Relationship among Sexual Knowledge, Sexual Attitudes, and Sexual Behavior of Junior High School Students in West Jakarta Hubungan Pengetahuan Seksual dan Sikap Seksual dengan Perilaku Seksual pada Siswa SMP di Jakarta Barat

Lack of sexual knowledge and increasing negative sexual attitudes in Indonesia could lead to risky sexual behavior. This problem increases teenage pregnancy, sexually transmitted infections, and abortion among adolescents. This study aimed to determine the relationship between sexual knowledge and sexual attitudes towards sexual behavior among junior high school students in West Jakarta. This study was cross-sectional, conducted on 544 junior high school students in West Jakarta. Measuring instruments used were characteristic questionnaires, sexual knowledge questionnaires, sexual attitude questionnaires, and sexual behavior questionnaires. Data analysis was performed using bivariate (chi-square). This study shows 79.2% of the respondents had low sexual knowledge, 45.6% respondents had negative sexual behavior, and 48.2% respondents had risky sexual behavior. This study finds that most male respondents had low sexual knowledge (80.8%), low sexual attitude (56.8%), and “less-safe” risky sexual behavior (60.0%), while “not-safe” risky sexual behavior (2.7%) was found higher in female respondents. Bivariate analysis shows a significant relationship between sexual knowledge (p=0.006; 95% OR=1.763 |95% CI=1.151-2.698) and sexual attitude (p=<0.001; OR=2.852 | 95% CI=2.0124.043) towards sexual behavior. In conclusion, low sexual knowledge and negative sexual attitudes increase the risk of risky sexual behavior.


INTRODUCTION
Adolescence is a period of development transition marked by puberty (1). In this phase, adolescents experience brain development that receives new information, increasing sensitivity towards new stimuli that influence the reward pathway. Therefore, adolescents tend to have rewardseeking behavior which will makes adolescents easily influenced by the environment, peers, social media, and various other factors for risk-taking behavior (2)(3)(4).
In the last few years there have been an increase in risky sexual behavior among adolescents. Sexual behavior is an act and or expression of adolescents with their partners related to the reproductive process, which can be generally found at puberty (3,5,6). Sexual behavior is also influenced by adolescent sexual scripts, including sexual attitudes and knowledge (7). Sexual behavior is considered risky if it can cause unwanted pregnancy, sexually transmitted infections, and mental-emotional disorders, such as depression and anxiety, among adolescents who are not mentally prepared to encounter sexual experiences (5,7). Rusmiati and Hartono (2015) stated that one in four Indonesian teenagers have risky sexual behavior (8). Suwarni et al., obtained data on petting (2.7%) and sexual intercourse (13%), while Susanto et al., recorded the sexual behavior present in Indonesian adolescents are touching (39.2%), kissing (13.3%), and masturbation (13.9%), while in which some of this behavior could lead to/result in various health risks in adolescents (9,10). The enhancement of sexual behavior among adolescence trough out the years are visible by analyzing the results of periodic national surveys conducted by Survei Demografi Kesehatan Indonesia (SDKI) or Indonesian Health Demographic Survey that stated that the percentage of age of the first sexual th intercourse in male and female have increase from the 59 th percentile on 2012 to the 74 percentile on 2017, the majority of first age of sexual intercourse were 18-19 years old on 2012 and age 17-18 years old on 2017 (11,12).
Sexual attitude is a subjective response of an adolescent towards reproduction health (3). Sexual attitude can be in the form of pride, privatization, viewpoint about sexual behavior consequences, and prevention (3). Positive sexual attitudes are a feeling of pride in maintaining selfesteem, having opinions about sexual behavior according to customs, and preventing risky-sexual behavior (5). A negative sexual attitude is where adolescents have a viewpoint of sexual behavior that is not according to traditions and does not acknowledge the consequences of sexual behavior and its prevention (5). Sexual attitude is affected by sexual knowledge, family relation, peers, sex, and religiosity (8). Changes towards sexual attitude may result from a shift in perceptions, methods of obtaining information, and social and cultural life that result in an increase of marital age and premarital sex due to globalization (9,13). According to SDKI in 2007, 2012, and 2017 revealed an increase in the adolescents' prevalence who agreed on premarital sex and a decrease in the attitudes towards maintaining virginity (11,12).
Sexual knowledge is the knowledge or perception of adolescents on reproductive health, sexual behavior, and changes during puberty (3,9). Sexual knowledge shapes adolescents' attitudes towards their behavior to maintain their sexual health and well-being (9,14). Sexual knowledge in Indonesia is still a taboo topic to be discussed. The data from Pusat data dan Informasi Kesehatan (InfoDATIN) or Center for Data and Health Information stated that most information on reproductive health in Indonesia originates from peers, whose validity cannot be assured (15). Lack of sexual knowledge will have an impact on the formation of negative sexual attitudes, which leads to risky sexual behavior among adolescents, such as touching, kissing, masturbation, petting, and sexual intercourse, and lead to unwanted pregnancy, abortion, and sexually transmitted infections (5,8,15).
The phenomenon of risky sexual behavior in adolescents recently increases among adolescents within younger age such as Junior High School students in West Jakarta. While there are a lot of studies regarding sexual behavior among adolescent in High School age, the studies on Junior High School students are infrequent, therefore this study was conducted on Junior High School students in West Jakarta who are still in early adolescence where their cognitive development is not yet mature (15)(16)(17). This was the first study conducted on Junior High School students in West Jakarta regarding sexual behavior. Based on risky sexual behavior issues among early adolescents, it was essential to research the relationship between sexual knowledge and sexual attitudes towards sexual behavior in junior high school students in West Jakarta (15)(16)(17). This study aimed to find out the characteristic, sexual knowledge, sexual attitudes, and sexual behavior in junior high school students in West Jakarta and to determine their relationships.

METHOD
This study is descriptive-analytic with a cross-sectional approach that was conducted from July to November 2019. The respondents were junior high school students in West Jakarta who were active students from July 2019 to November 2019. A district consist of three schools in West Jakarta were selected by random sampling, however one of the schools denied the permission to collect data because the topic is considered taboo. The author then searches the nearest district (consist of 11 schools) and randomly picked one to replace one of the schools from the first district. The respondents were selected using stratified proportional random sampling where the sample were first categorized based on their level of education; class VII (year one), class VIII (year two), and class IX (year three).
The inclusion criteria in this study were Junior High School students who have given their consent to participate. Data were collected using self-reporting questionnaires consisting of a characteristic questionnaire, a sexual knowledge questionnaire, a sexual attitude questionnaire, and a sexual behavior questionnaire. The data were then extracted and processed statistically using univariate and bivariate test analysis using chi-square. Respondents with incomplete data set from the questionnaire were excluded from analysis.
Sexual knowledge and attitudes were assessed using a selfreporting questionnaire validated by Muflih and Syafitri in 2018, with Cronbach alpha 0.73 and 0,70 respectively. The sexual knowledge instrument contained 15 items measuring knowledge of the definition and knowledge of the consequences arising from sexual behavior. The questionnaire answers were measured using the Guttman scale with an assessment based on 0 and 1 point. The final value was determined low if the score was 75% (score <11 points) and high if the score was 75% (score> 11 points) (5). The questionnaire measuring sexual attitude contained 15 items measuring feelings of pride, privatization, viewpoints of sexual behavior, consequences, and prevention. The questionnaire used a Likert scale, ranging from strongly agree (4), agree (3), disagree (2), and strongly disagree (1), and vice versa for questions with negative answers. The result of the assessment was negative if the score was 47 and positive if the score was >47 (5).
Sexual behavior was assessed using a self-reporting questionnaire validated by Muflih and Syafitri in 2018, with Cronbach alpha 0.89. The questionnaire contained 15 items measured in a Likert scale, rated as "not risky" if the respondent answered all as "never" or category 0 on all items in the questionnaire and "risky" if there were one or more answers as "ever" or category 1 in the questionnaire. Further, risky sexual behavior was divided into two that were "less safe" if the respondent's answer involved touching, kissing, and masturbation (question 1-6, 8-10) and "not safe" if the respondent's answer involved deep kissing, oral sex, petting, and vaginal sex (question 7, 11-15) (5).

Characteristics, Sexual Knowledge, Sexual Attitudes, and Sexual Behavior of Junior High School Students in West Jakarta
As many as 544 junior high school students aged ranging from 10-18 years (average age of 13.5 years) were obtained using systematic random sampling. From there, 54% were female, 34.9% were year VII, 34.2% were year VIII, and 30.9% were year IX students. There were 79.2% of respondents with low sexual knowledge, 45.6% of respondents with negative sexual attitudes, and 48.2% of respondents with risky sexual behavior (Table 1). Most of the male respondents had low sexual knowledge (80.8%), negative sexual attitudes (56.8%), and less safe sexual behavior (risky) (60%). In contrast, unsafe risky sexual behavior was more common among female respondents, which was 2.7% (Table 2). Low sexual knowledge was found in respondents in year VIII (81.7%), year IX (81.0%), and year VII (75.3%). This study also found negative sexual attitudes in year IX students (50.6%), year VIII students (44.6%), and year VII students (42.1%). There was also more common risky sexual behavior, which were less safe (55.4%) and not safe (3.6%) in year IX respondents ( Table 2).  (Table 3).  (19). Adolescents with low sexual knowledge do not have a deep understanding of reproductive health, sexual behavior, and changes in puberty; this knowledge will form the mindset that creates the sexual attitude of the teenager (3,5). Sexual knowledge is one of the protective factors that can delay the onset of first sexual intercourse, increasing the usage of condoms to prevent risky sexual behavior (7,9,14). Low sexual knowledge can cause teens to engage in risky sexual behavior without knowing the consequences.

Characteristics, Sexual Knowledge, Sexual Attitudes, and Sexual Behavior of Junior High School Students in West Jakarta
The results of this study showed that 45.6% of respondents possess negative sexual attitudes. This result is consistent with the research by Suwarni et al., in Pontianak that found 45.3% of respondents with negative sexual attitudes (10). Sexual attitude is a response owned by individuals regarding reproductive health, and an increase in negative sexual attitudes among adolescents is caused by a shift or change in perception, culture, social life, and the development of information technology (3,5,13). Sexual attitudes of adolescents determine the choice of sexual partners and behavior; thus, negative sexual attitudes in adolescents can cause risky sexual behavior, such as early sexual intercourse, multiple sex partners, and lack of contraception use (8,13,20). In addition to sexual knowledge, factors of religiosity, parental supervision, peers, and drug abuse also play a role in forming the sexual attitudes among adolescents (9,10,21,22).

Description of Knowledge, Behavior, and Sexual Attitudes of Junior High School Students in West Jakarta Based on Gender and Education Level
This study shows that low sexual knowledge (80.8%), negative sexual attitudes (56.8%), and risky sexual behavior (62.0%) are more common in males rather than in female respondents. Many aspects can influence the formation of knowledge, attitudes, and behavior in adolescents, one of which is family relationships. Research by Suwarni et al. (2015) states that an ineffective relationship between parents and adolescents can increase the risk of adolescents to obtain negative influences from their peers (10). InfoDATIN states that adolescent information about reproductive health in Indonesia comes from their peers, in which the truth cannot be guaranteed (15). Research by Suwarni et al., shows that male adolescents have more distant relationships with their parents than female adolescents so that peers would more easily influence sexual knowledge, sexual attitudes, and sexual behavior of male adolescents (10). Although female adolescents have a closer relationship with their parents, discussion on sexual health among parents and adolescents is still regarded as taboo in Indonesia. This condition is worsened by the number of pictures and games on the internet that could result in increased pornography consumption in Indonesia. Therefore, the prevalence of risky sexual behavior is still quite high among female respondents (36.4%) in this study (25). In addition to parental relationships, negative sexual attitudes and risky behavior can also be caused by immature puberty where the risk of risk-taking behavior is higher. A higher prevalence of risky sexual behavior can also be caused by a slower onset of male puberty (10-17 years) than that in women (9-14 years) (26,27).
This study shows that the prevalence of not safe risky sexual behavior is more common in female respondents (2.7%) than in males (2.0%). Research by Tadesse and Yakob stated that the initiation of risky sexual behavior outside the marriage among female adolescents could be due to curiosity, the influence of friends, money offered by men, coercion from partners, and drug abuse (28).
Research in Malaysia shows that despite protective factors from parental supervision, which are common in female adolescents, risky sexual behavior in adolescent girls still occurs due to factors such as coercion from partners, juvenile delinquency, and negative sexual attitudes  (29,30). This study also shows values of percentage of knowledge, attitudes, and sexual behavior that do not differ significantly between respondents in year VII, VIII, and IX. It may be due to respondents that are in the same age group.

The Correlation between Knowledge and Sexual Attitudes toward Sexual Behavior of Junior High School Students in West Jakarta
Bivariate analysis shows a significant relationship between knowledge (p=0.006; 95% OR=1.763 |95% CI=1.151-2.698) and sexual attitudes (p=<0.001; OR=2.852 | 95% CI=2.012-4.043) to the sexual behavior of junior high school students in West Jakarta. The analysis also shows that adolescents with low sexual knowledge are 1.763 times more likely to have a risky sexual behavior, and adolescents with negative sexual attitudes are 2.852 times more likely to have risky sexual behavior compared to adolescents with high sexual knowledge and positive sexual attitudes. The results of this study are in accordance with research conducted by Suwarni et al., that there is a relationship between sexual attitudes and intentions and risky sexual behavior with p=0.0001, and research by Susanto et al., that showed a relationship between reproductive health knowledge and sexual behavior with p=0.008 and sexual attitude towards sexual behavior with p<0.001 (9,10). Sexual behavior is one factor that shapes sexual attitudes, so sexual knowledge is not directly related to sexual behavior (9,14). The high prevalence of sexual knowledge, sexual attitudes, and risky sexual behavior in this study show the importance of preventive, curative, and rehabilitative efforts in adolescents in Jakarta to reduce the level of risky sexual behavior and its complications.
In conclusion, low sexual knowledge and negative sexual attitudes are consistent with increase in risky sexual behavior. The author suggests increasing the awareness of the importance of sexual education on early Junior High School Age by parents and teachers to prevent low sexual knowledge and negative sexual attitudes among early adolescence.