Factors perceived to affect intention of sexual behaviours among junior high school students in Muang District, Thailand

Abstract This study aimed to explore factors perceived to affect the intention of premarital sexual behaviours among junior high school students in Muang District, Thailand. A stratified random sampling technique was employed to select three schools out of ten public junior high schools. A situation analysis was conducted following a focus group discussion and in-depth interview. The informants included six junior high school students, five parents, three teachers, two health professionals and two school administrators. A thematic analysis was employed for the data analysis. Results illustrated negative attitude, social media, the internet use, socio-environmental space, peer pressure, social belief, low self-efficacy, generation gap and sexual education were the factors perceived to affect the intention of sexual behaviours. An integrated implementation of a comprehensive sexual education was the way forward to increasing self-efficacy.

ABOUT THE AUTHOR Baraka Sombo Baudouin completed the first Degree in Economics, a Master's degree in Health Security Financing and Management, and his Doctor of Public Health (Dr.PH) degree in Public Health. He had been a lecturer at educational college for 2 years in the Democratic Republic of Congo. He has published three articles in the international journals. He is now working as a volunteer at Red Cross, the Democratic Republic of Congo, where he is a project manager of Expanded Programme on Immunization supported by International Federation of Red Cross. He is developing a programme to increase the preventive intention on sexual behaviours among adolescents.

PUBLIC INTEREST STATEMENT
Initiating an early sexual behaviour exposes teenage to sexually transmissible disease, teenage pregnancy, abortion, etc. The sexual behaviour had widely drawn the attention of stakeholders for its adverse outcomes. The public health policies are assigned to prevent human behaviours that can harm quality of life or wellbeing of human beings. These human behaviours are from various sources and become high-risk factors when they are not investigated. It is from this perspective that qualitative methods were used in this study to provide a deeper understanding of factors believed to be associated with the intention of sexual behaviours. Results suggested that negative attitude, social media, the internet use, socio-environmental space, peer pressure, social belief, low self-efficacy, generation gap and sexual education were the factors perceived to affect the intention of sexual behaviours. In the end, the appropriate suggestions have been sent in this paper.

Introduction
A great need to reduce sexually transmitted diseases (STDs) including human immunodeficiency viruses (HIV) and acquired immune deficiency syndrome (AIDS) was needed in the lower northern region of Thailand. A gradual increase in morbidity of STDs was reported among young people by Ministry of Public Health (MoPH) in the lower northern region of Thailand. Over the ten years, from 2006 to 2016, the lower northern region of Thailand including Phitsanulok, Phetchabun Uttaradit, Tak and Sukhothai provinces experienced a gradual increase in sexually transmitted infections among young people. The morbidity rate for STDs increased from 4.6 in 2006, to 27.30 in 2016, per 100, 000 young people (MoPH, 2015(MoPH, , 2016.The study conducted among junior high school students at tree schools in Muang District, Phitsanulok Province illustrated that there was an increasing intention of sexual activities (Baudouin et al., 2019). In this study, sexual behaviours referred to sexual activities performed by junior high school students.
The actions recommended by the World Health Organization (WHO) that both matched to prevent the intention of sexual behaviours and the teenage pregnancy urged the change of social norms, the enforcement of law against the coercive sex, the financial support to teenagers, the education on the risks of engaging in early sexual behaviours and the increase in a health service accessibility to the adolescents (Chandra- Mouli et al., 2013).
In Thailand, when defining the Thai teenage pregnancy prevention and the alleviation Act of 2016, the concept of "abstinence-only until marriage education" raised by American society was passive in Thailand because the Thai society believes that teens become sexually active. Thailand opted for a comprehensive sexual education.
The comprehensive sexual education had been one of the choices to delay the sexual debut (Browne, 2015). Mayaud and Mabey (2004) emphasized that the primary intervention of STIs consisted of changing/modifying sexual behaviour by encouraging the delay of sexual relationships initiation, sexual abstinence, being faithful, promoting safe sex, which were basically taught in the Thai comprehensive sexual education programme.
The comprehensive sexual education, as described by the Thai Teenage Pregnancy Prevention and Alleviation Act of 2016, was based on six dimensions as proposed by the sexuality information and education council of United States of America. These six dimensions comprised the development of the route for the learners concerning the sexual issues, the biological development of the body (including its functioning, the mind, the sexual and reproductive health services, the hygiene, the attitudes and the value vis-a-vis a sexual relation, the sexual relationships, and the behaviour), the social norms which had influenced the sexual behaviour, the perceived behaviour of risk factors, and the individual ability and the skills.
According to the report of UNICEF (UNICEF, 2015), the comprehensive sexual education got extended in Thailand bearing significant results in the reduction of the teen pregnancy. For instance number of teenagers between the ages of 10 and 19 years who gave birth to a child decreased from 362 to 316 between 2011 and 2014. However, the proportion of the birth and the repeated birth did not decrease. The reasons evocated here were lining up between: 1) the guardians or the parents of pregnant adolescents did not address children sexual issues and had little supervision on their children; 2) the gender role in the comprehensive sexual education was that girls, although they got the sexual education, they were weak at negotiating the use of the condom; 3) the exposure to the social media, the peer influence changed their behaviour from perceiving the risk of sexual behaviours to the recklessness; 4) an inconsistent policy implementation, and an incoherent answer given to a same issue related to the sexual reproductive health; 5) a risky behaviour or a lifestyle such as the drugs and the alcohol use, the sex workers, sociodemographic factors like the economic status/economic barrier, the cultural norms, the peer pressure, the rural exodus, etc., and 6) the stigmatization of the younger mother by the guardians or the parents because their daughter became a mother at home (UNICEF, 2015).
Among the reasons behind the no decrease of the proportion of the birth and the no decrease in the repeated birth were the incoherent answer given to the sexual behaviour. The incoherent answer remained the major problem to be solved. Additionally, the integration of the comprehensive sexuality education was quite not fully implemented. The report of the Ministry of Education (MoE) of Thailand (MoE, 2016) revealed that the majority of teachers affirmed that the comprehensive sexual education was taught as a separate subject (83.3%) for instance, in vocational schools. Only two or three schools integrated the comprehensive sexual education as part of curriculum over 25 studied. The timing and the session were also different. Notably, the vocational schools provided the comprehensive sexuality education as a separate subject. The comprehensive sexual education was taught 18-20 learning sessions lasting 45-55 minutes, while as part, it was learned 6-13 sessions lasting 50-60 minutes. Additionally, not all topics were covered. The understanding was that the comprehensive sexual education was not integrally implemented, therefore induced low self-awareness.
According to the theory of planned behaviour, the intention is born of a perceived attitude, social norms and self-efficacy behaviours, and then produces a behaviour (Ajzen, 1985). The theory of planned behaviour was developed as a setoff of predicting a person's behaviour (Asare, 2015). Additionally, studies in psychology and sociology had shown that the intention causes the behaviours (Webb & Sheeran, 2006) and that the stronger the intention was engaged in an actual behaviour, the more likely it intended to accomplish that behaviour (Asare, 2015). Attitude, subjective norm and perceived behaviour were the sets which influenced person's belief to engage in a given behaviour (Leon et al., 2012), including the sexual behaviour as a typical case in this study. Basically, permissive attitude, perceived social norms and perceived self-efficacy created sexual intention, which created the sexual behaviour (Muhammad et al., 2017).

Sampling technique
Ten public junior high schools having 1795 students were numbered in Muang District. Junior high school students referred to 3 years of lower secondary students between the grades of 7-9 and between the ages of 12-15 years according to the Thai Education System. A stratified random sampling technique was used to select three schools out of ten. The ten schools were grouped in three strata comprising small, medium and large schools. One school was purposively selected out of each stratum. This resulted in selecting three schools. These three schools were located in the Sub-District of Phlai Chumphon health-promoting hospital area, Muang District, Phitsanulok Province. The health-promoting hospital, according to Thai health system, provides not only high quality comprehensive medical and nursing services, but also embraces the aims of health promotion, develops a health-promoting organizational structure and culture, including active, participatory roles for patients. Eighteen informants were invited to each group for discussion. However, only six students, five parents, two health professionals, three teachers and two school administrators accepted the invitation. The informants' low turnout in the study was justified by the fact that sexuality was a sensitive topic in Thai society. In total, 18 informants were willing to participate in the study. Apart from the category of students who were aged between 13 and 15 years, the informants were aged between 45 and 55 years.

Approaching informants
Prior data collection, the facilitator who was the corresponding author of this study, contacted the directors of the schools and the director of the health-promoting hospital. The purpose and the significance of the study were explained to them. On the consent, the invitation was sent to the informants. Additional formal consents were sought from the parents to allow their children to participate in the study.

Instrument
An interview form was used to question the informants. Open-ended specific questionnaires were employed to identify the factors perceived to affect the intention of sexual behaviours.

Data collection
A homogenous focus group discussion was conducted among five parents whose children were studying at the three-selected schools and six junior high school students. In-depth interviews were employed among two health care personnel, three teachers and two school administrators. The researcher was assisted by three research assistants who were Thai natives. They had prior been briefed on the methods of the data collection. They assisted in interviewing the informants. During the focus group discussion and the in-depth interview, they assisted in recording pieces of information. Prior to the audio recording, consents were obtained from the informants.
On 22 February 2019 four interviews were conducted namely with students, teachers and administrators of schools at Tha Thong Phitthayakhom School. The school meeting rooms were arranged for the focus discussions; while health personnel were in-depth interviewed at the Sub-District health-promoting hospital. The hospital meeting room was arranged for the interview. On 25 February 2019, an interview was conducted at Tha Thong Phitthayakhom School with parents of students. Each interview took around one hour and half. The informants were honoured by the researcher for their kindness.

Data analysis
For this study, a deductive thematic analysis was used. The thematic analysis meant a tool comprising a procedure to identify patterns and themes in qualitative data (Maguire & Delahunt, 2017). While being a tool, according to Braun and Clarke (2006), the identification of the themes in a thematic analysis is normally done in two ways. One way consists of coding data regarding framework or theory; while the other way consisted of coding data regarding data itself called also "data driven". The theoretical thematic or conceptual framework analysis also known as top-down approach is deductive, and is guided by a specific question; while a "data-driven" thematic analysis also known as bottom up is inductive, and is guided by data itself.
The identification of the themes was coded regarding conceptual framework and the theory of planned behaviours (Ajzen, 1991). The planned behaviours of the students regarding the intention to prevent sexual behaviours were driven by their perceived attitude (positive and negative attitude). Their planned behaviours were also driven by their perceived social norms (peer pressure and belief pressure).
The step below presented the six steps of data analysis as described by Braun and Clarke (2006): (1) Becoming familiar with the data/Generating the initial codes

Becoming familiar with data
In this first step of thematic analysis, the transcripts were thoroughly read and the following was the striking answer. As explained by an informant who was a health care personal: The problem with children is that they do not have enough knowledge and skills to refuse, reject premarital sexual behaviours. Most of children do not have the knowledge of their own body (referring to biological development of the body and its functioning etc.).

Generating initial codes
This part is concerned about organizing the data in structured way. It was about grouping the data meaningfully, in a systematic way, known as coding.

Searching for the themes
As signified previously, a thematic analysis was used in this study. The themes seized what seemed to be meaningful. Themes were formed by how significantly they contributed to answer specific questions (Braun & Clarke, 2006). Answers from the participants were reviewed in the guidelines with the theory of planned behaviour and conceptual framework.
An initial mapping tool was used to depict 10 themes of the study regarding the answers of the participants. These themes were social norms (peer pressure, social belief), attitude (positive and negative), self-efficacy, intention of sexual behaviours, solution to prevent the intention of sexual behaviours, sexual education, parenting style, age demarcation of students and people they consulted with (parents, teachers and health personals), social media, and the theme adverse outcome (STDs, teenage pregnancy and school dropout).

Reviewing the themes
The next consideration was whether the themes made sense. In this step, the initial themes were refined. Succinctly, (1) The theme social transformation was modified into social norms. Social norms broke up into two sub-themes peer pressure and (2) The sub-theme social belief. Social norms stood still in their components peer pressure and social belief.
(3) The theme positive attitude was eliminated because the answers of students indicated that the attitude was negative. Therefore, there remained negative attitude.
(4) The theme self-efficacy stood still, however was found low according to the answers of the informants. Therefore, the new theme low self-efficacy was created.
(5) The theme the intention of sexual behaviours was intact.
(6) The theme solution to prevent the intention of sexual behaviours and sexual education were combined to form the theme sexual education as one theme since the two themes explained the same idea.
(7) The theme parenting was modified according to the data. The data presented that there was low parenting style. In other way, parents intended rarely to communicate with their children. Therefore, there remained the theme low parenting style.
(8) The theme age demarcation did not change.
(9) The social media in its component the internet use was not modified.
(10) The theme negative outcome collapsed alongside the sub-theme STDs, teenage pregnancy and school dropout since they were not fitting in addressing the objective.
Therefore, nine autonomous themes were retained, namely peer pressure, social belief, attitude (negative), self-efficacy (low), sexual education (as to boost the self-efficacy which was low), low parenting, social media, age demarcation and intention of sexual behaviours.

Defining the themes
In this step, the themes and subthemes were defined. Essentially, this stage described how the nine autonomous themes, which were previously identified at the step 4, were reduced to two themes to address the objective and the policy implication of the study. On one side, the factors perceived to motivate/stimulate the intention of sexual behaviours, such as social norms (peer pressure and social belief), attitude (negative) and self-efficacy (low). On the other side, the perceived factor to refrain the intention of sexual behaviours, such as the sexual education (as the way to boost the self-efficacy which was low). Figure 1 below depicted the factors perceived to affect the intention of sexual behaviours. The results suggested that the social media, internet use, socio-environmental space, peer pressure, negative attitude and low self-efficacy stimulated the intention of sexual behaviours; while sexual education discouraged/refrained the intention of sexual behaviours.

Internet use, social media and negative attitude
The factors perceived to influence the intention of sexual behaviours were motivated by the adverse information/education students received on the internet and the social media including YouTube, TV, Twitter, Facebook, the internet, etc. This induced a negative attitude towards preventing the intention of sexual behaviours. As explained by an informant who was a parent: Various media make to communicate easily each other using phone calls, Facebook chats, etc. What follows is the meeting to have sex. Additionally, at present, an adolescent can freely and easily access media, videos clips, pamphlets or pornographic documentations, etc., which provoke sexual emotions.
The adverse information received from the social media and the internet were perceived as the great challenge to the sexual education programme, therefore challenge to self-awareness to prevent the intention of sexual behaviours and the adverse outcomes. Facing the challenge, the school had the policy of collecting students' phones in a basket. Students could take back their phones only when they were going back home. As explained by an informant who was a school administrator: We have the guideline of not using phones at school. Phones are kept in a basket and are given back to students when they are going back home.
Additionally, the attitude of students was negative towards preventing sexual behaviours and was mainly influenced by the adverse information students received on the social media and the internet use. As explained by an informant who was a student: The teenage sexuality is normal. Sexuality is not a serious problem.
Students viewed sexual behaviours a kind of activity anyone can enjoy on. When the informants of category teachers were asked whether sexual behaviours were a problem at school, they explained that students were obsessed with sexual behaviours. As explained by an informant who was a teacher: Yes, yes, children of nowadays are not like our generations, flirting each other, descent dressing, dare to ask for sex, etc. Children are very obsessed with the sexuality.
Studies depicted internet use and various social media access as a great challenge towards preventing the intention of sexual behaviours (Asekun-Olarinmoye et al., 2014). Likewise, this study showed that students received adverse information on internet and various social media. As confessed by an informant who was a teacher: The opinion is that today information technology progresses faster. There is no restriction, e.g., the TV show concerning a couple cheating each other. There should be an access with an age restriction. There is a lot on internet. The mobile phone has lines with various apps. Children receive adverse information/education from there (referring to TV show, YouTube . . .) very quickly. We do not know why the Ministry of Digital Economy and Society is not restricting children to have access to indecent documentations. For instance, when we watch news and find information on sex bouncing up; they should inform us by indicating age restriction.
The way forward could be phone users' registration by the age groups and restriction of the inappropriate apps to teenagers.

Socio-environmental space
Furthermore, the environmental conditions, such as hidden places were the barriers to prevent the intention of sexual behaviours. As explained by an informant who was a parent: At present, children often go to the public parks whereby the community leaders should set Closed-circuit televisions (CCTV) surveillance to discourage children to have funs (sexual activities).
Students mostly found the opportunity to behave sexually when they were at outreach of the guardians/parents and teachers, for instance in their own room/house, partner's room/house, friend's room/house, motel or hotel, car, public parks, etc. (Tangmunkongvorakul et al., 2011) Additionally, social norms referred to the perceived social pressure felt by a person towards taking part in a particular behaviour (Leon et al., 2012). Peer influenced the behaviour of students in two ways: one way was submitting the behaviour regarding what others perceived important norm and adjusting the behaviour accordingly. This was called social belief. An informant who was a parent explained: The children of these generations cannot be prohibited the sexual intercourse. It is difficult from being seen as the result of the current social environment.
Social belief environment seemed very enthusiastic and was a great pressure that students received to stimulate the intention of sexual behaviours (Leon et al., 2012;Muhammad et al., 2017).

Peer pressure
Another way student felt social influence was peer pressure. The students who perceived that a peer would approve sexual intercourse intended to go for it, or student who perceived that peer had prior been engaged in premarital sexual behaviours would partake with him/her (Cleland;Muhammad et al., 2017). The peer pressure stimulated the intention of sexual behaviours among students. An informant who was a student explained: What fuels to have more premature sex is being tempted by a lover, requesting for sex, going out privately, having closer friends etc.
Regarding peer pressure, sexual behaviours were fuelled by a coercive sexuality and friendships. In accordance with Grontvedt et al. (2015), men initiated sexual relationships to release pressure, while women were engaged in a sexual intercourse through relationships. Likewise, the coercive sexual intention was perceived among male students, compared to female students; while the sexual intention motivated by friendships was perceived among female students compared to male students. As explained by an informant who was a teacher: When they are closer to each other, there will be a need of sex. Male want to hug. Male want to catch. Female are afraid of losing friend. Hence, female cannot reject sexual intercourse.

Self-efficacy
Sexual education served as the guideline at different levels namely, at school level, at home level and also at any public governmental agencies level such health-promoting hospitals level. Sexual education taught students to situate themselves in the context of avoiding premarital sexual behaviours. Teaching provided skills on abstinence of premarital sexual behaviours and its negative outcomes. As explained by an informant who was a teacher: To prevent intention of sexual behaviour, we have the programme to teach the students. We try to teach them especially morals and ethics, allowing them to situate themselves in the context of avoiding premarital sexual behaviours, pointing out that having sex before age is not appropriate because it will cause them to lose a brighter future.
However, the health care personals explained that the students had a limited knowledge to prevent the intention on sexual behaviours, which induced the sexual abstinence when they felt peer pressure. As explained by an informant who was a health care personal: The problem with children is that they do not have enough knowledge and skills to refuse, reject premarital sexual behaviours. Most of children do not have the knowledge of their own body (referring to biological development of the body and its functioning).
The ability of students to prevent the intention of sexual behaviours was empowered by the knowledge students had acquired related to adverse outcomes during the sexual education classes (Leon et al., 2012;Muhammad et al., 2017). However, the generation gap between students and people students consulted with limited knowledge. The generation gap was seen as the barrier at the point that students feared to disclose their problem to the parents, teachers and health personals because students were younger and feared a repression. As explained by an informant who was a student: So far most of people who give the advice to us are of old age. We should have some of our friends trained and who are of our age to give us a counselling or advice. Because most of teenagers tend to consult more with friends than elders (referring to parents and teachers, health care personals etc.) due to fear of being reprimanded by them (elders).
The parents, teachers and health care personals were difficult to approach by children/students because students feared the repression. Likewise, it was illustrated in South Africa that students experienced a repressive reaction from the parents when they would like to seek for information about the sexual and reproductive health (Ngidi et al., 2016). This study illustrated that the generation gap was a real barrier to students to gain the information which could refrain the intention of sexual behaviours. Parents were imposing their own views without further discussing sexual and reproductive health issues with children.
Additionally, the frequent separations between parents and children induced by the job occupation led children and parents to have rare meetings to discuss sexual and reproductive health issues. As explained by an informant who was a teacher: Most of the students here are only children whose parents are not at home. Sometimes they go to work in countryside. This mode of living allows parents to separate with their children. Parents have no time to talk with their children. Children are left with relatives, especially, with the grandparents. Grandparents do not react when grandchildren behave sexually.
The other concept behind the management and the prevention of sexual behaviour was that a child or a younger person to whom an elder tells off a behaviour is not likely to repeat the same behaviour at least in the presence of the elder. Basically, identifying behaviours, classifying them, naming including the driving factors would help in managing sexual behaviours.
The job occupation allowed parents to separate from their children. Some of them were employed far away from their home. The employment at long distance induced not only their tardive return at home, but also made it hard for parents to communicate with their children (students). Frequent separations of the parents with children induced less children monitoring, less communicating with children and low parenting. Likewise, it was suggested by the study conducted in Tanzania that parents should watch on their children (Mlunde et al., 2012). When parents were at work, the grandparents were the perceived relatives who looked after their grandchildren. The grandparents were passive to tell off their grandchildren for behaving sexually. Basically, grandparents viewed sexual behaviours as playful, while teachers, parents and health personnel as a subject to great concerns. Relatives (grandparents) gave different answers to sexual behaviours compared to teachers, parents and health personnel. A unique and identical answer is required from all stakeholders involved in decision-making to prevent the intention of sexual behaviours.

Discussion
This paper aimed to explore perceived factors affecting intention of premarital sexual behaviours among junior high school students in Muang District, Phisttanulok Province. The social media and internet use, negative attitude, socio-environmental space, peer pressure and coercive sexuality, low self-efficacy level and the generation gap were the perceived behavioural determinants of students to stimulate the intention of sexual behaviours; while sexual education in its component of self-efficacy was the factor perceived to prevent the intention sexual behaviours.
The students received the adverse information/education on the social media and the internet making them reckless regarding the sexual behaviours and the adverse outcomes. This induced the negative attitude. This study incited phone users' registration by the age groups and suggested inappropriate apps restriction to teenagers. Relatives (grandparents) gave different answers to sexual behaviours compared to teachers, parents and health personnel: Some viewed sexual behaviours as playful, while others as a subject of great concerns. Therefore, this study suggested an identical and unique response to sexual behaviours across members of the family, relatives, health personnel and staff at school. The paper emphasized the self-efficacy of students was low. The informants explained that the students had a limited knowledge to prevent the intention of sexual behaviours. The reintegration of the sexual education to boost the self-awareness was the wish.
The situation analysis was marked by the identification of the perceived behavioural determinants which influenced intention of sexual behaviours. The practical approaches to induce behavioural change comprised three approaches, namely the sexual education programme, parenting, law and regulation approaches.
The results of this study were in conformity with Camilleri (2013) who found sexual behaviours were gradually attracting young people. Techasrivichien et al. (2016) explained sexual behaviours were increasing among new generations comparing with old ones. This study emphasized students