling was done. The categories in this study were the universities under investigation, and the classrooms were considered as clusters, which ranged between 400 and 9000 as proportionate with the number of students in the universities. The samples were randomly selected from the list of classrooms provided by the Education departments of the universities. Under the arrangements previously made by the professors, the subjects completed the questionnaires within the last 15 minutes of classroom sessions. The items of the questionnaires were associated with the items of demographic information, and three questionnaires of sexual abstinence attitude, sexual abstinence self-efficacy, and perceived norm of friends on sex were used.

Introducing the researcher to the students, the objectives and necessity of conducting the study were explained, and the students were asked to participate voluntarily in the project. They were also ensured that the information would be confidential.

Study tools including; Sexual abstinence attitude: 8 items scoring in a 5-option Likert scale with maximum 40 scores were included in the study and were divided in “poor, medium, and good” attitudes. Regarding the sexual abstinence self-efficacy, there were 8 items scoring in a 5-option Likert scale with maximum 40 scores, which were divided into “poor, medium, and good” self-efficacy [13Kaljee LM, Green M, Riel R, et al. Sexual stigma, sexual behaviors, and abstinence among Vietnamese adolescents: implications for risk and protective behaviors for HIV, sexually transmitted infections, and unwanted pregnancy. J Assoc Nurses AIDS Care 2007; 18(2): 48-59.
[http://dx.doi.org/10.1016/j.jana.2007.01.003] [PMID: 17403496]
]. Regarding the perceived norm of friends on sex, the disease control center questionnaire [14Pophan J, Hall E, Tonk D, et al. Assesment instrument for measuring student outcomes (Grade 7-12) 1999.] was used. The items were localized after translation and back translation, in accordance with the localization of the World Health Organization [15Asking young people about sexual and reproductive behaviours:Illustrative Core Instrumohnents: Hearing before the UNDP,UNFPF,WHO,WORLD BANK 2001.]. Before implementing the questionnaire in the pretest stage, the items were pretested on 10 female and 10 male students for mutual understanding and understanding of the words. In the next stage, a retest was used to evaluate the reliability of the items. Pearson correlation coefficients obtained for sexual abstinence attitude and sexual abstinence self-efficacy were 0.6 and 0.65, respectively. Cronbach's alpha was used to evaluate the internal validity. The results of Cronbach's alpha for the sexual abstinence attitude was 0.87 and for the sexual abstinence self-efficacy as 0.81. After collecting the data, they were analyzed using SPSS 20, Chi square test and Spearman.

3. RESULTS

The mean age of the females was 20.26±1.49, and that of males was 20.32±1.575. 919 participants (62.1%) were female, and 535 of them (36.1%) were male. 120 subjects (8.5%) lived in the village and 1300 subjects (87.8%) lived in the city, and 61 subjects (4.1%) did not answer.

The results of Table 2 show that 59.3% of male students and 86.8% of female students had poor sexual abstinence to sex before marriage. Moreover, the sexual abstinence self-efficacy of 29% of male students and 13.1% of female students, regarding the sexual abstinence before marriage, was strong (Table 1). Subjective peer norms showed that 21 (4.1%) boys and 231 (25.5%) thought that all peers have sex before marriage (Table 2). The results indicated that there was a weak but significant relationship between sexual abstinence belief and peer subjective norm to sex. That is, the stronger the belief in sexual abstinence is, the stronger the belief is that more of the friends will not have sex. Moreover, the more one believes in his/her abilities in sexual abstinence, the more they believe that more friends will not be involved in sex (Table 3).

Table 1
The frequency of abstinence attitude and abstinence self-efficacy in boys and girl's student.


Table 2
The frequency peer subjective norms in boys and girl's student.


Table 3
The correlation between abstinence attitude and abstinence self-efficacy with peer subjective norms.


4. DISCUSSION

The results of the study on attitudes towards sex before marriage showed that the attitude of sexual abstinence before marriage was poor in both male and female students, and the female students may have the tendency to have sex in particular. This issue in a qualitative study on adolescents showed that they believed that premarital friendships are growing among the youth, and if they do not enter into friendship, they will be excluded from their community. Further, they also like to know more about the characteristics of the opposite sex before marriage [6Mousavi SA, Keramat A, Vakilian K, Chaman R. Interpretation of opposite-sex friendship based on social ecology model in Iranian females. Iran J Psychiatry Behav Sci 2012; 6(2): 69-78.
[PMID: 24644485]
]. This issue reflects the role of peer pressure in this regard [16Envuladu EA, de Kwaak A, Zwanikken P, Zoakah AI. Exploring the factors influencing adolescent sexual behavior in plateau state Nigeria. Afr J Med Med Sci 2017; 7: 1-6.]. The present study showed that the stronger the young people's sexual abstinence attitude is, the more they believe that more friends will not be involved in sex. In addition, the more one believes in his/her abilities in sexual abstinence, the more they believe that more friends will not be involved in sex. The adolescents who believe in a limited sexual relationship in their friends, they are less likely to be involved in such relationships [17Simoni JM, Franks JC, Lehavot K, Yard SS. Peer interventions to promote health: conceptual considerations. Am J Orthopsychiatry 2011; 81(3): 351-9.
[http://dx.doi.org/10.1111/j.1939-0025.2011.01103.x] [PMID: 21729015]
]. The studies of America indicated that for the adolescents, the friends' behaviors are more effective than their personal behavior to be involved in high-risk behaviors [18Borsari B, Carey KB. Peer influences on college drinking: a review of the research. J Subst Abuse 2001; 13(4): 391-424.
[http://dx.doi.org/10.1016/S0899-3289(01)00098-0] [PMID: 11775073]
, 19Glick P, Khammash U, Shaheen M, et al. Perceived peer norms, health risk behaviors, and clustering of risk behaviors among Palestinian youth. PLoS One 2018; 13(6)e0198435
[http://dx.doi.org/10.1371/journal.pone.0198435] [PMID: 29927957]
]. The relationship between one's behavior and friends' perceived behavior showed that what adolescents thought about their friends affected their real behavior, which may lead them to have sex [19Glick P, Khammash U, Shaheen M, et al. Perceived peer norms, health risk behaviors, and clustering of risk behaviors among Palestinian youth. PLoS One 2018; 13(6)e0198435
[http://dx.doi.org/10.1371/journal.pone.0198435] [PMID: 29927957]
]. Baumgartner et al. (2010) showed that adolescents expected that their friends who were involved in high risk online sexual behaviors were more likely to engage in such activities [20Baumgartner SE, Valkenburg PM, Peter J. Assessing causality in the relationship between adolescents’ risky sexual online behavior and their perceptions of this behavior. J Youth Adolesc 2010; 39(10): 1226-39.
[http://dx.doi.org/10.1007/s10964-010-9512-y] [PMID: 20177962]
]. Other studies on alcohol consumption also showed that adolescents with alcoholic friends were more likely to be at risk for alcohol consumption [21Huang GC, Unger JB, Soto D, et al. Peer influences: the impact of online and offline friendship networks on adolescent smoking and alcohol use. J Adolesc Health 2014; 54(5): 508-14.
[http://dx.doi.org/10.1016/j.jadohealth.2013.07.001] [PMID: 24012065]
, 22Wang C, Hipp JR, Butts CT, Jose R, Lakon CM. Alcohol use among adolescent youth: the role of friendship networks and family factors in multiple school studies. PLoS One 2015; 10(3)e0119965
[http://dx.doi.org/10.1371/journal.pone.0119965] [PMID: 25756364]
].

CONCLUSION

Adolescence is a period of life during which social relationships outside the family are expanded. Therefore, society, including schools, are expected to provide opportunities for adolescents to acquire effective communication skills and sexual health. Nevertheless, policymakers should also make efforts to make laws and remove sexual taboos in society.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was approved by the Ethical Committee of Shahroud University of Medical Sciences, Iran (code : 890/08).

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Written informed was obtained from each participant prior to the study.

AVAILABILITY OF DATA AND MATERIALS

The datasets generated and/or analyzed during the current study are not publicly available due to the moral rules of Arak university of medical sciences but are available from the corresponding author [K.V] on a reasonable request.

FUNDING

This research was funded by Shahroud University of Medical Sciences under financial code of 9664.

CONFLICT OF INTEREST

There is no conflict interest between the authors.

ACKNOWLEDGEMENTS

This study was extracted from a Ph. D thesis performed at Shahroud University of Medical Sciences, Shahroud, Iran. Hereby, we extend our gratitude to the Research Deputy of the university and all the participants for their cooperation with this study.

REFERENCES

[1] Vakilian K, Mousavi SA, Keramat A. Estimation of sexual behavior in the 18-to-24-years-old Iranian youth based on a crosswise model study. BMC Res Notes 2014; 7: 28.
[http://dx.doi.org/10.1186/1756-0500-7-28] [PMID: 24410965]
[2] Mousavi A, Keramat A, Vakilian K, Esmaeili Vardanjani SA. Development and adaptation of Iranian youth reproductive health questionnaire. ISRN obstetrics and gynecology 2013; 2013
[http://dx.doi.org/10.1155/2013/950278]
[3] WHO. Countries [Internet] 2017.cited 16 April 2017 http://who.int/ countries/irn/en/
[4] Sexual Activity and Contraceptive Use Among Teenagers in the United States: 2011-2015 is available athttps://www.cdc. gov/nchs/data/nhsr/nhsr104
[5] Keramat A, Vakilian K, Mousavi S. Barriers to youths’ use of reproductive health services in Iran. Life Sci J 2013; 10: 943-9.
[6] Mousavi SA, Keramat A, Vakilian K, Chaman R. Interpretation of opposite-sex friendship based on social ecology model in Iranian females. Iran J Psychiatry Behav Sci 2012; 6(2): 69-78.
[PMID: 24644485]
[7] Vakilian K, Keramat A, Seyyed Abbas M. The necessity of developing AIDS and reproductive health indicators for Iranian adolescents in the national health system; The evaluation of indicators among 18-24 year old university students of shahroud, Iran: A cross-sectional study. Open Public Health J 2018; 11.
[http://dx.doi.org/10.2174/1874944501811010339]
[8] Shokoohi M, Karamouzian M, Mirzazadeh A, et al. HIV knowledge, attitudes, and practices of young people in Iran: findings of a National Population-Based Survey in 2013. PLoS One 2016; 11(9)e0161849
[http://dx.doi.org/10.1371/journal.pone.0161849] [PMID: 27626638]
[9] Vakilian K, Abbas Mousavi S, Keramat A, Chaman R. Knowledge, attitude, self-efficacy and estimation of frequency of condom use among Iranian students based on a crosswise model. Int J Adolesc Med Health 2016; 30(1): 30.
[http://dx.doi.org/10.1515/ijamh-2016-0010] [PMID: 27176740]
[10] Jonas K, Crutzen R, van den Borne B, Reddy P. Healthcare workers’ behaviors and personal determinants associated with providing adequate sexual and reproductive healthcare services in sub-Saharan Africa: a systematic review. BMC Pregnancy Childbirth 2017; 17(1): 86.
[http://dx.doi.org/10.1186/s12884-017-1268-x] [PMID: 28288565]
[11] Tekliuk RV, Serheta IV, Serebrennikova OA. Healh-related behaviour in adolescents who have received basic instruction in health promotion 2019.
[12] Sasson H, Mesch G. Parental mediation, peer norms and risky online behavior among adolescents. Comput Human Behav 2014; 33: 32-8.
[http://dx.doi.org/10.1016/j.chb.2013.12.025]
[13] Kaljee LM, Green M, Riel R, et al. Sexual stigma, sexual behaviors, and abstinence among Vietnamese adolescents: implications for risk and protective behaviors for HIV, sexually transmitted infections, and unwanted pregnancy. J Assoc Nurses AIDS Care 2007; 18(2): 48-59.
[http://dx.doi.org/10.1016/j.jana.2007.01.003] [PMID: 17403496]
[14] Pophan J, Hall E, Tonk D, et al. Assesment instrument for measuring student outcomes (Grade 7-12) 1999.
[15] Asking young people about sexual and reproductive behaviours:Illustrative Core Instrumohnents: Hearing before the UNDP,UNFPF,WHO,WORLD BANK 2001.
[16] Envuladu EA, de Kwaak A, Zwanikken P, Zoakah AI. Exploring the factors influencing adolescent sexual behavior in plateau state Nigeria. Afr J Med Med Sci 2017; 7: 1-6.
[17] Simoni JM, Franks JC, Lehavot K, Yard SS. Peer interventions to promote health: conceptual considerations. Am J Orthopsychiatry 2011; 81(3): 351-9.
[http://dx.doi.org/10.1111/j.1939-0025.2011.01103.x] [PMID: 21729015]
[18] Borsari B, Carey KB. Peer influences on college drinking: a review of the research. J Subst Abuse 2001; 13(4): 391-424.
[http://dx.doi.org/10.1016/S0899-3289(01)00098-0] [PMID: 11775073]
[19] Glick P, Khammash U, Shaheen M, et al. Perceived peer norms, health risk behaviors, and clustering of risk behaviors among Palestinian youth. PLoS One 2018; 13(6)e0198435
[http://dx.doi.org/10.1371/journal.pone.0198435] [PMID: 29927957]
[20] Baumgartner SE, Valkenburg PM, Peter J. Assessing causality in the relationship between adolescents’ risky sexual online behavior and their perceptions of this behavior. J Youth Adolesc 2010; 39(10): 1226-39.
[http://dx.doi.org/10.1007/s10964-010-9512-y] [PMID: 20177962]
[21] Huang GC, Unger JB, Soto D, et al. Peer influences: the impact of online and offline friendship networks on adolescent smoking and alcohol use. J Adolesc Health 2014; 54(5): 508-14.
[http://dx.doi.org/10.1016/j.jadohealth.2013.07.001] [PMID: 24012065]
[22] Wang C, Hipp JR, Butts CT, Jose R, Lakon CM. Alcohol use among adolescent youth: the role of friendship networks and family factors in multiple school studies. PLoS One 2015; 10(3)e0119965
[http://dx.doi.org/10.1371/journal.pone.0119965] [PMID: 25756364]
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