Social Connectedness as a Predictor of Sexual Behaviour

This chapter describes the systematic literature review that was conducted to examine the existing quantitative evidence of social connectedness as a predictor of sexual behaviour among Asian adolescents globally. The results and conclusions from this review informed the data analysis.

Adolescence is a pivotal period that can impact on future health and wellbeing of individuals, including sexual and reproductive health (1). During this period, there are many factors that influence behaviour which can eventually contribute to negative or positive health outcomes (2). The quality of an adolescent’s social relationships and emotional attachment with family, peer group, school, community and culture is important for their positive development which can help them to become a healthy adult (3). As detailed in the previous chapter, the influence of social connectedness, including parenting in adolescents (4), neighbourhood and school environments and, family and peer norms, on adolescent sexual behaviour is known (5). However, whether these influences impact on sexual behaviour of Asian adolescents is unclear.

In many Asian cultures sexuality and sexual behaviour is viewed as taboo topics with strict restrictions placed on young Asians (6) with likely influences on their sexual behaviours. The aim of this systematic review is to identify the influence of social connectedness on sexual behaviour outcomes among Asian adolescents. This systematic review is a narrative summary of the quantitative findings rather than a meta-analysis.

Methods

Search strategy

A systematic review was conducted on studies reporting social connectedness as predictors of sexual behaviour among Asian adolescents. Articles were searched in the following databases: Scopus, PsychInfo and Medline (Ovid) using the search terms including variations of the Boolean terms for sexual behaviour (e.g. sexual health OR reproductive health OR sexual activity OR sexuality OR intercourse), connection (e.g. social environment OR social network OR kinship OR attachment OR bonding OR connectedness OR connectivity OR parenting OR family OR peer relationship), students (e.g. adolescents OR teens OR youth OR young people) and Asia (e.g. Indian OR Chinese OR Southeast Asian). We also included specific ethnic groups according to Stats NZ, for expanding the results for all of the Asian groups (e.g. Bangladeshi, Japanese, Korean OR Nepalese OR Pakistani OR Afghani OR Sri Lankan OR Filipino OR Taiwanese OR Cambodian OR Vietnamese OR Burmese OR Indonesian OR Laotian OR Malay OR Thai OR Eurasian) (7). Furthermore, we searched for relevant articles manually by reviewing the reference lists of the recent review articles and through Google Scholar.

Eligibility criteria

The papers from the search were retrieved and read to ascertain if the eligibility criteria for the systematic review were met.

Inclusion criteria were:

• All quantitative studies measuring association between social connectedness and sexual behaviour, even if it was not the main domain.
• All studies published in peer-reviewed journals between the year 2008 and 2016.
• The studies published in English language.
• All studies comprising of adolescents (10 to 19 years of age) as their study population.
• All studies conducted in an Asian country or with the Asian population.

Exclusion criteria were:

• Qualitative studies.
• Mixed method studies that did not report or include quantitative findings relevant to the review question.
• Interventional studies.
• The studies comprising of only non-Asian groups or with no ethnicity provided.

Results

The initial search identified 531 articles (292 in Scopus, 167 in PsychInfo and 72 in Medline (Ovid)), of which 193 remained after exclusion of irrelevant titles and duplicates (Figure 1). Furthermore, the abstracts were thoroughly screened using eligibility criteria. After excluding nine reviews, 79 articles were selected from abstract screening. Among the 79 selected articles, four were made available via interlibrary loan whereas full text was not available for another four articles. Subsequently, 39 articles were excluded as they did not meet the age criteria i.e. 10 to 19 years from the remaining 75 articles.

The remaining 36 articles were thoroughly read and categorised into the study types (24 quantitative, eight qualitative and four mixed method studies). Of these 24 quantitative studies, two were rejected by topic among which one dealt with sexual orientation only whereas the other was about recruiting Chinese American population for HIV/AIDS study. Another two studies were rejected as they used same dataset i.e. Thai Family Matter Project. One study was excluded as it was an interventional study and did not match the eligibility criteria. Another study which was based on mixed ethnicity was excluded as it did not report findings for Asian population separately.

The remaining 18 articles from the quantitative studies were selected to be included in the review and the outcomes and results were extracted for analysis. An additional article was added from the manual reference search which lead to 19 final articles for the systematic review. Figure 1 shows the detailed processing of all the 531 articles for final inclusion in the analysis.

Quality of the individual studies were assessed by using Quality Assessment Tool for Quantitative Studies from Effective public Health Practice project assessment tool headings (27). The parts for dropouts and withdrawal of participants was excluded as majority of the studies were cross-sectional studies. The studies were assessed in terms of study design, selection bias during participation selection, data collection method and confounders used as independent variables. The studies were given points according to the assessment and the quality was established after adding up the total points.

The extracted data from the final studies were compiled in an Excel sheet. This segregation of data represented different aspects, including: country of survey, published year, age group of participants, sample size, study type, dependent and independent variables used, and major findings of the study. The data were compiled according to the type of connectedness and the type of relationship shown by the study.

Figure 1 Selection of research articles to review

Results from the 19 studies that met our inclusion criteria are summarised in the evidence table (Appendix 1) and in the summary table (Table 1). The overall findings are first presented followed by the results for each of the five sub-constructs/domains of social connectedness and, for male and female adolescents.

Most studies included in our review were cross-sectional (n=14) in nature (8-21). However, there were some studies that used longitudinal survey data (n=4) (22-25), and there was one case-control study (26).

All studies included had strong qualities to be assessed as a quantitative study with the sample size ranging from 420 to 23645 participants. Sample size estimation and total response rate were taken into consideration for selection bias. One study did not mention the response rate in the study (Predictors of sexual risk behaviour among adolescents from welfare institutions: Malaysia) and one study had less than 80% response rate ( health risk behaviour among foreign born). Remaining studies had response rate of over 80% for their analysis. All studies used demographic characteristics as independent variable and were used to adjust and identify differences in the outcome variable. Almost all studies used self-administered questionnaire for data collection through various means such as paper based questionnaire and internet based questionnaire. Three studies used face to face interview with the participants (Concurrent multiple health risk behaviors among adolescents in Luangnamtha province, Lao PDR) (Premarital Sexual Intercourse Among Adolescents in an Asian Country: Multilevel Ecological Factors) (Gender Differences in Partner Influences and Barriers to Condom Use Among Heterosexual Adolescents Attending a Public Sexually Transmitted Infection Clinic in Singapore) among which two studies adopted similar method of self-administering sensitive questions at the end of the data collection (Premarital Sexual Intercourse Among Adolescents in an Asian Country: Multilevel Ecological Factors) (Gender Differences in Partner Influences and Barriers to Condom Use Among Heterosexual Adolescents Attending a Public Sexually Transmitted Infection Clinic in Singapore).

Most studies (n=18) included in the review were conducted in Asian countries, whereas one study was conducted in the USA (25). This study identified differences in the predictors of sexual behaviour among different Asian groups in the USA. Another study conducted in Singapore focussed on recognising the differences between local Singaporean adolescents and foreign-born adolescents (11). It emphasised on the variation in the results due to acculturation gap between children and their parents, and the effect of robust risk factors on both the groups (11).

Three studies included immigrants as their participants for the study (11, 24, 25). A study conducted among local and non-local Hong Kong students displayed how immigration status was associated with sexual behaviour (24). The non-local students migrating from China had stronger desire to engage in sexual behaviour than the local students from Hong Kong. The study explained how the Chinese immigrants who were strictly controlled from sexual materials were more involved in risky behaviour in Hong Kong as they were more exposed to the contents. Furthermore, Choo et al. (2010) presented similar findings which reported significantly higher rates of sexual intercourse among foreign-born adolescents (11). The pressure and expectations from parents to present themselves in a certain way created additional trauma in the non-local adolescents (28). Therefore, acculturation difficulties and generation gap were mentioned as causative factor for reduced bonding with family as well as increased risky sexual behaviour (11, 25).

Sexual initiation and sexual debut at an early age was described as a risky sexual behaviour in most (16 out of 19) of the studies (8, 9, 11-18, 20, 21, 23-26). The main outcome variable was condom use in six studies, multiple sexual partners in three studies (12, 14, 21) and sexually transmitted diseases in one study (22).

Table 1 Summary of studies according to specific domain

Domain	Specific influence	Risk factors	Protective factors	No association
Family	Parental communication and connectedness	One study	Six studies (12, 16, 18, 19, 23, 26)	One study (25)
	Authoritative parents/parental supervision	One study (26)	One study (18)	One study (16)
	Parental disapproval		One study (9)
	Proper family structure and functioning	One study (14)	Six studies (12, 20-22, 24, 26)
School	Schooling and attachment to school		Four studies (8, 9, 12, 13)	One study (21)
Peer	Peer influence	Eleven studies (10-13, 17, 19-21, 23, 25, 26)
	Peer support		Three studies (16, 17, 20)
Community	Societal attributes/good neighbourhood		Three studies (21, 24, 26)
	Exposure to media	Two studies (9, 15)

Overall, most studies included in this systematic review focussed on family and peer connectedness (Table 1). Most studies having family connectedness as main domain showed that family connectedness could act as a protective factor against risky sexual behaviour, whereas most studies having peer relationship as the main domain showed that peer connectedness could act as risk factor in adolescents for adopting risky sexual behaviour. Likewise, more attachment with school could also act as a protective factor. Exposure to violence and easy access to media in the community could act as risk factor for risky sexual behaviour whereas, having good societal attributes and good neighbourhood could act as a protective factor against risky sexual behaviour.

Sub-constructs/Domains

Family

There are many studies that suggest parental connectedness and parent-children relationship to relate directly with their children’s behaviour (29). Seven studies measured relationship between parental communication/connectedness and sexual behaviour (10, 12, 16, 18, 19, 23, 25, 26). There was enough evidence (six out of seven studies) to show protective relationship between parental connectedness/communication and sexual behaviour (12, 16, 18, 19, 23, 26). Most studies used measures such as parental communication, maternal communication, parental connectedness, discussion about sex with parents, support from parents and functioning happily married parents. Lack of support from mother in females and having divorced parents in males were significantly associated with premarital sex in Singapore (26) In contrast, one study showed negative correlation between parental communication and sexual behaviour. The study conducted among Asian American Pacific Islanders (AAPI) did not support the notion that mothers’ perception of sexual discussion would be protective against sexual initiation, which was assumed due to culture and language barriers among different generations (25). This study however, showed differing results between perception of mothers and their children in which the mother’s perception of sexual discussion was protective against sexual initiation whereas, the perception of adolescent on sexual discussion had no significant association with sexual initiation and behaviour.

Two studies measured association between parental monitoring and sexual behaviour among adolescents among which one showed protective nature (18), whereas the other showed no relationship (16). One study showed negative association between authoritative parenting and premarital sexual initiation (26).

One study showed protective relationship between parental disapproval of having sex and sexual intercourse (9).

Almost all studies that mentioned family connectedness/functioning/intactness/structure showed protective factor for risky sexual behaviour (n=6) (12, 20-22, 24, 26). Conversely, one study showed the contradicting result. Family intactness acted as risk factor for sexual risk behaviour among the female adolescents of Malaysia (14). However, there was sufficient evidence to suggest that proper family structure/proper functioning family can be protective factor for risky sexual behaviour.

School

Five studies measured association between schooling/attachment to school and sexual behaviour among adolescents (8, 9, 12, 13, 21). Most of them suggested that better schooling and attachment to school can be protective for risky sexual behaviour in adolescents (n=4). In a study conducted among Thai adolescents, school attachment acted as a significant protective factor for intentions to have sex (9). Similarly, individual school level satisfaction was concluded to be a protective factor for sexual activities among Japanese high school students (8). However, in a study conducted in Cambodia, school attachment showed no association with risky sexual behaviour after controlling for covariates, which showed protective factors for female adolescents before adjustments (21).

Peer

Twelve studies measured association between peer attachment/influence and risky sexual behaviour. Among them, nine studies showed how peer-influence and peer pressure is related to risky sexual behaviour (10-13, 19, 21, 23, 25, 26), whereas one study showed how peer support is related to risky sexual behaviour (21). Two studies showed both these relationships in their results (17, 20).

After categorising peer relationship into peer pressure and peer support, peer support and attachment with friends were found to help the adolescents to abstain from risky sexual behaviours (n=3) (16, 17, 20). Correspondingly, there was enough evidence to show (n=11) that peer pressure and influence can be a risk factor for adolescents involving in risky sexual behaviour (10-13, 17, 19-21, 23, 26). Lee et al. revealed how peer-influence and peer support/attachment can have varying effect on South Korean adolescents’ behaviour (17). While sexting photos of others, adolescents were found to be highly influenced by the peers and their pressure. This risky behaviour was minimal when it came to someone they were attached with and had close connection with. Similar to this result of peer attachment, risky sexual activity was found to be minimal among the adolescents who had supportive friends and shared close bond with each other (16).

Community/Neighbourhood

All studies assessing relationship between community/neighbourhood and sexual behaviour showed similar results (n=3) (21, 24, 26). Belonging to a disturbed neighbourhood and exposure to violence in the community were significantly associated with increasing risky sexual behaviour among adolescents. In a study conducted among 500 Singaporean adolescents, exposure to gang activities in neighbourhood among boys was significantly associated with higher risk of premarital sexual initiation. The same study showed how history of sexual abuse was associated with premarital sexual initiation among female adolescents (26). Another study conducted among high school students in Cambodia also reported the association between risky sexual behaviour and exposure to community violence in females (21).

In contrast, adolescents having positive youth development attributes and those with the intention to help others by benefitting the society were less likely to be involved in risky sexual behaviour (24), indicating a protective factor.

In addition, two studies showed how easy access to sexually explicit online contents from the community could lead to risky sexual behaviour among adolescents (9, 15). These studies show that more exposure to contents in the community could cause increase in risky sexual behaviour among adolescents.

Gender differences

Nine out of 19 studies included in our study measured differences in sexual behaviour and connectedness according to sex (10, 13-15, 18, 20, 21, 24, 26). These were done for the multivariate analysis to identify the predictors according to different gender. Li et al. examined the role of self, familial and extra-familial systems as factors of premarital sex in the study conducted only among male adolescents in Bangladesh (23). Contrary to this study, Ahmadian et al. scrutinized the risk and protective factors for sexual behaviours among female students in rural Malaysia (12).

Most of the studies had similar results for both the sexes. Four studies out of nine mentioned peer influence to be one of the major predictors for risky sexual behaviour (13, 20, 21, 26) .The results were similar for both males and females. In a study conducted in Hong Kong, both boys and girls showed risky sexual behaviour due to lack of confidence to resist peer pressure (13).

Family functioning and intactness can be a major protective factor for risky sexual behaviour among adolescents as mentioned by seven studies. The gender categorisation revealed that proper family functioning and family intactness can be a protective factor for risky sexual behaviour, mostly among female adolescents (14, 20, 21). de Irala et al. also suggested that female adolescents are more sensitive and they care more about the supporting environment than the male adolescents (15).

While delving into the intentions that the adolescents had to engage in sexual intercourse, boys had stronger intention than girls to engage in sexual relation in couple of years (24). Exposure to community violence, abuse and bad neighbourhood were associated with the increase in risky sexual behaviour in both the gender.

Discussion

This review indicates that there is a protective association between sexual behaviour and parental connectedness (parental communication, maternal communication, parental connectedness, discussion about sex with parents, support from parents and functioning happily married parents), family connectedness/functioning/intactness/structure, school connectedness, peer attachment and support, and belonging to community with good values. The findings are similar to a previous review of studies conducted from 1985 to 2007 among adolescents (3) from United States of America, Europe, Australia and New Zealand. The findings of which suggested insufficient evidence for peer connectedness and community connectedness. It included over 190 studies for analysis and categorised the findings into eight domains: family connectedness, parent–adolescent general communication, parent–adolescent sexuality communication, parental monitoring, peer connectedness, partner connectedness, school connectedness, and community connectedness. This review includes only 19 studies leading the domains to be generalised into four categories. Nevertheless, this review among Asian adolescents has enough studies that discuss peer connectedness but not community connectedness.

The studies included in this review have moderate to strong rating based on the quality assessment. Inclusion of many cross-sectional observational studies have lead the studies to slightly lower the assessment points. However, the final rating still shows the studies to be moderate to strong quantitative studies.

Six out of eight studies showed family connectedness to be protective factor, which was similar to the review conducted among American high-risk youths attending alternative high school where family connectedness acted as a protective factor against sexual risk-taking (30, 31). In contrast, peer influence and authoritative parenting could act as a risk factor for risky sexual behaviour among Asian adolescents. The result is similar to other reviews and studies conducted among adolescents in general (32, 33). Adolescents who have sexually active friends are more likely to be sexually involved themselves (32). Similarly, being exposed to violence in the community/neighbourhood could also lead to engaging in risky sexual behaviour. In contrast, those adolescents who had good opinion about their neighbourhood were less likely to engage in risky sexual behaviour. There are studies showing that engagement in the community activities and participation in the neighbourhood could display protective factor against risky sexual behaviour (34).

There was no significant association between school attachment and sexual behaviour in a study conducted in Cambodia. The significant association was shown to be peer delinquency and peer pressure in this study. While discussing about closeness, adolescents are more inclined to be influenced by their friends than their family and school (35, 36). This could also mean that the adolescent participants of the study were chose the factors that were more likely to influence their behaviour rather than choosing all the factors responsible.

While most of the results were similar for boys and girls, family connectedness was shown as a protective factor mostly for females. de Irala et al. suggested that female adolescents are more sensitive and they care more about the supporting environment than the male adolescents (15). It has also been known that females are more likely to be monitored and supervised than the males by their family (37-39). The difference in the supervision and monitoring carried out by the parents could possibly lead to different behaviour that they exhibit. In contrast, family connectedness acted as a risk factor for sexual risk behaviour among the female adolescents in Malaysia. This result is contradictory to other findings from the literature. This may be due to the difference in perception about connectedness with family and the exclusion of parental monitoring as an influencing factor (14). Studies have shown that controlled behaviour by the caregiver fosters good relationship between caregiver and the adolescent (29).

There was no significant correlation between perception of parental communication and sexual behaviour among Asian American Pacific Islander adolescents. The reasons behind could possibly be the adaptation behaviour of adolescents who value the perception of their mother more than themselves (25). Hence, there is a need for more in-depth research about the perception of connectedness and sexual behaviour among Asian adolescents.

Cultural influence on connectedness with their family, peers, school or neighbourhood and sexual behaviour among Asian adolescents is discussed in many studies (40-43). Sex is viewed as a taboo topic in Asian cultures and the influence of traditional values still hold a strong position in the lives of Asian adolescents which could cause problems in social connectedness (44). Therefore, there is a need of more in-depth research on this topic to use interventional studies to address social connectedness among Asian adolescents.

The results show awkwardness and embarrassment among Asian adolescents to talk about sex related issues with their family, teachers and other relatives. Parents and schools have mentioned that sex-talks with their children could help them ease up in getting correct information which could influence their sexual behaviour (41, 42). Hence, there is a need to introduce positive youth development programs that help the families to adopt positive parenting, effective communication, familial support, and increase adolescents’ engagement (3). In addition, there should be programs in schools to provide interactive sex education which are culturally sensitive and are delivered in a right-based approach (3, 45). These could help the adolescents in receiving correct information and reduce the guilt and anxiety in them controlling them to show deviant behaviour.

This systematic review performs two major tasks: reviewing and comparing the evidence in the past by summarising the literature, and exploring the nature of social connectedness factors that are associated with risky sexual behaviour among Asian adolescents. This specifically targeted synthesis can also help people in designing structured programs for Asian adolescents. In addition, review done in a systematic manner to evaluate the relationship between social connectedness and sexual behaviour offers an analytical dimension to the studies to be conducted in future.

This review, however, has some limitations. Although it consists of the quantitative studies that show association between social connectedness and sexual behaviour, it misses out on the findings of qualitative studies. Moreover, quantitative studies included in the review does not contain randomised controlled trials as this review does not aim to evaluate specific interventions targeted to assess the relationship between social connectedness and sexual behaviour. Only peer-reviewed journals are included in the review to ensure inclusion of rigorous studies. Hence, the search strategy adopted for this review may have missed out on the studies that are not indexed in the databases, resulting in publication bias. This review is exclusively based on Asian adolescents and does not include non-Asian studies for comparison purpose. Furthermore, due to the small number of studies published, the review does not consist of a meta-analysis which could have more clearly described the link between social connectedness and sexual behaviour.

S.N	Study	Country	Publish Date	Age group	Study population	Study type	DV	IV	Findings
1	The Contextual Effect of School Satisfaction on Health-Risk Behaviors in Japanese High School Students	Japan	2010	15 to 18	2600	Cross-sectional study	Sexual activity	School satisfaction	Individual school satisfaction acts as protective factor against sexual activity
2	Correlates of Precoital Behaviors, Intentions, and Sexual Initiation Among Thai Adolescents	Thailand	2012	13 to 14	420	Cross-sectional study	Experienced sexual intercourse	Parental disapproval, School attachment	Parental disapproval and school attachment were protective.
3	Factors influencing sexually transmitted infections among adolescents in South Korea	South Korea	2015	12 to 15	714	Longitudinal	STI from sexual intercourse	Family characteristics	Family cohabitation was protective for low STI rate
4	Gender Differences in Partner Influences and Barriers to Condom Use Among Heterosexual Adolescents Attending a Public Sexually Transmitted Infection Clinic in Singapore	Singapore	2013	14 to 19	964	Cross-sectional study	Condom use	Peer connectedness, Relationship with parents	Peer influence was risk for condom use. Parental communication had no association with condom use.
5	Health Risk Behaviours of Foreign-Born Adolescents in Singapore: Exploration of Risk Factors in an Asian Context	Singapore	2010	11 to 17	1489	Cross-sectional study	Sexual intercourse	Peer pressure	Peer pressure for foreign born was risk factor for sexual intercourse
6	Individual, familial and extra-familial factors associated with premarital sex among Bangladeshi male adolescents	Bangladesh	2010	15 to 19	1048	Longitudinal	Premarital sexual experience	Relationship with parents, Peer communication	Respect to parents was protective, peer communication risk factor for sexual intercourse
7	Risky Sexual Behavior among Rural Female Adolescents in Malaysia: A Limited Role of Protective Factors	Malaysia	2014	13 to 17	770	Cross-sectional study	Premarital sexual experience, Condom use, Multiple partners	Family domain, Peer domain, School attachment	Peer influence, lack of school attachment and incomplete family risk factor for risky sexual behaviours
8	Sexual Behavior and Intention to Engage in Sexual Behavior in Junior Secondary School Students in Hong Kong	Hong Kong	2013	12 to 15	4106	Longitudinal study	Sexual activity	Family functioning, Social attributes	Family functioning and good social attributes protective for risky sexual behaviours
9	Concurrent multiple health risk behaviors among adolescents in Luangnamtha province, Lao PDR	Laos	2011	14 to 19	1360	Cross-sectional study	Sexual health risk behaviours: Sexual experience, Condom use	Peer influence, Schooling	Schooling in boys protective and peer pressure risk factor for risky sexual behaviour
10	Predictors of sexual risk behaviour among adolescents from welfare institutions in Malaysia: a cross sectional study	Malaysia	2014	12 to 19	1082	Cross-sectional study	Sexual risk behaviours: Sexual experience, Condom use, Multiple partners	Family connectedness, Parental connectedness	Family connectedness in girls risky for sexual behaviours
11	Premarital Sexual Intercourse Among Adolescents in an Asian Country: Multilevel Ecological Factors	Singapore	2009	14 to 19	500	Case-control study	Premarital sexual experience	Peer pressure, Family relationship, Exposure to violence in community	Peer pressure, incomplete family, exposure to violence in community, authoritative parenting risk for premarital sex
12	Relationships, love and sexuality: what the Filipino teens think and feel	Phillipines	2009	13 to 18	3044	Cross-sectional study	Sexual experience	Exposure inc ommunity	More exposure in community causes more sexual intercourse
13	Sexual Activity Among Malaysian School-Going Adolescents: What Are the Risk and Protective Factors?	Malaysia	2014	12 to 17	23645	Cross-sectional study	Sexual activity	Parental bonding, Peer connectedness	Parental connectedness and peer support are protective. No association between parental supervision and sexual activity
14	Effects of Self-Control, Social Control, andSocial Learning on Sexting Behavior Among South Korean Youths	South Korea	2016	14 to 18	1612	Cross-sectional	Sexual health risk behaviours	Peer influence	Peer pressure risk factor for sexual health risk behaviours
15	Factors Associated With Gender Differences in Parent-Adolescent Relationships That Delay First Intercourse in Japan	Japan	2008	15 to 18	1268	Cross-sectional	Sexual behaviour	Parent-adolescent relationship	Parental monitoring and parental communication are protective
16	Interaction Effects Between Exposure to Sexually Explicit Online Materials and Individual, Family, and Extrafamilial Factors on Hong Kong High School Students’ Beliefs About Gender Role Equality and Body-Centered Sexuality	Hong Kong	2015	14 to 18	503	Cross-sectional	Exposure to sexual materials	Parental bonding, Peer connectedness	Peer pressure and low communication with parents are risk factors.
17	Maternal Influences on Asian American–Pacific Islander Adolescents’ Perceived Maternal Sexual Expectations and Their Sexual Initiation	USA	2010	15 to 17	433	Longitudinal data	Sexual initiation	Sexual discussion with mother	Maternal sex discussion risk factor for sexual initiation
18	Role of Individual, Family, and Peers in Sexual Initiation Among Late Adolescents Attending Institutions of Higher Learning in Malaysia	Malaysia	2016	18 to 19	1572	cross-sectional study	Sexual intercourse, Use of contraceptive	Family, Peer and School domains	Dysfunctional family, peer pressure risk factor whereas peer support protective factor
19	Role of risk and protective factors in risky sexual behavior among high school students in Cambodia	Cambodia	2010	14 to under 20	1049	cross-sectional study	Sexual intercourse, Multiple sexual partners, Use of condom	Family, Peer and School and Community domains	Family support protective, peer influence and community violence risk factors for sexual behaviours.

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