PREVALENCE OF SEXUAL INITIATION AND ASSOCIATED FACTORS IN LATE ADOLESCENCE: A STUDY IN SELECTED TERTIARY LEVEL INSTITUTIONS IN MALAYSIA SHAZIMAH BT. ABDUL SAMADMalaya of FACULTY OF MEDICINE UniversityUNIVERSITY OF MALAYA KUALA LUMPUR 2016 PREVALENCE OF SEXUAL INITIATION AND ASSOCIATED FACTORS IN LATE ADOLESCENCE: A STUDY IN SELECTED TERTIARY LEVEL INSTITUTIONS IN MALAYSIA SHAZIMAH BT. ABDUL SAMADMalaya of THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PUBLIC HEALTH FACULTY OF MEDICINE UNIVERSITY OF MALAYA KUALA LUMPUR University2016 UNIVERSITY OF MALAYA ORIGINAL LITERARY WORK DECLARATION Name of Candidate: Shazimah Binti Abdul Samad Registration/Matric No: MHC110008 Name of Degree: Doctor of Public Health Title of Project Paper/Research Report/Dissertation/Thesis (“this Work”): Prevalence of Sexual initiation and Associated Factors in Late Adolescence: A Study in Selected Tertiary Level Institutions in Malaysia Field of Study: Public Health I do solemnly and sincerely declare that: (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title of the Work and its authorship have been acknowledged in this Work; (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutesy an of infringement Malaya of any copyright work; (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (“UM”), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by any means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM. UniversitCandidate’s Signature Date: Subscribed and solemnly declared before, Witness’s Signature Date: Name: Designation: ABSTRACT The purpose of this study was to determine the psychometric properties of the Susceptibility to Peer Pressure Scale as well as the prevalence of sexual initiation and its risk factors among late adolescents attending tertiary level institutions. The temporal gap which exists between the maturation of the adolescents’ prefrontal cortex and their socio- emotional system predisposes them to engage in sexual initiation. The newly discovered independence that is associated with college environment further increases the propensity among late adolescents to initiate sexual intercourse. As this behaviour may result in negative consequences, such as unintended pregnancy, unsafe abortion or sexually transmitted infections, it is important to identify the crux of the matter in enabling the design and the implementation of risk reduction strategies. This study was conducted in two phases. Phase I comprised the establishment of the psychometric properties and the factorial invariance across gender of the Susceptibility to Peer Pressure Scale, one of the instruments used in Phase II. Both exploratory and confirmatory factor analyses were utilized. A cross-sectional study, employing a multistage stratified sampling method was conducted to establish the prevalence of sexual initiation and other related sexual behaviours as well as the correlates of engagement in sexual initiation in Phase II. A self- administered questionnaire based on adaptation of the Urie Bronfenbrenner’s social- ecological model which comprised several instruments to assess the characteristics of individual’s, familial and peer characteristics as well as school engagement was utilized. TheUniversity correlates of sexual initiation were determinedof Malaya via multivariate logistic regression analyses adjusting for complex samples. A total of 1652 unmarried adolescents aged 18 and 19 years from six public and private institutions of higher learning in the Central region of Malaysia participated in this study. Overall, the Malaysian version of the Susceptibility to Peer Pressure Scale displayed good psychometric properties in terms of its construct validity, internal consistency and test-retest reliability in measuring iii susceptibility to peer pressure. Multi-group confirmatory factor analyses established the invariance of this scale across gender. The prevalence of sexual initiation among late adolescents was 9.8% (95% CI [8.3, 11.6]) with males reporting a higher rate of sexual engagement. Higher likelihood of sexual initiation was associated with perception of close friends have had sex, higher susceptibility to peer pressure and living in non-intact families among males and females. However, some gender differences were identified. As for males, Malays, current smokers, lifetime alcohol consumers, lifetime illicit drug use, early puberty, involvement in a relationship, and higher peer attachment were associated with sexual initiation. Sexual engagement among females, on the other hand, was linked to lifetime cigarette use and higher self-esteem. Females who reported higher religiosity and higher peer attachment were less likely to engage in sexual intercourse. The established risk factors originated from the elementsMalaya of the adolescents’ immediate environment and their interactions. Thus, risk reduction strategies should conflate these elements in securing better outcomes. It isof imperative to tailor these strategies based on gender differences. Future studies should contemplate qualitative research in exploring these risk factors. University iv ABSTRAK Objektif kajian ini adalah untuk mengenalpasti ciri-ciri psikometrik Skala Kecenderungan terhadap Tekanan Rakan Sebaya dan kadar inisiasi aktiviti seksual pranikah serta faktor-faktor berkaitan dengannyadi kalangan remaja berumur 18 dan 19 tahun di institusi-institusi pengajian tinggi. Di kalangan remaja, wujud jurang di antara kematangan korteks prefrontal dan sistem sosio-emosi yang mungkin mempengaruhi penglibatan mereka dalam seks pranikah. Kebebasan daripada kongkongan ibu bapa setelah melanjutkan pelajaran ke institusi pengajian tinggi turut meningkatkan kecenderungan remaja untuk mengadakan hubungan seks. Punca penglibatan remaja dalam aktiviti ini perlu dikenalpasti bagi merangka strategi pencegahan agar kesan-kesan negatif seperti kehamilan, pengguguran yang tidak selamat atau penyakit jangkitan kelamin dapat dihindari. Kajian ini dijalankan dalamMalaya dua fasa. Fasa I merangkumi penentuan sifat-sifat psikometrik dan faktor invarians merentasi jantina bagi Skala Kecenderungan terhadap Tekanan Rakan Sebaya,of satu instrumen yang digunakan dalam Fasa II dengan penggunaan analisa faktor penerokaan dan pengesahan.Fasa II pula melibatkan kajian rentas yang menggunakan pensampelan rawak berperingkatuntuk menentukan kadar inisiasi seksual pranikah dan tingkah-laku seksual berkaitan, serta faktor-faktor yang berkait dengan penglibatan dalam seks pranikah di kalangan remaja. Data untuk kajian ini telah dikumpul menggunakan borang soal selidik isi sendiri, berpandukan adaptasi daripada model ekologi sosial Urie Bronfenbrenner, yang merangkumiUniversity beberapa instrumen untuk menilai ciri-ciri individu, kekeluargaan, dan rakan sebaya serta penglibatan sekolah. Analisis regresi logistik bergandayang disesuaikan untuk sampel kompleks telah digunakan. Sejumlah 1,652 remaja yang belum berkahwin, berumur 18 dan 19 tahun daripada enam institusi pengajian tinggi awam dan swasta di wilayah Tengahdi Malaysia telah menyertai kajian ini. Skala Kecenderungan terhadap Tekanan Rakan Sebayamemaparkan sifat-sifat psikometrik yang baik dari segi v kesahihan, konsistensi, dan kebolehpercayaan dalam mengukur kecenderungan terhadap tekanan rakan sebaya. Selain itu, analisis faktor pelbagai kumpulan mengesahkan kesahihan penggunaan skala ini bagi pelajar lelaki dan perempuan. Kadar inisiasi seksual pranikah di kalangan remaja adalah 9.8% (95% CI [8.3, 11.6]) di manapelajar lelaki melaporkan kadar inisiasi seks yang lebih tinggi. Bagi pelajar lelaki dan perempuan, inisiasi seksual berkait dengan persepsi pengalaman mengadakan hubungan seks di kalangan rakan karib, kecenderungan yang lebih tinggi terhadap tekanan rakan sebaya, dan tinggal bersama keluarga yang tidak lengkap.Terdapat perbezaan dalam faktor-faktor yang mempengaruhi aktiviti ini antara jantina. Bagi lelaki, bangsa Melayu, perokok semasa, remaja yang pernah mengambil minuman beralkohol, penggunaan dadah haram, pencapaianakil baligh yang lebih awal, penglibatan dalam sesuatu hubungan, dan lebih rapat dengan rakan sebaya adalah berkait dengan seksMalaya pranikah. Sebaliknya, perhubungan seksual bagi pelajar perempuan, adalah berkait dengan mereka yang pernah menghisap rokok dan mempunyai harga diri yang lebihof tinggi. Pelajar perempuan yang melaporkan penglibatan dalam aktiviti keagamaan yang lebih kerap dan lebih rapat dengan rakan sebaya adalah kurang berisiko untuk melibatkan diri dalam hubungan seks. Selain itu, faktor risiko didapati berpunca daripadaelemen-elemen persekitaran dan interaksi di antara faktor-faktor ini dengan remaja. Oleh itu, strategi-strategi pengurangan risiko perlu menggabungkan elemen-elemen ini bagi memperolehi hasil yang lebih baik. Selain itu, adalah penting untuk menyesuaikan strategi-strategi ini dengan perbezaan