Factors influencing pre-marital sexual intercourse among unmarried young individuals in Cambodia

Background: Sexual behavior of young individual are recognized as one of the main health priority in society. In Cambodia, young individual who hasten to involve in sexual intercourse, contributes to their high risk of various health issues, particularly those related to sexual reproductive health. This research will identify specific characteristics that have strong relationships with pre-marital sexual intercourse among unmarried young individuals in Cambodia. Methods: A binary logistic regression in a multivariate analysis of secondary data was applied from the 2014 cambodian demographic and health survey. the data about pre-marital sexual intercourse were assessed with the CDHS questionnaire including as age, sex, education, place of resident, risky behavior, living arrangement, and exposure to mass media, knowledge about sexual and reproductive health and HIV prevention. Results: age (p = 0.000), sex (p = 0.000), place of residence (p = 0.000), staying away experience (p = 0.001), and smoking behavior (p = 0.000), were significantly associated with pre-marital sexual intercourse among unmarried young individuals. Conclusion: Appropriate reproductive health promotion programs and disease prevention strategies must be organized for target groups of young individuals who engage in pre-marital sexual intercourse. Moreover, comprehensive reproductive health education should be disseminated to increase awareness of risky sexual behavior and allow young individuals to make informed decisions regarding their sexual practices.


Introduction
United Nation reported that young people aged 1524 years old account for 1.2 billion among the 7.6 billion of total population globally in 2015. This number is projected to grow by 7% which means that they will account for nearly 1.3 billion of the world population by year 2030. 1 The high proportion of people in this age group have been regarded as one of the vulnerable groups that are most affected by various conditions, particularly those related to sexual and reproductive health (SRH). 2 Globally, a great deal of researches presently has shown that young individuals currently are sexually active, which means that they hasten to engage in sexual intercourse. A study conducted among young people (aged 17-20 years) in Northern Thailand revealed that 62.4% of male and 34.4% of female had experience sexual intercourse. 3 Young individual who engage in early sexual debut are more likely to encounter with sexual health issue 4 such as teenage pregnancy (mostly unplanned), unsafe abortion, and sexually transmitted diseases. 5,6 In addition, beginning initiation of sexual intercourse early are key indicators of potential risk such as loss of self-respect, depression, and sexual transmitted infections. 7 Young individual who begin their sexual activity earlier are found to have sex with high risk behavior and are less likely to use contraceptive method. 8 The socio-demographic of young individual which comprises of personal, family and peer had a strong influence on experience of their sexual behavior. 9 Cambodia has a young population structure compared with that of other countries in Southeast Asia such as Thailand, Vietnam, and Singapore. 10 The study of risky sexual behavior among young individual in Cambodia showed that the sexually active young individual are having risky sexual behavior such as engage in multiple sexual partner and less likely to use condom. 11 Furthermore, seeking for reproductive health services among Cambodian young individual is considered paucity which bring even more vulnerable to their sexual health. 12 In addition to this study, when concentrated on the most at risk young female, a study found that the majority of those who have been pregnant  15 indicating that young individuals remain at a vulnerable position and are more likely to participate in early unsafe sexual practices.
Currently, Cambodia has a high proportion of young individuals in aged 15-24 years. In consequences, policies, programs, and development planning are required to respond effectively to their health issues, particularly in relation to reproductive health issues. Moreover, understanding of the factors that influence pre-marital sexual intercourse among young individuals is important to identify those who are at high risk of unsafe pre-marital sexual behavior and to determine solutions to their real situation and needs. Therefore, the present study aimed to examine the association between factors influencing pre-marital sexual intercourse among unmarried young individuals in Cambodia.

Methods
Study design and sample selection. This study analyzed the secondary data of the Cambodia Demographic and Health Survey (CDHS) 2014 which was the latest Demographic and Health survey conducted in Cambodia. This survey represents the information of population and health issues of Cambodian women and men aged 15-49 years nationally. This dataset provides an extensive information of sexual and reproductive health of young individual in the context of premarital sexual intercourse. The participant involved in this studied was young individual aged 15-24 years which is in accordance to the criteria defined by the United Nation. 16 To measure the premarital sexual experience of young individual, this studied selected young individual who were unmarried at the time of the survey. The total sample size for this survey was 4,972 young individual (comprised of 3,580 women and 1,392 men).
Variables. Pre-marital Sexual Intercourse was selected as outcome variable for this study. The question on premarital sexual intercourse was developed from the CDHS questionnaire that asked about age at first sexual intercourse: How old were you when you had sexual intercourse for the very first time? There are three possible answers for this question such as never had sexual intercourse, age at first union and age when had sexual intercourse. Each item was categorized into two categories as follows: YES (for had ever had pre-marital sexual intercourse) and NO (for never had sexual intercourse). While those who responded age at first union was dropped from the sample.
The explanatory variable in this study was knowledge about SRH and HIV prevention which refers to respondent's ability to answer the questions related to sexual transmitted diseases. Four questions were used for measuring this knowledge: Can people reduce their chance of getting AIDS virus by using a condom every time they have sex?; Can people reduce their chance of getting AIDS virus by having just one uninfected sexual partner who has no other sexual partner?; Is it possible for a healthy-looking person to have AIDS virus?; Do you know a place where people can go to get tested for AIDS virus? Score from these questions was classified into 3 categories: good knowledge (=4 score); moderate knowledge (=2-3 score); and poor knowledge (≤1 score). Other explanatory variables were age, sex, education, and place of residence, risky behavior (smoking), living away experience, living arrangement, and exposure to mass media. Data analysis. Data were analyzed using statistical software STATA version 14. Two analysis were applied in this study. First analysis employed descriptive statistics to determine frequencies of each variables such as age, sex, education, place of resident, risky behavior, living arrangement, and exposure to mass media, knowledge about SRH and HIV prevention and pre-marital sexual intercourse. Second, this study applied binary logistic regression as multivariate analysis to access the association between factors influencing pre-marital sexual intercourse and other selected variable, p ≤ 0.05 was considered statistically significant. The study was carried out in accordance with the ethical standards of the Helsinki Declaration. Informed consent was obtained from respondents at the start of the individual interviews. Demographic and Health Survey maintained strict standard for protecting the privacy and confidentially of respondent during data collection and data processing. Table 1 represents the frequency and percentage distribution of background characteristics among unmarried young individuals in Cambodia. Among the 4,972 selected respondents, the majority were unmarried young women (72%), and more than half (66.25%) of the total sample were aged 15-19 years. Most respondents were in secondary school, followed by primary school, higher than secondary school, and having no education (61.93%, 24.54%, 11.34%, and 2.19%, respectively). More than half of the respondents lived in rural areas (61.6%), whereas only 38.4% lived in urban areas. Regarding the frequency of exposure to mass media, most respondents reported that they did not read the newspaper or magazine at all (53.3%), whereas 30.35% read a newspaper or magazine less than once a week and only 16% read a newspaper at least once a week.

Results
Overall, 42% of respondents listened to the radio at least once a week, 29% listened to the radio less than once a week and 27.7% did not listen to the radio at all. More than half of the respondents watched television at least once a week (67.4%), whereas 15.9% did not watch television at all. More than half of the respondents (67.5%) did not access the internet at all, whereas only 25.3% accessed the internet at least once a week. The results, as summarized in Table 1, indicate that television is the most popular form of mass media among unmarried young individuals in Cambodia. Furthermore, 96% of unmarried young individual did not engage in pre-marital sexual intercourse, whereas only 4% were engaged in pre-marital sexual intercourse.
Multivariate analysis. The effect of each independent variable on the dependent variable pre-marital sexual intercourse among unmarried young individuals were summarized in Table 2. Unmarried young individuals aged 20-24 years are five times more likely to engage in pre-marital intercourse compared with those aged 15-19 years (p = 0.000), indicating a significant relationship with age. Moreover, considering the sex of the respondents, unmarried young men are almost 11 times more likely to engage in pre-marital sexual intercourse compared with young women (p = 0.000).
Regarding the place of residence, unmarried young individuals who live in rural areas are 60% less likely to engage in pre-marital sexual intercourse compared with those who live in urban areas (p = 0.000). Unmarried young individuals who lived away from their home are almost two times more likely to engage in pre-marital sexual intercourse (p = 0.001). Moreover, risky behavior (smoking) also plays an important role in the pre-marital sexual behavior of unmarried young individuals. Respondents who reported smoking were 3.8 times more likely to engage in pre-marital sexual intercourse (p = 0.000).
Other factors such as education, knowledge about SRH and HIV prevention; living arrangement; and media exposure, such as reading the newspaper, listening to the radio, watching television, and accessing the internet, did not show a statistically significant association with pre-marital sexual intercourse among unmarried young individuals in this study.

Discussion
The descriptive statistics in this study reported that unmarried young individuals in Cambodia mostly did not engage in pre-marital sexual intercourse. The proportion of those who engaged in pre-marital sexual intercourse was 4.02% (11.9% for men and 0.95% for women). Our study showed that the prevalence of premarital sexual intercourse among Cambodian unmarried young individuals was low compared with that in other neighboring countries such as Thailand 3 . However, premarital sexual intercourse is unacceptable in Cambodian society. Therefore, the prevalence of pre-marital sexual in this study is considerably high. Moreover, due to the sensitive nature of such cultural issues in the Cambodian society, the proportion of those who engaged in pre-marital sexual intercourse may still be underreported.
In regard to age differences (15-19 versus 20-24 years), our study confirmed that the percentage of unmarried young individuals who engage in pre-marital sexual intercourse is high among the older age group (20-24 years). This result is consistent with previous studies that were highlighting the same phenomenon that early sexual practices tend to appear among older young individual. 17 It is obvious that younger individuals (aged 15-19 years) may be less likely to engage in pre-marital sexual intercourse, but when considering sexual behavior, younger individuals have riskier sexual behavior than older individuals. 18 Our findings demonstrate the differences by sex in premarital sexual practices among unmarried young individuals in Cambodia. The finding that the proportion of unmarried young men who engaged in pre-marital sexual intercourse is high compared with that of unmarried young women is consistent with the findings of some previous studies, which indicate the difference between sexual practices according to the sex of young individuals. When the sex of individuals is considered, young men are more likely to initiate in premarital sexual intercourse than young women possibly because of the health consequences experienced by men and women. 19,20 The good explanation to support this finding is because of young women may at higher risk of sexual health consequences such as acquiring STI/HIV, teenage pregnancy and experience stillbirth. 21 Moreover, another best explanation to support this finding is the double standard of sex in society. In Cambodia, men seem to have more freedom than women. Women are expected to follow social norm and beliefs which allow men to enjoy their 'gender privilege', while December 2019 | Vol. 23 | No. 3 women under-value their own capacity and potential. 22 Simultaneously, confirming the traditional norm, which strongly values a woman's virginity before marriage, contributes to the fact that women are less likely to initiated in to pre-marital sexual compare to young man.
The place of residence was another factor associated with pre-marital sexual intercourse among unmarried young individuals. The finding of this study that unmarried young individuals who live in rural areas are less likely to engage in pre-marital sexual intercourse is in contrast with the findings of some previous studies. 23 However, our results can be argued by the differential development settings between urban and rural areas in the Cambodia society. Urban Cambodia seems to be more developed than rural Cambodia. Entertainment places, such as clubs, karaoke lounges, and large shopping malls, are more available in urban areas than in rural areas. 24 Therefore, compared with young individuals from rural areas, those from urban areas may have more chances for socialization with their peers and entertainment activities and are at a higher risk of various risky behaviors, which can lead them to initiate sexual intercourse.
Result from our findings showed that the incidence of engaging in pre-marital sexual intercourse is higher in young individuals who live away from their home, with almost two times the incidence compared with those who never have lived away from their home. The possible explanation for this finding is that young individuals who live away from their home live independently and are out of control of elder household member, including their parents, grandparents, relatives, or other guardians. They have more freedom than young individual who never lived away from home, to engage in various risky behaviors, including early sexual initiation. 25 Regarding risky behavior, our findings reveal a statistically significant relationship between smoking and pre-marital sexual intercourse, with almost four times the number of unmarried young individuals who smoke engaging in pre-marital sexual intercourse. With the limitation of using secondary data, we assumed that smoking is regard as a proxy factor which is not itself directly influence to pre-marital sexual intercourse of young individual, but it serve in place of an unobservable factor that significantly influence on premarital sex of young individual.

Conclusion
The results of our study among young individual in Cambodia found that young individual at the higher age group (20-24 years), male young individual and those who live in urban area are more likely to engage in premarital sexual intercourse compare to their counterpart.
Moreover, experience living away and smoking behavior are also factors which influencing premarital sexual intercourse among unmarried young individual in Cambodia. The result suggested to develop appropriate reproductive health promotion programs specifically for those who live in urban areas. In fact, government and related ministry should provide comprehensive education on SRH issues and disease prevention programs for young individuals with regard to protection from other types of sexually transmitted diseases.