LITERATURE REVIEW
Definition of safe sex and STIs
Safe sex involves engaging in sexual activities while ensuring protection against sexually transmitted infections (STIs), including chlamydia, gonorrhea, syphilis, mycoplasma genitalium, HIV, and hepatitis B, as well as preventing unplanned pregnancies Practicing safe sex is crucial to safeguard both you and your partner from health risks associated with unsafe sexual practices.
Safe sex, as defined by the UNFPA, encompasses sexual and reproductive health, which is characterized by complete physical, mental, and social well-being in relation to the reproductive system This concept highlights the importance of individuals being able to engage in a satisfying and safe sexual life.
Sexually transmitted infections (STIs) are contagious diseases that can be transmitted through various forms of sexual contact, including skin-to-skin touching, oral, vaginal, and anal sex Anyone can contract an STI, and many individuals may be unaware they are infected If left untreated, STIs can lead to severe health complications, including infertility, and can be passed on to sexual partners The only definitive way to determine if you have an STI is through testing (Leeds, 2018).
Sexually transmitted diseases (STDs) are infections spread through sexual contact, caused by microorganisms that thrive on the skin or mucous membranes of the genital region The warm, moist environment of these areas facilitates the growth of bacteria, viruses, and yeasts, leading to the transmission of various diseases Common STDs include HIV/AIDS, chlamydia, genital herpes, genital warts, gonorrhea, syphilis, and certain types of hepatitis.
STDs are also known as a morbus venereus or venereal disease (William C Shiel
STDs and STIs refer to the same health issues, but the terminology differs among healthcare professionals The term "infections" is often preferred because "diseases" can imply a visible problem, whereas many STDs may not present any noticeable signs or symptoms.
Sexually transmitted diseases (STDs) are infections that are transmitted through sexual contact Many public health experts advocate for the term "sexually transmitted infections" (STIs) to better reflect the current understanding of these conditions (American Sexual Health Association, 2016).
Sexually transmitted diseases (STDs) are infections caused by various bacteria, viruses, and even small insects They can be transmitted through sexual contact with an infected individual, including sexual intercourse or through oral, manual, or genital contact with the infected areas or sores.
Safe sex knowledge encompasses understanding sexual health, including reproductive health care, partner choice, and family planning decisions (Department of Health and Health Services, 2018) It is crucial, especially for young individuals, as inadequate guidance can lead to negative behaviors Various factors influence safe sex knowledge, such as gender, parental guidance, community awareness, educational environments, economic issues, and cultural beliefs Misinformation about sexual health can result in significant health risks and social challenges, including STDs like HIV, unintended pregnancies, unsafe abortions, and increased maternal morbidity and mortality (Hendrana et al., 2015).
Understanding sexually transmitted infections (STIs) involves recognizing their types, transmission methods, symptoms, and potential consequences It is essential to learn effective protection strategies to reduce the risk of STIs, as outlined by the Department of Health and Human Services (2018).
Socio-demographic information and health behaviors can be effectively assessed using multiple-choice questions, which may include an 'other' option for respondents to provide additional details This allows for the specification of key demographic factors such as age, gender, and ethnicity (Vongxay, 2017a).
According to the World Health Organization (2006), sexual health knowledge includes information about sexuality, reproduction, family planning, specific sexual health services, autonomous partner choice, and sexual health issues This understanding can be assessed through three statements that participants can evaluate.
‘true’, ‘false’ or ‘don’t know’ The number of correct answers can be the outcome measure (Femke Albers, 2017)
The concept of measurement for knowledge of safe sex
Safe sex emphasizes the importance of individuals having access to accurate information and a variety of contraception methods that are safe, effective, affordable, and acceptable It is crucial for people to be informed and empowered to safeguard themselves against sexually transmitted infections (STIs) Additionally, when women choose to become mothers, they should have access to services that support a healthy pregnancy, safe delivery, and the well-being of their newborns (UNFPA).
Sexuality is a fundamental aspect of human life, encompassing physical, psychological, spiritual, social, economic, political, and cultural dimensions Providing age-appropriate, culturally relevant, and scientifically accurate sexual education is essential for young people This education plays a crucial role in HIV prevention and is vital for achieving universal access to reproductive health services By implementing comprehensive sexual education programs, we can significantly reduce the risks of HIV, other sexually transmitted infections (STIs), and unintended pregnancies.
Birth control methods are non-infectious and cannot be transmitted between individuals, as they do not involve viruses, bacteria, or pathogens Choosing the most suitable contraceptive method is essential for preventing unplanned pregnancies Notably, condoms are unique as they effectively prevent both pregnancy and sexually transmitted infections (STIs), whether used alone or alongside other contraceptive methods.
To develop the questionnaire based on 4 previous studies as detailed below
1 Based on a study by Petrick, the tool consists of 15 questions and mentions the student’s actual knowledge of sexual health and safe sex knowledge topics, in particular three questions are asked about knowledge of safe sex It asked questions about how a woman can get pregnant, types of birth control, and sexually transmitted diseases Almost all of the questions on the survey were multiple choices This study was approved by the Institutional Review Board (IRB) at the University of Colorado, Boulder; the Health Outreach for Latin America Foundation; and the Medical General of Chacraseca which is appointed by Nicaragua’s Ministry of Health (MINSA) (Petrick, 2016)
The consequences of unsafe sex and STIs
Epidemiologic surveillance data showed that adolescents under the age of 20 years have higher rates of unintended pregnancies and STIs and HIV/AIDs (Hamilton, Martin, & Ventura, 2009)
Every year, approximately 15 million girls are married before turning 18, with 90% of births to girls aged 15 to 19 occurring within marriage (WHO, 2019a) In developing countries, around 20,000 girls under 18 give birth daily, totaling 7.3 million births annually, although the actual number of adolescent pregnancies is significantly higher (UNFPA, 2017a).
Adolescent pregnancy leads to significant life changes for girls, often resulting in the end of their education and reduced job opportunities This situation increases their vulnerability to poverty and social exclusion, while also negatively impacting their health Complications from pregnancy and childbirth are the leading cause of death among adolescent girls, highlighting the severe risks associated with early motherhood Furthermore, adolescent pregnancy contributes to maternal and child mortality, perpetuating cycles of ill-health and poverty across generations.
Sexually transmitted infections (STIs) are a significant global health issue, contributing to acute illness, infertility, long-term disability, and death, with profound medical and psychological effects on millions of individuals, including men, women, and infants The concern is particularly acute among adolescents, as they represent the demographic with the highest rates of STIs, with up to 60% of new infections occurring in individuals aged 15 to 24 Additionally, this age group accounts for half of all people living with HIV worldwide, highlighting the urgent need for targeted health interventions.
Sexually transmitted infections (STIs) pose a significant public health challenge for both men and women The prevalence of STIs is increasing in both developed and developing nations, driven by various economic, sociological, and demographic factors.
Sexually transmitted infections (STIs) pose significant health risks beyond their immediate effects, primarily spreading through sexual contact, including vaginal, anal, and oral sex Some STIs, such as chlamydia, gonorrhoea, hepatitis B, HIV, and syphilis, can also be transmitted through non-sexual means like blood Additionally, these infections can be passed from mother to child during pregnancy and childbirth, leading to severe outcomes such as stillbirth, neonatal death, and congenital deformities STIs like herpes and syphilis can increase the risk of HIV acquisition by three-fold or more The human papilloma virus (HPV) is linked to cervical cancer, while gonorrhoea and chlamydia are major contributors to pelvic inflammatory disease (PID) and infertility in women The rising rates of STIs and HIV among adolescents pose a critical challenge to their health and well-being.
Sources of knowledge about safe sex and STIs
Sexual education in school curricula plays a crucial role in preventing STIs and promoting safe sex practices among students By integrating human development and sexual health into health courses, students gain essential knowledge to make informed choices in their lives (Global News, 2017) Research indicates that sex education is vital for children and adolescents, as it helps prevent unwanted pregnancies, coercive sexual activity, and STIs, including HIV/AIDS (Ramiro & Matos, 2008; UNESCO, 2009b) Parents recognize sexual education as fundamental in addressing various health and social issues, such as HIV/AIDS, unwanted pregnancies, and sexual abuse (Fentahun et al., 2012) Comprehensive sex education encompasses topics like human anatomy, reproductive health, emotional relationships, and methods of contraception, equipping young people with the necessary tools to practice safe sex and protect themselves from STIs (Fentahun et al., 2012; McManus & Dhar).
To reduce the sexual reproductive health (SRH) problems in Laos, the Ministry of Education and Sports introduced the life skills curriculum into high schools in
In 2003, key modules on HIV, AIDS, STIs, and reproductive health were integrated into core subjects like natural science and biology (Sychareun, 2017; UNICEF, 2011) This comprehensive and age-appropriate sex education empowers young people to explore their emotions, feelings, and personal values effectively.
School-based sex education plays a crucial role in preventing unwanted pregnancies and promoting positive sexual health by providing students with essential knowledge about sexually transmitted infections (STIs) and reproductive biology (Acharya et al., 2016).
The education system in the Lao PDR faces significant challenges, especially in rural areas, where girls are more likely to drop out of school than boys According to the 2015 Population and Housing Census, 91,662 girls aged 6-16 have left school, often due to early marriage and childbearing This situation places adolescents at a higher risk of sexually transmitted infections and HIV/AIDS, as highlighted by UNFPA (2017b) Additionally, Lao adolescents struggle to make informed and responsible decisions regarding their sexual health and behavior (Vongxay, 2018).
Despite receiving education in schools, adolescents often pursue more comprehensive information about sexual health Various social and cultural influences, including the roles of parents, peers, and the school environment, significantly impact their sexual knowledge.
In 2013, it was found that adolescents often acquire knowledge about safe sex from various sources, including television, the Internet, healthcare providers, and peers Over 80% of individuals aged 15 to 19 reported receiving formal sexual health education regarding birth control and STIs/HIV Additionally, children and adolescents are exposed to messages about sexual health multiple times a week from diverse channels such as media, schools, and family, although the quality of this information can differ significantly Research indicates that sexuality education interventions are effective in preventing or reducing the risks of adolescent pregnancy, HIV, and STIs, benefiting both those with and without chronic health conditions and disabilities.
Situation for knowledge about safe sex among adolescents
Knowledge of safe sex is very important for adolescents because it helps them to avoid unwanted pregnancies, STIs infections and HIV/AIDS (Dummies,
Unsafe sex is a significant health risk, ranking second among the top ten contributors to disease burden, primarily due to HIV/AIDS, which has claimed over 32 million lives since the 1980s (WHO, 2018c; UNAIDS, 2019) Each year, nearly one million teenage girls face unintended pregnancies, highlighting the urgent need for comprehensive sexual education Understanding safe sex practices is crucial for adolescents to prevent complications and make informed decisions about sexual activity (Shaw, 2009).
Research indicates that adolescents with lower educational attainment tend to become sexually active at an earlier age and often lack sufficient knowledge about contraceptive methods To prevent unplanned pregnancies and sexually transmitted infections (STIs), it is crucial for these young individuals to receive comprehensive information about family planning and to modify their behaviors accordingly.
A study in Laos identified the primary cause of teenage pregnancies as insufficient access to sexual education Respondents highlighted that many teenagers lack knowledge about contraceptives and how to prevent pregnancy, leading to unintended pregnancies and subsequent school dropouts The rules against pregnancy and marriage during schooling exacerbate this issue, limiting future opportunities for young girls This underscores the critical need for improved sexual and reproductive health literacy (SRHL) to empower teenagers and prevent early pregnancies.
A study conducted in India revealed that adolescents have limited awareness of sexual health, leading to widespread misconceptions Many young individuals mistakenly believe that pregnancy cannot occur during their first sexual experience and that symptoms of infection will resolve without treatment Additionally, some think that pregnancy can result from mere physical contact, such as hugging This lack of understanding was evident, as only 21% of participants were able to answer sexual health questions accurately.
A study revealed that misconceptions about sexual health are prevalent, with only 6.6% of respondents correctly understanding that sex during menstruation can lead to pregnancy Furthermore, just 17.1% could accurately define safe sex as a means to prevent unwanted pregnancies and sexually transmitted infections (STIs) Awareness of the dual benefits of proper knowledge and condom use among youths was limited, with only 20% recognizing this importance Overall, only 34% demonstrated a theoretical understanding of safe sex practices (Kumar & Tiwari, 2003).
A study in Brazil indicated that knowledge of contraceptive methods among students was alarmingly low, with only 25.7% in public schools and 40.8% in private schools being informed (Martins et al., 2006) Furthermore, research showed that inadequate knowledge was prevalent among adolescents under 14 years (48.3%), increasing to 55% at age 15 and 92% by age 19 Notably, the use of contraceptive methods was not directly linked to knowledge levels, highlighting the influence of other factors such as the age of first sexual intercourse, timing of sexual initiation, access to contraceptives, presence of a steady partner, partner resistance to contraceptive use, a desire for pregnancy, and poor parent-child communication on sexual topics (Queiroz, 2000).
In India, there is a significant lack of awareness regarding the transmission and prevention of infections, particularly among adolescent girls A study revealed that over one-third of participants did not correctly understand the signs and symptoms of STIs beyond HIV/AIDS Alarmingly, 30% believed HIV/AIDS was curable, while 49% opposed the availability of condoms for youth Additionally, 41% were uncertain if contraceptive pills could prevent HIV, and 32% thought they were only for married women Only 13% recognized that having multiple sexual partners increases the risk of HIV infection These findings highlight the urgent need for gender-based sex education in Indian schools to address STIs, safe sex practices, and contraceptive use The discrepancies in knowledge may stem from varying educational backgrounds, as 59% of respondents cited pregnancy prevention and STI avoidance as their primary motivations for safe sex (McManus & Dhar, 2008; Chukwu et al., 2017).
Situation regarding a knowledge of STIs
Awareness and understanding of sexually transmitted infections (STIs) are crucial for preventing transmission and encouraging early treatment, particularly in developing countries where management often relies on a syndromic approach that requires visible symptoms for diagnosis Many individuals, especially women, may be asymptomatic and therefore do not seek medical care, putting them at higher risk for complications from untreated infections It is essential for women of reproductive age to be well-informed about STIs, including their symptoms and potential complications, as this knowledge can prompt timely healthcare seeking Additionally, understanding that some infections can be asymptomatic and knowing protective measures can help reduce risky behaviors and lower transmission rates.
A study conducted in India revealed that adolescent girls lack a comprehensive understanding of sexually transmitted infections (STIs) beyond HIV/AIDS Notably, 71% of participants were unaware of the effects of genital herpes, while 43% and 28% did not recognize the consequences of syphilis Furthermore, 33% failed to identify genital ulcers and painful urination as infection signs, and 22% were unaware that vaginal discharge is a significant indicator of STIs in women Additionally, nearly half (49%) believed that condoms should not be accessible to youth, and over a third (41%) were uncertain about the contraceptive pill's usage and its effectiveness against HIV About 32% thought the pill was inappropriate for young individuals, asserting it should only be used by married women (McManus & Dhar, 2008).
A study conducted in Nigeria revealed that 66% of adolescents had prior knowledge of sexually transmitted diseases (STDs), with 91% recognizing that STDs can be contracted from seemingly healthy individuals Among the respondents, 51% reported having engaged in sexual intercourse, and 58% were aware that condom use can prevent STDs Additionally, 45% demonstrated knowledge of STD signs and symptoms The primary sources of information included schools (57%), homes (46%), hospitals (36%), and media such as radio, the Internet, or newspapers/magazines (29%) While 53% of adolescents claimed to understand STDs well, 10% admitted to a lack of understanding (Oluyemi et al., 2015).
A study conducted in West Java, Indonesia, revealed that 56.5% of respondents demonstrated poor knowledge regarding sexually transmitted infections (STIs) Attitudes towards STIs were fairly balanced, with 53.2% holding positive views and 46.8% negative The primary sources of STI information identified by participants were teachers (66.5%), followed by television and radio (45.3%), friends (37.8%), newspapers and magazines (21.2%), mothers (16.2%), siblings (7.2%), and fathers (6.5%) (Hendrana et al., 2015).
A study conducted in Indonesia revealed that over half (56%) of senior high school students aged 15 to 19 lacked knowledge about sexually transmitted infections (STIs) While 60.1% recognized that having multiple sexual partners increases the risk of STIs, only 39% understood that bacteria are not the only cause However, a significant majority (78.1%) identified that AIDS is caused by HIV, and 61.9% were aware of the transmission of STIs from mother to fetus Additionally, there was a strong awareness (79.9%) regarding the transmission of STIs through shared syringe needles (Hendrana et al., 2015).
Factors associated with knowledge of safe sex and STIs
This section summarizes existing research on safe sex knowledge and sexually transmitted infections (STIs), highlighting the significant impact of socio-demographic factors Previous studies offer valuable insights into various analytical findings that will inform the methodologies and frameworks used in this research Specifically, the study will focus on socio-demographic variables, including age, gender, family background, school environment, peer relationships, media influence, and religious beliefs, which are elaborated upon in detail.
Age significantly influences awareness of safe sex practices and sexually transmitted infections (STIs) Research indicates that individuals typically receive their initial education about contraception and STIs/STDs between the ages of 12 and 15 (Nguyen, 2017).
Adolescence, as defined by the WHO, spans ages 10 to 19 Research in Turkey indicates that early and middle adolescents often lack comprehensive knowledge about preventive measures for sexual intimacy and are more prone to dismissing infection symptoms (Kaptanoğlu et al., 2013) Similarly, a study in Philadelphia revealed that early adolescents scored lower in STI/STD knowledge compared to their middle and late counterparts, with late adolescents demonstrating the highest overall knowledge scores (Clark et al., 2002).
Research indicates that sex significantly influences knowledge about health issues Studies reveal that males generally possess less knowledge than females regarding various diseases For instance, a study in Vietnam found that female students outperformed their male counterparts in recognizing the causes and symptoms of STDs, including the association of abdominal pain with these infections (Sjửqvist & Gửthlin, 2011) Furthermore, women demonstrate a superior understanding of birth control and contraception compared to men (Nguyen, 2017).
A study conducted in Malaysia revealed that female university students possess a higher level of knowledge about sexually transmitted infections (STIs) compared to their male counterparts, with 53.0% of females demonstrating adequate knowledge versus 44.3% of males The prevalence ratio for this finding was 0.836, with a 95% confidence interval of 0.710 to 0.984 (Folasayo et al., 2017).
Parents play a crucial role in educating their children about sexual issues and values, especially as they enter puberty and experience bodily changes At this stage, parents should guide their children to prevent early teenage pregnancies and the spread of HIV/AIDS Research indicates that many teens prefer seeking sexual health information from their parents over other sources like health centers or friends Notably, female students are more inclined to discuss reproductive health topics, particularly regarding safe sex practices, due to a parental emphasis on abstinence and pregnancy prevention.
A study in southern Ethiopia revealed that 59.3% of secondary school students discussed contraceptive methods with their parents, while 67% talked about STDs/HIV/AIDS, and 50.4% considered discussing sexual intercourse Additionally, 55.5% of respondents engaged in conversations about unwanted pregnancies Research indicates that when parents communicate about sexual health topics, adolescents are less likely to engage in risky sexual behavior and tend to delay their first sexual encounter Parental discussions can significantly reduce the risk of STIs, including HIV and AIDS, and prevent complications like teenage pregnancy For instance, teens who had healthy discussions with their parents about sex and birth control were twice as likely to know how to use condoms compared to those who did not Similarly, a study in Nigeria found that 34% of medical students had conversations with their parents about safe sex, enabling them to identify methods to avoid STIs and unwanted pregnancies.
Research indicates that mothers often take the lead in providing sexual education to their children, particularly concerning STIs, HIV, and birth control methods Studies show that mothers view themselves as more effective communicators on these topics compared to fathers Notably, among participants who discussed unwanted pregnancies with their mothers, a significant 82.8% reported knowledge of at least one contraceptive method, such as condoms and abstinence.
Knowledge of teachers about safe sex and STIs
Many adolescents acquire fundamental sexual knowledge through school-based sex education programs, often during or before middle school These programs primarily aim to enhance understanding and promote abstinence among youth, delay the onset of sexual activity, reduce the number of sexual partners, and increase awareness of condom use and other birth control methods to prevent unsafe sexual practices.
A study in Laos revealed that 96% of students considered sexual education in schools crucial for learning how to advocate against unsafe sex The findings indicated that 74% of students were educated about puberty, 60% about STIs, and 52% about contraception and family planning (UNFPA, 2017b) Research shows that curriculum-based sex education, particularly STI/HIV programs, is moderately linked to a reduction in risky sexual behaviors among adolescents, such as unprotected sex (Holman, 2014) Additionally, a study in northern Nigeria found that 56% of respondents were aware of methods to prevent pregnancy, with 57% of males and 55% of females knowledgeable about pregnancy prevention strategies Further analysis indicated that awareness of pregnancy risks at first sexual intercourse was significantly related to the type of school attended (Adeokun, Ricketts, Ajuwon, & Ladipo, 2009).
Teachers play a crucial role in shaping knowledge about safe sex and STIs, as schools increasingly integrate sexuality education into their curriculums (Amu & Adegun, 2015).
In numerous countries, teachers are viewed by teenagers as the most credible source for sexual education, highlighting the importance of incorporating their perspectives into the development and implementation of sexual education programs (Mkumbo, 2012) In Laos, 46% of students prefer to learn about sexual and reproductive health through teacher-led consultations (UNFPA, 2017b) In the United States, 55% of girls and 43% of boys receive sexual health education from teachers, with a focus on birth control, while 59% of girls and 66% of boys learn about STIs and HIV from the same source (Donaldson et al., 2013).
Adolescents primarily acquire sexual education through conversations with friends, who serve as vital sources of information and social references during their development (Widman et al., 2014) This peer communication is more influential than other sources, such as media, religion, and parents, in providing knowledge about contraception and sexually transmitted infections (STIs/STDs) (Bleakley et al.).
A study conducted in western Ethiopia revealed that 50% of students discussed contraceptive methods, with only 4.1% addressing unwanted pregnancies among peers This dialogue led to awareness of at least one contraceptive method for preventing unwanted pregnancies, with 47.7% of students knowing about condoms and 37.1% familiar with abstinence Additionally, over half (54.1%) engaged in discussions about HIV/AIDS, enhancing their understanding of common STIs, including HIV/AIDS and gonorrhea.
A study conducted in Nigeria found that most respondents learned about safe sex from friends rather than parents, with 60% reporting their initial information came from peers In contrast, only 34% of students had engaged in discussions about safe sex or sex education with their parents or guardians (Chukwu et al., 2017).
Theoretical conceptual framework
This study utilized elements of the Knowledge-Attitude-Practice (KAP) model, focusing on the "Knowledge" aspect derived from literature review The conceptual framework identified three key factors influencing adolescents' understanding of safe sex and sexually transmitted infections (STIs): individual characteristics, interpersonal influences (including family, school, peers, and media), and social-cultural factors such as religion These factors guided the research period, reflecting students' knowledge regarding safe sex and STIs (Isachsen & Svenkerud, 2011; Nguyen, 2017; Petrick, 2016; Sjửqvist & Gửthlin, 2011; UNFPA, 2017b).
Conceptual framework of knowledge for safe sex and STIs in Vientiane High School
- Parental communication about safe sex and STIs o School o Peers o Mass media
Knowledge of students about safe sex and STIs
Knowledge of safe sex ( poor, and good knowledge)
Knowledge of STIs (poor, and good knowledge)
SUBJECTS AND METHODS
Subjects
The target populations of this study were high school students in Vientiane High School, Vientiane Capital, Lao P.D.R
Students who were studying in grades 10 to 12 in Vientiane High School during the
2019 academic year were considered to be eligible participants for this study
Students were unwilling and/or unable to provide informed consent and students who were absent from school at the time of data collection.
Setting and duration
Vientiane, the capital of the Lao PDR, is situated in the central region of the country and encompasses nine districts, boasting a population density of 209 people per square kilometer—eight times higher than the national average According to the Lao Statistics Bureau, Vientiane Capital exhibits superior socio-economic status compared to other regions, highlighted by its leading education and literacy rates Only 2.4% of its population has never attended school, in stark contrast to the national figure of 13.1% The city is home to 52 high schools, 40 lower secondary schools, and 11 upper secondary schools, reflecting its commitment to education.
The study took place at Vientiane High School, the largest and one of the most prestigious high schools in Laos, situated in the urban district of Chanthabuly The school features four distinct classroom types: general, talent, bilingual, and ICT classrooms, which facilitate online learning For the academic year 2018/2019, the school had a total enrollment of 3,227 students, including 1,861 females across grades 6 to 12 Notably, among the 1,507 students in grades 10 to 12, there were 896 female students.
The data collection time for this study was two months, i.e from January to February, 2019.
Study design
The design of this study was analytical cross-sectional, using the quantitative research method.
Sample size
The study focused on high school students in grades 10 to 12 at Vientiane High School, comprising a total population of 1,507 students The sample size for the research was determined using a specific calculation formula.
Formula for sample size calculation
The sample size was calculated using the formula below:
- Zalpha/2 = level of confidence according to the standard normal distribution ( for level of confidence of 95%,z= 1.96)
In this study, the expected proportion (p) of students possessing good knowledge about safe sex and sexually transmitted infections (STIs) is analyzed Due to the absence of reference proportions from prior research, we utilized a value of p at 0.5 to maximize the sample size for our analysis.
To ensure the validity of the findings and to avoid dropout subjects, we increased the attrition rate by 10 %
So, the total sample size was 337 participants
Sampling method
The study employed stratified sampling, categorizing participants into three high school grades: 10, 11, and 12, with representation proportions of 21%, 38%, and 41%, respectively The total sample size was allocated accordingly, requiring 71 participants from grade 10, 128 from grade 11, and 138 from grade 12 The first stage involved selecting classes for the study.
On average, each class has about 36 or 38 students, with the sample size of about
In our study, we randomly selected 10 classes from a total of 41 available classes at the school Specifically, we chose nine classes from grade 10, 16 from grade 11, and 16 from grade 12 to ensure a comprehensive representation across all grade levels.
Finally, student participants in each classroom were selected by a systematic random sampling technique (Figure2.1) Table 2.1 shows the proportion of students and classrooms, which were selected from each grade level
Figure 2.1 Flow chart of sampling procedures in Vientiane High School
Table 2.1 The proportion of students and classrooms which were selected from each grade level
Number of students /class rooms
Estimate of students /class room
Number of classrooms to be selected
Total number of students from grade 10 to grade 12 = 1507 students
Data collection method
This study used a questionnaire for data collection (Self-Administered Questionnaire)
A self-administrated structured questionnaire contained questions on socio- demographic characteristics, a knowledge on safe sex and STIs, and information about related factors such as school, family, peer and religious attributes
The self-administered questionnaire was designed to eliminate researcher bias, ensuring that data collection was independent of the researchers' opinions This method was both convenient and time-efficient, allowing respondents to answer at their own pace without the pressure of scheduled interviews Additionally, the low distribution cost enabled the researchers to reach a larger participant pool without incurring significant expenses However, a notable drawback was the lack of detail in responses, as fixed-answer formats limited the opportunity for respondents to express their true feelings on various topics.
The process of data collection
- The questions and variables included in the questionnaire were prepared based on various related studies found in the literature review
The questionnaire was initially developed in English and subsequently translated into Lao It underwent pretesting with 30 respondents in a non-study school prior to the data collection phase.
During the data collection process, investigators clearly communicated the research objectives and methods to respondents, ensuring they understood before completing the self-administered questionnaires Additionally, a parental consent form was obtained alongside the participants' consent.
- All questionnaires were checked for completeness and consistency during the fieldwork after each interview
Research instrument to adapt questionnaire
The questionnaires were divided into six parts as follows:
This part contained four questions including information about the participant’s individual level characteristics relating to ‘age, gender, ethnicity, and grade of study’
The questionnaire gave information about the participant’s interpersonal level, which focused on the ‘family structure’ This part contained two questions about living arrangements and family size
Part 3: Knowledge of safe sex
The questionnaires were validated through a new set of questions designed to measure knowledge of safe sex, informed by previous research studies (Acharya et al., 2016; Chukwu et al., 2017; Petrick, 2016; UNFPA, 2017b) This section included 13 items focused on understanding methods to prevent infections, particularly in reducing new HIV cases, AIDS, STIs/STDs, and preventing unwanted pregnancies Respondents were scored based on their correct answers, with a total possible score ranging from 0 to 13 points.
The questionnaires were validated with a new set of questions designed to measure knowledge of sexually transmitted infections (STIs), informed by prior research (Isachsen & Svenkerud, 2011; Petrick, 2016; Svensson & Waern, 2013; UNFPA, 2017b) This section included 33 items focused on the names, causes, routes, symptoms, and prevention methods for STIs, along with the symptoms and complications of STDs Respondents received scores ranging from 0 to 33 based on the number of correct answers provided, serving as an indicator of their knowledge level.
Part five focused on the interpersonal level such as family communication, school related factors, peer related factors, and mass media related factors
This part contained eight questions (Holman, 2014; UNFPA, 2017b) about the information communicated concerning knowledge safe sex and STIs These questions measured answers using categories, which were, classified as “Never”, “Rarely”,
“Sometimes”, and “Often” during their lifetime This part also asked which family members like to talk with one another about safe sex knowledge and STIs
This part contained five questions (Petrick, 2016; UNFPA, 2017b) The questionnaire gave information about students attending school, sexual education topics, time allocated to study and providing adequate sexual education in school
The section included seven questions (Holman, 2014) focused on the communication of information regarding safe sex and sexually transmitted infections (STIs) Responses were categorized into four classifications: “Never,” “Rarely,” “Sometimes,” and “Always.”
“Often” during their lifetime This part also asked which friends liked to talk with fellow students about safe sex knowledge and STIs
The questionnaire assessing knowledge sources for safe sex and STIs was structured into two segments, each featuring seven multiple-choice questions that categorized responses as yes (1) or no (0) It explored where students obtain information on family planning and STIs, including HIV/AIDS, from various mass media outlets The sources examined included magazines, films and television, newspapers, radio, and social media platforms such as Facebook, Twitter, and YouTube (Petrick, 2016).
Part 6: Social and cultural factors “Religious factors”
The questionnaire included five questions that explored participants' religious factors, focusing on their beliefs, the significance of religion in their lives, attendance at religious services, and their religion's stance on premarital sexual intercourse and birth control (Petrick, 2016).
Variables
This study examined three groups of independent variables: individual characteristics such as age, sex, ethnicity, and grade of study; interpersonal factors including family structure, parental communication, school influences, peers, and mass media; and social and cultural aspects like religion The dependent variables focused on participants' knowledge of safe sex and sexually transmitted infections (STIs).
Definitions, measurements and questionnaire concept
The definitions for variables in the study
Understanding safe sex equips students with essential knowledge about various methods to prevent HIV infections, AIDS, and STIs/STDs, while also helping them learn how to avoid unwanted or unintended pregnancies.
Students demonstrated an understanding of sexually transmitted infections (STIs) by being able to identify and categorize various types, recognize their causes and transmission routes, and understand the associated signs and symptoms Furthermore, they were informed about effective prevention methods to reduce the risk of STIs.
Measurement of knowledge about safe sex
Every correct answer for the 13 questions received a 1 point score (Svensson & Waern, 2013)
In determining the level of knowledge for each respondent about safe sex
, the response of the questionnaire items 1, 2, 4, 5, 7, 8, 9,10,11,12 and 13 was scored as follows:
“Don’t Know or Unsure” = 0 points
The response of the questionnaire items 3 and 6 was scored as follows:
The study assessed safe sex knowledge using 11 positive and two negative questions, with participants responding with "Yes," "No," or "Don't Know/Unsure." Correct answers earned one point, while "Don't Know/Unsure" and incorrect responses received zero points The total scores exhibited a normal distribution, allowing the researchers to categorize knowledge levels based on the mean: good knowledge was defined as scores equal to or above the mean, while poor knowledge was categorized as scores below the mean (Hendrana et al., 2015; Megersa et al., 2017; Sjửqvist & Gửthlin, 2011).
The personal knowledge scales of the questionnaire were tested for Kuder-Richarson
In a non-study high school, the Kuder-Richardson 20 (KR-20) value was assessed before data collection from a sample of 30 respondents, yielding a KR-20 value of 0.7777 for knowledge of safe sex This result exceeds the commonly accepted threshold of 0.7, indicating a reliable measure of respondents' understanding of safe sex practices.
Measurements of knowledge of STIs
The section for a knowledge of STIs had 33 questions and each question received a one point score for every correct answer (Svensson & Waern, 2013)
Determining the level of knowledge about STIs
The response of the questionnaire items 1,3,4,5, 7,8,9,10,11,15,16,17, 20, 21,
22, 23, 24, 25, 26, 27, 28, 29, 30 and 31 was scored as follows:
The response of the questionnaire items 2, 6, 14, 12, 13, 18, 19, 32 and 33 of each respondent was scored as follows:
The study assessed knowledge of sexually transmitted infections (STIs) through 24 positive and nine negative questions, offering three response options: Yes, No, and Don’t Know or Unsure Correct answers earned one point, while “Don’t Know or Unsure” and incorrect answers received no points The resulting knowledge scores followed a normal distribution, allowing the researchers to use the mean to classify knowledge levels, designating scores equal to or above the mean as good knowledge and those below as poor knowledge (Hendrana et al., 2015; Megersa et al., 2017; Sjửqvist & Gửthlin).
The personal knowledge scales of the questionnaire were evaluated for Kuder-Richardson 20 (KR-20) values prior to data collection, involving a sample of 30 respondents from a non-study high school A commonly accepted benchmark in practice is a KR-20 value of 0.7, indicating reliability The KR-20 value for knowledge of sexually transmitted infections (STIs) was found to be 0.9309, demonstrating excellent reliability.
Statistical analysis
Before data entry, completeness and consistency were thoroughly checked EpiData was utilized for data entry, while Stata 13.0 facilitated the analysis Descriptive statistics were employed to evaluate the frequency and percentage of both independent and outcome variables Univariate and multivariate logistic regression tests were conducted to calculate odds ratios, assessing the association between independent and outcome variables A 95% confidence interval was used to estimate the precision of the odds ratios, with narrower intervals indicating higher precision A p-value of less than 0.05 was deemed statistically significant (Megersa et al.).
Ethical approval
The study received ethics approval from the Human Research Ethics Committee of the Hanoi University of Public Health (Approval Number: 018-464/DD.YTCC, December 12, 2018) and the Ethical Review Board of the University of Health Sciences (Approval Number: 103/18, Vientiane Capital, December 12, 2018) Additionally, the principal of the target school granted permission for the surveys to be conducted with the students.
Verbal consent was obtained from the parents or guardians of each participant prior to the study, with approval from the National Ethics Committee for Health Research, given the sensitive nature of the topic and the adolescent age of respondents Participants were informed about the research objectives, procedures, and potential risks before the interviews, and confidentiality agreements were established to protect their privacy Each participant had the right to withdraw from the study at any time if they felt uncomfortable, and all collected information was kept strictly confidential To ensure anonymity, interviewers instructed participants not to write their names on the questionnaires, using only a code number for identification Participation was voluntary, and informed consent was secured from all participants.
RESULTS
Socio-demographic characteristics of participants
There were 337 students from Graded 10 to 12 at Vientiane High School enrolled in this study The participants were aged between 14 and 20 years and the mean age was
The study involved 16 participants (SD = 1.09), with a predominant female representation of 66.4% Ethnic composition revealed that 83.9% were ethnic Lao, while 8.6% identified as ethnic Tai Notably, over 75% of the participants resided with their parents, and 8% lived solely with their mothers Additionally, three-quarters of the participants hailed from families consisting of five or fewer members.
Table 2.3 Students’ knowledge of safe sex
1 It is better to have only one sex partner for a sexual relationship 72 63.7 156 69.6 228 67.6
2 A condom should be used correctly and consistently for a safe sex purpose 98 86.7 186 83.0 284 84.2
3 A condom cannot prevent STIs/HIV infection 65 57.5 95 42.4 160 47.4
4 Have had sexual intercourse with only one partner without HIV 48 42.4 103 45.9 151 44.8
5 Prevention of AIDS is no sex with risky persons 76 67.2 161 71.8 237 70.3
6 Sex during menstrual cycle cannot protect from pregnancy 29 25.6 52 23.2 81 24.0
7 Even first time sexual intercourse can cause pregnancy 88 77.8 169 75.4 257 76.2
8 Safe sex (i.e sex which is free from the risk of unwanted pregnancy and STD/AIDS) 48 42.4 99 44.2 147 43.6
9 Condoms can help prevent pregnancy 95 84.0 137 61.1 232 68.8
10 Birth control pill can help prevent pregnancy 61 53.9 123 54.9 184 54.6
11 Birth control injection can help prevent pregnancy 45 39.8 119 53.1 164 48.6
12 Abstinence can help prevent pregnancy 79 69.9 167 74.5 246 73.0
13 Intrauterine Device (IUD) can help prevent pregnancy 50 44.2 104 46.4 154 45.7
Note: Presented only yes answer
Knowledge of participants about safe sex
Table 3.2 highlights participants' knowledge of safe sex practices, revealing that a significant majority understood that consistent and correct condom use leads to safer sex Over 75% of students recognized that engaging in sexual intercourse for the first time could result in pregnancy, while 73% acknowledged that abstinence is an effective method to prevent pregnancy However, less than 25% of participants correctly identified the likelihood of becoming pregnant from intercourse during a regular menstrual cycle.
Table 2.4 Level of knowledge about safe sex
Level of knowledge (score) Number ( n37) Percentage (%)
Mean =7.49 and SD ± 2.438, Median=7, Min=0,Max
The knowledge level for safe sex
In a study assessing knowledge of safe sex, participants achieved a mean score of 7.49 with a standard deviation of ± 2.438 on the 13-question assessment The findings revealed that just over half of the participants demonstrated poor knowledge of safe sex practices.
Table 2.5 Knowledge of students about STIs
Signs and symptoms of STIs
The way of prevention STIs
30 Get tested before marriage/ before starting new relationships
32 Birth control pills offer excellent protection
33 Once you have had an STI and have been cured, you can’t get it again
Note: Presented only yes answer
The knowledge of participants about knowledge of STIs
Table 3.4 highlights participants' knowledge of sexually transmitted infections (STIs), revealing that most correctly identified HIV/AIDS as an STI, while over three-quarters recognized that influenza is not sexually transmitted Alarmingly, less than a third were aware that the Human papillomavirus (HPV) is an STI, and just over a third understood that viruses can cause STIs More than half correctly identified that unclean water does not cause STIs, and a majority recognized that sexual intercourse and shared needle use are routes for STI transmission However, only a bare majority considered weakness a symptom of STIs, and concerningly, just over a third knew that discharge from the penis or vulva indicates infection On prevention, most participants understood the importance of getting tested before marriage or starting a new relationship, and a significant majority acknowledged that consistent condom use is an effective method for preventing STIs.
Table 2.6 Level of knowledge among students about STIs
Level of knowledge (score) Number (N37) Percentage (%)
Mean 30 and SD ± 5.095, Median, Min=0,Max)
The knowledge level of STIs
A study assessing knowledge of sexually transmitted infections (STIs) through 33 questions revealed an average score of 17.30 with a standard deviation of ± 5.095 The results categorized participants into two groups, indicating that a slight majority demonstrated good knowledge of STIs.
Table 2.7 Communication about knowledge of safe sex and STIs between students and family members/peers during their school life
Communication with family members Communication with peers
1.Talked about condom use when having sexual intercourse
2.Talked about taking the contraception pill when having sexual intercourse
3.Talked about avoiding multiple sex partners
6.Talked about changes during puberty
7 Discussed not having sex before marriage
8.Talked about how to use condoms and protect yourself from becoming pregnant
Communication about a knowledge of safe sex and STIs between students and family members/peers
Table 3.6 highlights the communication patterns regarding safe sex and STIs among high school students, revealing that about 25% of respondents discussed puberty changes with relatives and peers 3-5 times during their school years Approximately one-third preferred discussing STIs, including HIV/AIDS, with peers 1-2 times, while only a quarter engaged in such conversations with family Notably, one-third of students never talked about puberty changes with family, although most discussed physical changes with friends A significant majority of participants never spoke with relatives about condom use or pregnancy prevention, yet nearly two-thirds felt confident discussing condoms with peers However, a slight majority of students never engaged in conversations about family planning with their peers.
A survey revealed that the majority of respondents preferred discussing safe sex and STIs with their mothers, while conversations with both parents together and separately with fathers were also common.
Nearly 75% of participants preferred to communicate with close girlfriends, while over one-third engaged in discussions with boyfriends Less than one-third interacted with general friends, and only a small percentage communicated with a girlfriend or boyfriend.
Table 2.8 School factors related to sexual education
School factor Number ( n= 337) Percent (%) Attending school
Topics related to Sexual education
The sexual health subject integrated
Hours approximately covering SRH per week
Provide adequate information about SRH
Sexual education in the school
A significant majority of students (96.1%) attended school regularly and received sexual education, with puberty changes being the most frequently discussed topic, followed by STIs, including HIV/AIDS Sexual education was primarily integrated into biology lessons, while nearly three-quarters of students reported it being included in global studies and a smaller percentage in geography classes One-third of students indicated they learned about sexual health for approximately two hours per week, while nearly 10% studied for one hour, and less than 5% reported more than two hours Notably, over half of the students could not recall the number of hours spent on sexual health education Less than half felt the information provided by the school was of medium standard, with a third considering it adequate.
Table 2.9 Mass media sources of family planning and STIs/HIV/AIDS information
Sources of information from mass media
Sources of information for family planning from mass media
Sources of information for STIs including HIV/AIDS from mass media Number
Mass media sources of information on family planning and STIs/HIV/AIDS
Table 3.8 highlights the primary sources of information on family planning and STIs, including HIV/AIDS, among respondents The most cited source for family planning knowledge was Facebook, with films/television and YouTube also being significant, as over two-thirds of students utilized these platforms In contrast, for STIs, including HIV/AIDS, film and television emerged as the leading information sources, slightly surpassing online options, although the difference was minimal.
Religion accepts sexual intercourse before marriage
Religious factors
Table 3.9 reveals that the majority of participants identify as Buddhists, with over 75% indicating that religion plays a significant role in their lives More than half expressed a preference for attending religious services Additionally, a substantial portion of participants noted that their religious beliefs discourage premarital sexual intercourse, and nearly 75% reported that their faith disapproves of the use of birth control.
Knowledge of safe sex Knowledge of STIs
Univariate analysis of factors associated with knowledge of safe sex and
Association between demographic characteristics and family factors with knowledge of safe
In a univariate logistic regression analysis, socio-demographic factors showed no significant association with knowledge of safe sex (P-value>0.05) However, individuals living with others demonstrated a notable correlation, being over two times more likely to possess good knowledge of safe sex compared to those living with parents (COR=2.6, 95%CI=1.2-5.5) Additionally, the analysis revealed that grade level significantly influenced knowledge of sexually transmitted infections (STIs), with Grade 12 students exhibiting less awareness than their Grade 11 and Grade 10 counterparts (P-value0.05).
Table 2.13 Univariate logistic regression analysis of school factors associated with knowledge of safe sex and STIs
Knowledge of Safe Sex Knowledge of STIs
Topics have Studies Related to:
Sex Education and Family Planning
Association between school factors with knowledge of safe sex and STIs
Table 3.12 highlights a significant association between school factors related to sexual education and students' knowledge of safe sex (P-value 0.05).
Table 2.15 Univariate logistic regression analysis of religious factors associated with knowledge of safe sex and STIs
Knowledge of safe sex Knowledge of STIs
Low knowledge Good Knowledge CO
Religion is acceptable to have sexual intercourse before marriage
Religion is acceptable to use birth control
Association between religious factors associated with knowledge of safe sex and STIs
Table 3.14 presents the findings from a univariate logistic regression analysis examining the relationship between religious factors and adolescents' knowledge of safe sex and STIs The analysis reveals that adolescents belonging to religions that endorse the use of birth control are nearly twice as likely to possess knowledge about safe sex compared to those from religions that do not support it, with a crude odds ratio (COR) of 1.8 and a 95% confidence interval (CI) of 1.1 to 2.9.
Table 2.16 Multivariate logistic regression analysis of the factors associated with knowledge of safe sex and STIs
Studied topic about family planing
Religion accepts use of birth control
Studied topic about family planing
Studied topic about STIs including HIV/AIDS
Multivariate logistic regression analysis of factors associated with students’ knowledge of safe
A comprehensive analysis was conducted to identify key factors influencing knowledge of safe sex and sexually transmitted infections (STIs), utilizing a multivariate logistic regression model Independent variables significantly correlated with knowledge levels (P-value