The reproduction and pregnancy knowledge score indicated relatively poor reproduction and pregnancy knowledge among the study respondents. The lack of knowledge about sex and reproduction among youth has been reported in many developing countries
[20–22]. Poor knowledge of young people about sexual and reproductive health resulted in youth commencing sexual activity without accurate information about reproductive health, thus putting themselves at risk of engaging in unsafe sexual practices, resulting in STIs or unwanted pregnancies
[21, 22]. This indicates that women may benefit from SRH education and should not be deprived of it. Fears that sex education encourages or increases sexual conduct have been proved unfounded. Evidence showing that sex education can help delay first intercourse for adolescents
 should be made known publicly. The notion that higher SRH knowledge does not translate into non-risky sexual behaviour has been agreed upon by many studies
The study has shown that while there is good awareness of contraceptive types, knowledge deficits were illuminated in knowing how to use contraception and where to obtain contraceptives. This knowledge deficiency may contribute to the non-use of contraception when they have their first sexual intercourse or inconsistent use of contraception among those in a relationship. The major practical implication of these findings is that reproductive health education should include appropriate teaching about pregnancy prevention, and how to use and to obtain contraception. Much evidence has been presented in favour of contraception education, which helps counter the unfounded myths of premarital contraception teaching and learning among parents and providers. It has been shown that sex education that includes contraception does not increase sexual activity
, but rather encourages correct and consistent use of contraception for STI protection
The gradient of increasing knowledge scores with increasing family socio-economic status in the univariate analysis indicates that young women with a lower family economic and social status have a higher likelihood of sexual and reproductive health risks, and should be the prime target of future intervention. Findings also pointed out that young women with strict parents were less knowledgeable in both reproductive health and contraception. In our recent in-depth interview study (Wong LP: Qualitative inquiry into premarital sexual behaviours and contraceptive use among multiethnic young people, submitted), parental strictness was found to limit communication about sex in our community. Thus, there is a serious need for communication concerning sexual and reproductive topics between children and parents
The findings of this study are in concordance with the results regarding Muslims in Tehran, Iran, where those who did not consider themselves religious displayed better knowledge about reproductive health than those who labeled themselves as religious
. It was reasoned that respondents who reported themselves to be highly religious displayed more traditional cultural sensitivities and religious norms that posed challenges in acquiring SRH knowledge
. Given that religious leaders are close to the people in their communities, and are sought to lead on secular issues, it is of priority that reproductive health teaching is integrated in respective national or ethnic religious education programmes. It was also revealed in this study that knowledge was intricately linked to cultural sensitivity surrounding sexual issues. The Malays, the majority of whom are Muslim, had lowest reproductive and contraceptive knowledge scores relative to the Chinese. These ethnic disparities in knowledge scores highlight the need for tailored information on sexual reproductive and contraception for the respective Malay, Chinese, Indian and aborigine of Sabah and Sarawak, respectively. Ethnic-specific reproductive health intervention is important to meet the reproductive and sexual health needs of young women in multiethnic community because knowledge disparities are likely to affect behaviours and, ultimately, reproductive health outcomes among these groups of women.
The fact that pre-university students demonstrated higher reproduction and pregnancy, and contraception knowledge scores than all the other groups may be somewhat due to the pre-university course that covers lessons on Human Reproduction, as part of the Biology course taught though lectures. The undergraduate year 1 to 3, not all of whom had attended the pre-university program, had never had formal sex or human reproduction education, thus, had relatively lower level of knowledge. This is important as it implies that SRH education increased levels of knowledge.
Students who have never dated had significantly lower knowledge on reproduction than those who had dated, which indicates the need to educate young women in general before they begin dating. Earlier school sex education can be beneficial as it was found that earlier lessons on sexual issues was not correlated with earlier onset of sexual intercourse
. With regard to knowledge about contraception, particularly worrisome is finding that the group currently in a relationship had significantly lower scores in awareness of contraceptive types. Despite having limited knowledge, they have relatively higher permissive attitudes towards sex.
With regard to attitudes towards premarital sex, our univariate results showed family socio-economic status was not associated with premarital sex attitudes, but rather parental strictness. Although higher parental strictness resulted in a low level of sexual reproduction and contraception knowledge, it has the advantage of contributing to less liberal premarital sex attitudes among our study respondents. Studies in Western countries found that authoritarian control have negative effect on child sexual activities. While parental monitoring can be protective, it was found that youth tend to engage less in sexual activities if parents have a moderate style rather than being overly strict
. Therefore, it has been suggested that educating parents about the importance of proper parental monitoring, without intrusion, may ensure low risk of sexual behaviour among youth
. In this study, however, strict parenting has positive effect where it yields less liberal attitudes on premarital sexual intercourse. It could be because of traditional Asian-style upbringing that emphasises obedience and respect towards parents. The underlying rationale of this observation is unclear and warrants further investigation to determine if strict Asian parenting should be encouraged in the context of premarital sexual intercourse prevention.
It was found in the study that those who had initiated sexual intercourse hold more liberal attitudes than those who never had intercourse, which indicates that liberal premarital sexual attitudes affect actual sexual behaviour. The impact of the attitude concept and its relationship to behaviour suggests that sustained and traditional socially or culturally constructed conservative premarital sex norms, despite the trend towards more liberalisation in the attitude to premarital sex in modern society is essential.
The most important finding in our study is that we are able to prove that higher reproduction and contraception knowledge do not result in more permissive attitude towards premarital sex. The pre-university students with higher reproduction and pregnancy, and contraception knowledge scores than all the other groups were found to have less permissive attitudes in relation to premarital sexual behaviour. Further, the significant inverse correlation between premarital sexual attitude scores (where higher scores corresponded to opposing premarital sex) and all the other knowledge scores showed that learning about reproduction or pregnancy and contraception does not result in more liberal attitudes on premarital sexual attitudes. This, therefore, may potentially offer essential benefits in prevention of premarital sexual intercourse among young women.
The study respondents themselves disapproved of the availability of contraception for unmarried youth. Such less liberal attitudes to providing contraception to unmarried youth may constitute a barrier to adolescent or young unmarried women contraceptive use. Dealing effectively with contraceptive stigma among unmarried youth requires appropriate sexual health information though numerous channels such as sexual health education in schools, parental guidance, media or reproductive health facilities. Nevertheless, it has been reported that provision of sexual and reproductive health information and services to unmarried young people received unfavourable responses from parents, which resulted in a significant obstacle to the adoption of safe sex practices young unmarried people
. Acceptance of provision of SRH services for unmarried young people has not been examined in our local context, but it is anticipated to face obstacles from religious conservatism in our society, as well as parents. A community sex education programme for young people themselves and training parents to be more effective as sex educators of their children seems to be a plausible solution
The multivariate analysis showed that being Chinese, older age and with dating experience generally implied an increased knowledge about reproduction and pregnancy. The findings from the multivariate analysis indicated that it is necessary to reinforce contraception education among younger women, the Malay ethnic group, higher level religiosity, no dating experience and rural settings. While being religious was associated with lower level reproduction and contraception knowledge, it appears to provide some protective effect against premarital sexual conduct as exhibited in less liberal attitudes in relation to premarital sexual behaviour. However, it should be noted that there is a possibility of incongruities in expression of attitudes and actual sexual behaviour. Study results from Western countries have been inconsistent, with findings of inverse relationship between religiosity and sexual permissiveness
, but also others that reported religiosity was not a consistent predictor of premarital sexual attitudes or coital activity
[32–34]. Limited evidence emerged from local or Muslim region, thus further studies are needed to support this claim.
Most study respondents identified magazines, the Internet and friends as their most common sources of sexual information. An important source of information, that is, parents, were not identified by many as a source of information on sexual related matters. Positive parent-teen communication has been linked to less risky sexual behaviour among teenagers (Holtzman and Rubinson 1995). These facts emphasise once again the importance of parents in creating a climate for open parent-adolescent communication about sexually related matters at home. Our previous qualitative study (Wong LP: Qualitative inquiry into premarital sexual behaviours and contraceptive use among multiethnic young people, submitted), revealed that many were even less likely to communicate with parents because of the fear that their parents would mistakenly perceive enquiring about sexually-related information as indicating that they had engaged in sexual intercourse. Several factors identified in this study that contributed to lack of access to reproductive and sexual information such as embarrassment, and not knowing where to obtain information warrant urgent action for improving access to and use of information. The survey respondents' belief that safe sex practices and contraceptives information seeking are only necessary for married women should be changed. Women should be encouraged to engage in seeking reproductive information during adolescence. Less than one percent (12 persons) reported that they had already had sexual intercourse could be in part due to under-reporting because of customary sensitivities concerning sexual conduct. The small number of respondents who reported having had sex lead us to being unable to assess correlates of having ever had sexual intercourse and to determine the factors associated with contraceptive use. The key issue indicated by the findings, despite the small number who reported having had sex, was the tendency for non-condom use at first sexual intercourse and on most occasion of sexual intercourse, which exposes one to risk of both unwanted pregnancies and sexually transmitted infections. This finding corresponds to the results of numerous studies; the prevalence of condom use during first sexual intercourse was low among young people
[35–37]. It has been suggested that intervention designed to increase condom use among young women to prevent sexually transmitted infections and unintended pregnancies is warranted and, in particular, promotion of condom use at first intercourse is important as it has been shown to predict future condom use
As also noted by many other studies
[39, 40], the young women in this study faced substantial physical, social and psychological barriers to accessing contraception. Lack of access to contraception indicates that availability or accessibility to contraception is critical in increasing the chances of young women using the method when needed. Therefore, a comprehensive approach towards eliminating all factors that may deprive youth of access to reproductive services is required. Conventional family planning services designed for married women should also try to provide services for the young
. The concern that providing contraceptive services may promote premarital sexual intercourse can be overcome by developing specific skills for counselling the young
In many Asian cultures, reproductive health decision-making is based upon male authority and power. The fact that girls want to be perceived as obedient to partners’ refusal to use contraception indicates male dominance over female’s choice of contraception decision-making in this study sample. Studies have shown that women with less power to refuse sex or to insist on condom use relative to their male partners are more likely to have unprotected intercourse
, and male dominance in decision-making has been reported to hinder the ability of women to practice family planning
. Young women were encouraged to have more enlightened and contraceptive-conscious attitudes
, to increase communication with partners about contraceptives
[45, 46], to increase effective contraceptive use. It is imperative that contraceptive and reproductive health education is reinforced among males as support from male partners can help to increase contraceptive use and to decrease the likelihood of adolescent pregnancy
[45, 47]. Asian women should understand that male-dominant decision-making in sexual and reproductive health matters puts women at a disadvantage. Gender stereotypes of submissive females and powerful males can make it impossible for women to refuse unwanted or unprotected sex, and to negotiate condom use. Therefore, it may be beneficial to teach men to reject the ideology of traditional masculinity and advocate the attitude of liberalism towards SRH matter, for the benefit of both males and their partners.
It is particularly worrisome that some reported that they did not use any contraception during a first sexual intercourse because they trust their partners. This may imply that the women in this study relied on “know your partner” or the Implicit Personality Theory in assessing the riskiness of partners
, which perceived knowing partners’ nonpromiscuous sexual history as reason for unprotected intercourse. It has been suggested that intervention efforts must emphasise that one is not invulnerable to infections, and not practicing safer sex with a partner they trust or whom they perceive might not be risky as in the Implicit Personality Theory may put them at risk of the negative consequences of unprotected sexual intercourse
Considering the embarrassment of procuring condoms, behavioural intervention to cultivate positive attitudes on condom acquisition and to overcome embarrassment over condom purchases is needed. Thus, there is a need to expand access to youth-friendly SRH services to cater for contraceptive needs of young people
. Given the reasons for social taboos surrounding SRH issues and social disapproval of premarital sex in Muslim countries like Malaysia, unmarried young people may be embarrassed about acquiring contraception or accessing reproductive health educational information and services. Therefore, the basic components of reproductive services should include specially trained providers, privacy and confidentiality of services provided.
In interpreting these results, there are certain limitations in the study design that might impact upon the conclusions drawn. The major limitation of this self-report behavioural questionnaire is socially-desirable response bias. Given that premarital sex is culturally unacceptable in Malaysia, it is not possible to determine whether the students in this study tended to under-report their sexual experience. Additionally, because the study design was cross-sectional, results can only be considered exploratory and the directionality cannot be assessed. Another significant drawback is the use of purposive sampling, which limits generalisation about the entire population. The strength of this study lies in its large sample of young women obtained from one of the largest public universities in Malaysia; students were from across the whole country and offered a demographically representative sample for the study.