The Correlation between Perceived Peer Norms in Attitude and Self-Efficacy Premarital Sexual Behavior

Background and Aims: Adolescence is a period of life in which high-risk behaviors, including sexual behaviors, put the adolescents at risk for sexually transmitted diseases, including AIDS. This research aimed at studying the relationship between peers' perception of sexual behavior and adolescents' attitudes and self-efficacy. Materials and Methods: This cross-sectional study used a multi-stage method to examine 1500 subjects in the universities of Shahroud, Iran. The questionnaires were consisted of sexual abstinence attitude, abstinence self-efficacy and peer subjective norms. To ensure the confidentiality of information, the questionnaire was distributed among 1500 students in six universities anonymously, and students҆ field of study was not mentioned. The collected data was analyzed with descriptive (Mean, Percent) and inferential tests (independent t-test, chi2, and Spearman test) using SPSS 18 software.


INTRODUCTION
Adolescence is a period of life in which high-risk behaviors, including sexual behaviors, put the adolescents at risk for sexually transmitted diseases, including AIDS [1,2]. It is estimated that 55% of male and female adolescents have sex by the age of 18; 42% of female adolescents at the age range of 15-19 years old, and 44% of male adolescents [3,4]. Various factors such as low knowledge about sexually transmitted diseases and reproductive health, passing a long time from the age of puberty to marriage, peer pressure, lack of life skill training, transition from traditional to modern society, access to new technologies put adolescents at risk of high-risk sexual behavior [5,6]. A study conducted in Iran on youth reproductive health indicators showed that young people had low knowledge about HIV, and only 26% of males and 19% of females had heard of sexually transmitted diseases [7]. In addition, the studies in Iran indicated that 19.8-41% of the young people in the age range of 18-24 years old had sex for at least once before marriage [1,8]. The use of condoms at this age range among the females and males was 16 and 27%, respectively [9]. Lack of sexual training puts adolescents at risk for sexually transmitted diseases, HIV,unwanted pregnancies,unsafe and illegal abortions [10]. The 2015-2020 Adolescents Health Strategy emphasized the improvement of health literacy from childhood to adolescence as a strategic target to improve the conscious decision-making development in the developing countries. This strategy is in line with the effects of social norms of peers, family, and school, which "may put the adolescents at risk or protect them" [11]. The model of human ecology shows that the microsystems of friends and family play a key role in directing adolescents towards the high risk behaviors including sexual behaviors. Furthermore, according to the theory of social norms, peers have an effective role in the involvement of adolescents in high-risk behaviors. This effect is rooted in adolescents' beliefs about norms that are common among peers. Such norms may influence the way adolescents dress and behave, as well as their use of media [12]. This study aimed at studying the relationship between peers' perception of sexual behavior and adolescents' attitudes and self-efficacy.

METHODOLOGY
This study was analytical cross-sectional research. It was conducted on 1500 students in the age range of 17-24 years old in the universities of Shahrud city between 2010 and 2011 in Iran. Multi-stage sampling was done. The categories in this study were the universities under investigation, and the classrooms were considered as clusters, which ranged between 400 and 9000 as proportionate with the number of students in the universities. The samples were randomly selected from the list of classrooms provided by the Education departments of the universities. Under the arrangements previously made by the professors, the subjects completed the questionnaires within the last 15 minutes of classroom sessions. The items of the questionnaires were associated with the items of demographic information, and three questionnaires of sexual abstinence attitude, sexual abstinence self-efficacy, and perceived norm of friends on sex were used.
Introducing the researcher to the students, the objectives and necessity of conducting the study were explained, and the students were asked to participate voluntarily in the project. They were also ensured that the information would be confidential.
Study tools including; Sexual abstinence attitude: 8 items scoring in a 5-option Likert scale with maximum 40 scores were included in the study and were divided in "poor, medium, and good" attitudes. Regarding the sexual abstinence selfefficacy, there were 8 items scoring in a 5-option Likert scale with maximum 40 scores, which were divided into "poor, medium, and good" self-efficacy [13]. Regarding the perceived norm of friends on sex, the disease control center questionnaire [14] was used. The items were localized after translation and back translation, in accordance with the localization of the World Health Organization [15]. Before implementing the questionnaire in the pretest stage, the items were pretested on 10 female and 10 male students for mutual understanding and understanding of the words. In the next stage, a retest was used to evaluate the reliability of the items. Pearson correlation coefficients obtained for sexual abstinence attitude and sexual abstinence self-efficacy were 0.6 and 0.65, respectively. Cronbach's alpha was used to evaluate the internal validity. The results of Cronbach's alpha for the sexual abstinence attitude was 0.87 and for the sexual abstinence self-efficacy as 0.81. After collecting the data, they were analyzed using SPSS 20, Chi square test and Spearman.

RESULTS
The mean age of the females was 20.26±1.49, and that of males was 20.32±1.575. 919 participants (62.1%) were female, and 535 of them (36.1%) were male. 120 subjects (8.5%) lived in the village and 1300 subjects (87.8%) lived in the city, and 61 subjects (4.1%) did not answer.
The results of Table 2 show that 59.3% of male students and 86.8% of female students had poor sexual abstinence to sex before marriage. Moreover, the sexual abstinence selfefficacy of 29% of male students and 13.1% of female students, regarding the sexual abstinence before marriage, was strong ( Table 1). Subjective peer norms showed that 21 (4.1%) boys and 231 (25.5%) thought that all peers have sex before marriage ( Table 2). The results indicated that there was a weak but significant relationship between sexual abstinence belief and peer subjective norm to sex. That is, the stronger the belief in sexual abstinence is, the stronger the belief is that more of the friends will not have sex. Moreover, the more one believes in his/her abilities in sexual abstinence, the more they believe that more friends will not be involved in sex (Table 3).   Table 3. The correlation between abstinence attitude and abstinence self-efficacy with peer subjective norms.

P R
Abstinence attitude-how many of your single friends do you think have never had sex? 0.001 0.176 Abstinence self-efficacy-how many of your single friends do you think have never had sex? 0.001 0.151

DISCUSSION
The results of the study on attitudes towards sex before marriage showed that the attitude of sexual abstinence before marriage was poor in both male and female students, and the female students may have the tendency to have sex in particular. This issue in a qualitative study on adolescents showed that they believed that premarital friendships are growing among the youth, and if they do not enter into friendship, they will be excluded from their community. Further, they also like to know more about the characteristics of the opposite sex before marriage [6]. This issue reflects the role of peer pressure in this regard [16]. The present study showed that the stronger the young people's sexual abstinence attitude is, the more they believe that more friends will not be involved in sex. In addition, the more one believes in his/her abilities in sexual abstinence, the more they believe that more friends will not be involved in sex. The adolescents who believe in a limited sexual relationship in their friends, they are less likely to be involved in such relationships [17]. The studies of America indicated that for the adolescents, the friends' behaviors are more effective than their personal behavior to be involved in high-risk behaviors [18,19]. The relationship between one's behavior and friends' perceived behavior showed that what adolescents thought about their friends affected their real behavior, which may lead them to have sex [19]. Baumgartner et al. (2010) showed that adolescents expected that their friends who were involved in high risk online sexual behaviors were more likely to engage in such activities [20]. Other studies on alcohol consumption also showed that adolescents with alcoholic friends were more likely to be at risk for alcohol consumption [21,22].

CONCLUSION
Adolescence is a period of life during which social relationships outside the family are expanded. Therefore, society, including schools, are expected to provide opportunities for adolescents to acquire effective communication skills and sexual health. Nevertheless, policymakers should also make efforts to make laws and remove sexual taboos in society.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
The study was approved by the Ethical Committee of Shahroud University of Medical Sciences, Iran (code : 890/08).

HUMAN AND ANIMAL RIGHTS
Not applicable.

CONSENT FOR PUBLICATION
Written informed was obtained from each participant prior to the study.

AVAILABILITY OF DATA AND MATERIALS
The datasets generated and/or analyzed during the current study are not publicly available due to the moral rules of Arak university of medical sciences but are available from the corresponding author [K.V] on a reasonable request.

FUNDING
This research was funded by Shahroud University of Medical Sciences under financial code of 9664.