Prevalence and possible risk factor of Premarital Sexual Behaviour among 1 Nepalese Adolescents

24 Background: To determine the prevalence of premarital sex and its risk factors in Nepal. 25 Methods: A cross-sectional study was carried out among adolescents in Nepal. A self- 26 administered questionnaire was used to collect information from 6,147 unmarried adolescents. 27 Random sampling by using a lottery method was applied to select 20 colleges from all three 28 districts. All the students who were studying at those colleges were enrolled in the study. Simple 29 and multivariate logistic regression analyses were carried out to analyse the associations of risk 30 factors and premarital sex. 31 Results: The prevalence of premarital sex was 38.1%. Male students were more likely to engage 32 in premarital sex (adjusted odds ratio [AOR]=2.04, confidence interval [CI]=1.76-2.36) than 33 female students. Alcohol consumption (AOR=1.26, CI=1.08-1.47), smoking (AOR=1.69, 34 CI=1.41-2.02), drug use (AOR=1.85, CI=1.23-2.83), going to night clubs (AOR=1.46, CI=1.24- 35 1.70), clothing style of girls AOR=1.35, CI=1.15-1.58), clothing style of boys (AOR=3.51, 36 CI=2.74-4.53), and unmarried friends having sex (AOR= 1.51, CI=1.31-1.73) were found to be 37 major influencing factors for premarital sex. Moreover, students who had never received sex 38 education were 2.92 times more likely to engage in premarital sex (CI=2.22-3.85) than those 39 who had previously received sex education. 40 Conclusions: We found several risk factors associated with premarital sex in Nepal. Preventing 41 premarital sex may require the promotion of sex education.


54
Premarital sex is defined as any and all forms of sex before marriage (1). Youth risk behaviour 55 surveillance in 2013 revealed that 46% of the students in the USA had engaged in sexual 56 intercourse. The prevalence of ever having sex was highest among black males, followed by 57 Hispanic students. Approximately 14% of the black students had sexual intercourse before the 58 age of 13 (1). In 2016, the prevalence of premarital sex was 27.6% among secondary school 59 students in Nigeria (2). Moreover, the prevalence of premarital sex was 39.7% among young 60 people in Ethiopia (3). Results from developing countries such as Indonesia, Nepal,Thailand,61 and the Philippines suggest that risky behaviours such as premarital sex and substance abuse are  Previous studies on kindred area suggest that individual, family and peer factors such as age; 75 rural family residence; alcohol consumption; smoking habits; attitude towards virginity; having a 76 boyfriend; peers' sexual behaviour, including having friends with dating experience; having 77 close unmarried friends engaging in premarital sex; discussing sexual matters with friends; going 78 to night clubs; viewing pornographic materials; parents education; and parental status (whether 79 raised by a single parent or both parents) had a strong influence on premarital sex among higher 80 secondary level students (8-11). Notably, household, community and country differences are also 81 considered to be predictors of the risk of premarital sex (12). However, many factors are still 82 unknown, especially in underdeveloped areas.

83
Previous reports on premarital sex in Nepal show that one-third (32%) of the Nepalese 84 population is aged 10-24 years, and this age group has the greatest need for sexual and 85 reproductive health services (13). As in other Asian countries, premarital sex is taboo in Nepal,86 discouraging sexual contact between young unmarried males and females (10). Due to the 87 increase in late marriage, decrease in family influence on adolescents, and increase in 88 urbanization as well as exposure to media, globalization and modernization, sexual and 89 reproductive behaviour among adolescents have been changing (10, 11). Although sufficient 90 information and formal education about sexual and reproductive health are provided, the rate of 91 premarital sex has been increasing worldwide (14). An average of 29% of boys and 23% of girls 92 are sexually active and engage in premarital sex in many parts of the world (15).

94
Over the past few decades, premarital sex among adolescents has increased globally, especially 95 in the Western world, and it is becoming increasingly acceptable (16,17 Valley showed that almost two-fifths of the students had engaged in premarital sex (10).

98
However, the study did not explore possible lifestyle factors and was conducted with a small 99 sample size. Based on the above, this study investigated more than 6,147 adolescents aged 17-19 100 years in three regions by random stratification; it was expected that risky lifestyles would be 101 related to premarital sexual behaviour, providing a theoretical basis for subsequent universal 102 education and interventions. Therefore, we performed a study to assess the prevalence of and risk 103 factors for premarital sex in Nepal.

106
An institution-based quantitative survey was conducted among 6,147 students aged 17, 18, and 107 19 years from colleges in Kathmandu Valley after written informed consent was obtained.

108
Kathmandu Valley was selected as the study area because it comprises three districts 109 (Kathmandu, Bhaktapur, and Lalitpur). It is also the capital of Nepal. The majority of students 110 come to this area from different parts of the country after completion of secondary level 111 education to attend higher education institutions. Thus, Kathmandu was selected as the study site 112 so that we could obtain a sample of adolescents from all regions of the country. The study was approved by the ethical review board of the Nepal Health Research Council.

116
Confidentiality was assured, and no personal information of students, as well as colleges, was 117 disclosed without the permission of the respondents. A specific code was assigned to each 118 college and its students, and they were asked not to include their name or the name of the 119 institution on their questionnaire. The sample colleges were not publicly disclosed, so the 120 possibility of anyone outside the core research team tracing the reported sexual behaviour of 121 respondents and their associated college was impossible.

123
Sample size and sampling 124 We used the following formula to calculate the sample size: The minimum sample size required was 6,147.

133
Random sampling by using a lottery method was applied to select 20 colleges from all three 134 districts. The list of all public and private colleges from the Nepal Education Board was 135 considered the sample frame. All the students who were studying at those colleges were enrolled 136 in the study. The data were collected using a structured self-administered questionnaire prepared in the local 140 language (Nepali). The questionnaire consisted of questions about sociodemographic 141 information, risk behaviour, sexual behaviour and knowledge about health consequences.

142
Questions related to the knowledge and practice of premarital sex were asked to obtain research 143 data. The participants were asked, "Do you have a boyfriend/girlfriend?", "Have you ever been 144 involved in sexual activities?", "Do you smoke/consume alcohol/use drugs/go to night clubs?".

145
Additionally, major questions related to their family relationships and pocket expenses were 146 asked. If a participant answered "Yes", he or she was considered to have had premarital sex. The 147 outcome was thus converted to a dichotomous variable. Approximately 30 minutes was provided 148 to complete the questionnaire. The validity of the questionnaires was verified by pretesting 400 149 samples before actual data collection. All the students who were unmarried and willing to 150 participate were eligible to participate in the study. The information of all the students at each 151 college was collected at the same time so that information bias was minimal. Due to the sensitive 152 nature of the study, the students were asked to sit on separate benches (one student per bench) 153 during the break time. Written informed consent was obtained from the students prior to 154 administering the questionnaire and information sheet. Students were told to keep their 155 completed questionnaires and consent forms together and individually place them in a specific 156 location inside the classroom before leaving the classroom so that the identity of the respondents 157 would not be revealed to survey enumerators.

159
The data analysis was carried out using descriptive statistics and inferential statistics. Bivariate 160 statistics including chi-square tests and t-tests were computed to evaluate the differences in 161 sociodemographic characteristics among adolescents who engaged in or did not engage in 162 premarital sex. A multivariate analysis was carried out using logistic regression with the 163 following formula (18). A P-value of 0.05 was considered statistically significant.

165
Odds ratio: The collected data were entered into Epi-data version 3.2 and then extracted and imported into    This study identified the situation and possible influencing factors of premarital sex in Nepal.

226
Through our research, we attempted to analyse a large sample size of adolescents from different 227 parts of the country to increase the generalizability of our findings. The study results showed that 228 there was a significant self-reported prevalence of premarital sex despite Nepal being a low-229 income and highly religious country. In the multivariate analysis, students who smoked, 230 consumed alcohol and used drugs were more likely to have engaged in premarital sex than those 231 who did not, while receiving sex education was found to be a major protective factor.

232
This study showed that the prevalence of premarital sex among adolescents was 38.1%. The 233 findings of the Nepal Demographic and Health Survey showed that 25% of unmarried men and 234 1% of unmarried women have had premarital sex (13). An institution-based cross-sectional study 235 conducted in Nepal showed that 24.6% of the respondents had engaged in premarital sex (11).

236
Another study conducted in India reported that 16-18% of the respondents had engaged in 237 premarital sex (19). The prevalence found in our study is high compared to those in these studies.

238
This might be because adolescents today are more accepting of premarital sex than they were in 239 previous years and because the strict confidentiality measures we took enabled respondents to 240 share sensitive information. However, it is important to note that premarital sex is still a social 241 taboo in Nepal, so there might be underreporting, with the true numbers being even higher than 242 those reported here. .

266
This study showed that adolescents who were not living with family were 1.16 times more likely Ethiopia-based study identified that adolescents who did not live with their parents were six 273 times more likely to engage in premarital sex than those who did live with their parents (AOR: 274 6.6 95% CI 1.9-23.7, p-value: <0.05) (21). These results are consistent with our study findings.

275
This is likely because adolescents who do not live with their parents have more independence 276 and less parental monitoring than those who live with their parents, giving them more 277 opportunities and freedom to engage in premarital sex.

278
In our study, it was found that respondents whose monthly pocket expenditures were >3,000 279 were more likely to have engaged in premarital sex than those whose pocket expenditures were ≤ 280 3,000. A study conducted in India identified that adolescents who had more spending money 281 were more likely to engage in premarital sex than those with less spending money (AOR: 2.13 282 95% CI 0.99-4.62) (28). In Ethiopia, a study found that college students who were given 283 spending money were more likely to engage in premarital sex than those who were not (AOR: 284 2.2 95% CI 1.14-4.05) (9). Another Ethiopia-based study also reported that providing spending 285 money significantly increased the chance of engaging in premarital sex (AOR: 3.07 95% CI 286 1.96-4.81) (15). These findings align with our study results. This is likely because adolescents 287 who receive spending money are financially able to date girls, attend parties, consume alcohol, 288 or buy pornography, all of which increase the likelihood of premarital sex. In addition, 289 adolescents who receive spending money might even pay for sex.

290
In our study, substance use was significantly associated with the practice of premarital sex.

291
Adolescents who consumed alcohol, smoked cigarettes, or used drugs were more likely to have 292 engaged in premarital sex than those who did not.

328
Our study found that adolescents who had not received sex education were three times more 329 likely to have engaged in premarital sex than those who had received sex education. A UNFPA 330 report indicated that adolescents who received appropriate comprehensive sex education 331 programmes were more likely to delay their sexual debut than those who did not receive 332 appropriate education (34). In Uganda, a study that surveyed primary schools before and after a 333 two-year educational intervention reported a higher risk ratio for sexual activity before the 334 intervention in both males (risk ratio: 2.45, p-value: 0.001) and females (risk ratio: 1.76, p-value: 335 0.001) than after the intervention (35). A study conducted in India recommended the introduction 336 of sex education in primary schools to ensure safe sexual behaviour among adolescents (36).

337
These studies align with the findings of our study. This is likely because adolescents who do not 338 receive sex education have very few opportunities to discuss their RH queries, and they are likely 339 to discuss RH with peers who have incomplete knowledge, purchase pornography or are 340 involved in paid sex, thus preventing them from making healthy decisions about their sex life.

341
There are some limitations in our study. First, the study was cross-sectional in nature, and a 342 causal relationship cannot be established between the variables. Due to the sensitive nature of the 343 study, the information regarding premarital sex, number of partners and age at first intercourse