Sexually transmitted infections (STIs) are considered a significant public health threat worldwide, more prevalent in developing countries due to high population density and mobility, and are widespread due to exposure to various risk factors [1, 2]. As evidence that people of reproductive age have a high risk of developing STIs throughout their lifetimes, as of 2021, 95.6% of the 38.4 million people living with HIV/AIDS (PLWHA) worldwide were women [3]. However, Indonesian STI data are still difficult to access. A previous study in a primary care clinic in Jakarta found that the prevalence of STIs was 34.2% overall, with gonorrhoea occurring in 22.4% of cases, syphilis in 7.1%, and HIV prevailing in 4.7% of cases [4].

A growing body of evidence revealed that women are more disadvantaged by STIs-related issues due to a higher risk of developing the disease due to the unique vaginal anatomy, but having more debilitating complications because of the lack of STI symptoms, the threat of antimicrobial resistance, risks of infertility and pelvic inflammatory disease, and high-risk pregnancy [5-7]. Every week, around 4,900 young women aged 15–24 become infected with HIV [3]. Also, human papillomavirus (HPV), which attacks the reproductive system, have more severe consequences in women (cervical cancer) than in men [8]. This worrying issue worsens Indonesian women with their specific needs and challenges regarding reproductive health issues, such as hostile circumstances, lack of access to health information, poverty, and misconceptions due to cultural beliefs [9]. Due to the rapid urbanisation in developing countries, there is an enormous abundance of health-related misinformation available online. Unfounded health myths and health beliefs are also perpetuated through telling and retelling. Additionally, seeking medical help is delayed because many initially turn to alternative medicine solutions. All of these factors may aggravate the progression of the disease [10, 11].

On the other hand, given the various unique factors contributing to the rising STI incidences, urbanisation may play a critical role in spreading the disease. In urban environments, with more entertainment options like pubs and clubs, women are more exposed to risky behaviours, such as increased premarital sex and frequent multiple sexual intercourses [12-14]. Additionally, urban areas tend to have higher concentrations of commercialised sexual workers and drug users, possibly due to rising urban impoverishment [12]. It is also important to note that higher population densities may lead to more frequent human interactions and shifting social norms and thus may promote STI transmission [15, 16]. Although urban residents often have better health, education, and wealth, socioeconomic inequities are frequently made worse in Indonesian settings. These differences may determine a person’s general health and affect how infections pattern [15, 16].

Local characteristics such as knowledge, attitudes, and practices (KAP) of women should be established first to develop educational programs and interventions to control the occurrence of STIs. However, this data on the Southeast Asia population remains limited [17, 18], and most KAP studies on STIs come from Africa [19-23]. Furthermore, due to traditional and revived social norms that maintain tight taboos on premarital sex and stigmatise participants, it is challenging to understand the issues concerning sexuality and reproductive health in Indonesia [24]. This situation results in a lack of apolitical discussion of STIs within communities [25]. A recent study from urban communities in Indonesia only focused on HPV infection and did not necessarily explore the overall understanding of STIs [26]. Other studies merely highlighted the incidence of STIs [4] and sexual well-being [27] among adolescents rather than elaborating on the KAP among women. Striving to fill the research gap and overcome the issue of women’s STIs, this study aimed to understand the characteristics of the socio-demographic profile of reproductive-age women in an urban community health centre in Jakarta, Indonesia, as well as explore the association between KAP and STIs.

This work contributes to the sparse but expanding body of research on the understanding of STIs among women of reproductive age in urban environments of the Southeast Asia region. Westernisation and other ‘modernising’ influences have contributed to increasing sexual permissiveness amongst Indonesian youth, especially women [53]. Premarital sex among sexually active girls has been reported to be increasing by 23% worldwide [54, 55] and found to be more common in urban areas, such as Jakarta, as a result of changing norms and values that make this behaviour increasingly acceptable among young people, especially in the context of a romantic relationship [25]. These phenomena will increase STIs, which will be more prevalent in sexually active women of childbearing age. This age group has become a significant factor in spreading STIs, mainly due to partnered sexual activity, pregnancy, and childbirth [7]. In this regard, our present work spotted a higher proportion of younger adults with a mean age of 26.80 ± 4.64 years as participants, older than in a previous study in urban Nigeria (19.90 ± 2.50 years) [22]. Age has been associated with susceptibility to STIs related to their sexual exploration at a young age [56]. It also tends to be related to premarital sexual behaviour. Although the results were not statistically significant, a previous study in India indicated a tendency that females aged 15–19 were more likely (OR: 1.99, 95%CI: 0.68–5.83, p>0.05) to have premarital sexual intercourse than those aged 20–24 [57]. Adolescents are more likely to engage in risky behaviours that might end in STIs because of peer, cultural, and social pressures [58]. The situation might worsen since most Indonesian youths are unaware of how to prevent STIs [25, 59].

The high prevalence of premarital sex and STIs followed the understanding level and sexual behaviour associated with formal education [59]. Our subjects possessed sufficient education level (60% of women had passed SHS), in line with a local governance survey of East Jakarta, which revealed that 49.57% of citizens had passed SHS [29] and similar to a study in urban Nigeria (64%) [22]. This study found that higher educational attainment has significantly contributed to high-level knowledge of STIs and their prevention. We found that more than 80% of our respondents had good knowledge, comparable to the study in the urban community of Nigeria (66%) [22]. The level of knowledge of our participants who represent the urban Indonesian community was much higher than in research conducted in rural community health centres in Indonesia, which found the percentage of visitors who had good knowledge was 54% in West Kalimantan [60] and 50% in Riau [61, 62]. These different results may reflect ongoing challenges of urban-rural disparity in education expansion and the utilisation of primary health care in providing specific and targeted health promotion among the Indonesian population [63, 64]. However, urban women still lack knowledge on a specific topic (HPV infection) since only 32.4% of women had good knowledge in an earlier study [26].

Moreover, compared to the rural study focusing on reproductive health issues in Indonesia, our findings indicate a significant disparity in knowledge between urban and rural Indonesia [62]. We also noted that education level was the sole robust predictor of knowledge level over age, marriage, and parity, conforming to prior studies in Indonesia [4], Nigeria [20] and Malaysia [35], which also indicated no relationship between these socio-demographic characteristics towards knowledge level of STIs. Therefore, we emphasise that education and knowledge have a crucial role in reducing the phenomenon of risky sexual behaviour, STIs and other reproductive health-related issues today. Supporting this idea, a Taiwan study also stated that educational attainment is the most potent determinant of the timing of first marriage, lowering the level of sexual activity and thus lowering the probability of marriage at young ages [65]. More educated women are more likely to successfully control the biological urges to engage in premarital sexual activities. They are more aware of the risks associated with this kind of activity, including the increased risks of contracting STIs and unwanted pregnancies [65].

In elaborating on marriage and childbearing characteristics, this study found that about 74% of women were married, with 46% and 28% primiparous and multiparous, respectively. Although sexual activity is not merely determined by marital and parity status, at least this information gives us approximations of the number of participants with experience of sexual intercourse. Marriage is thought to be a risk factor for developing STIs and HPV-related cancers. A study in China found a higher pregnancy rate to be significantly associated with increased cervical cancer risk (OR 3.8–4.2), while a higher number of live births increased the OR for cervical cancer by around 16.8 (p<0.05) in women with more than three live births [66]. In light of this, a meta-analysis showed that women with high parity had 2.65 times the likelihood of acquiring cervical cancer compared to women with low parity (OR 2.65, 95%CI: 2.08–3.38) [67]. Since cervical cancer is also a debilitating impact of STIs (i.e., HPV infection), thus this should also be our concern, and we reinforce a suggestion towards women of reproductive age to routinely conduct cervical screening when they have a history of sexual intercourse, either marital or premarital, to confirm whether HPV infection is present.

It was found that 88% of women had a positive attitude about STIs in this study, higher than in previous studies in rural areas of Indonesia (46.7–70.0%) [60, 61] and Ethiopia (54.5%) [23]. These results were probably due to our participants’ high level of knowledge (but not necessarily due to their level of education), where good knowledge was predicted to enhance 7.8 times higher odds of having favourable attitudes. Meanwhile, education was not associated with attitude (OR 1.56, p=0.556). This link between knowledge and attitude can be explained by the fact that, according to the theory of planned behaviour, knowledge is a critical modifier of positive attitudes [68]. Someone with extensive knowledge tends to be positive in attitude (related to screening for STIs, seeking health personnel, and avoiding pornography) [69]. Similar to the insignificant association between the socio-demographic profiles and knowledge, we also confirmed that a socio-demographic profile is insignificantly associated with participants’ attitudes in this study. In contrast, a Malaysian study found that age was associated with attitude despite not being associated with knowledge [35].

Although our knowledge and attitudes regarding STIs were favourable at first glance, hurdles still exist in urban regions of Indonesia since the community's health literacy level varies between and within regions. Adolescent sexuality is still heavily stigmatised in Indonesia [27]. Moreover, we failed to capture the association between knowledge and attitude toward practice. However, various studies have revealed similar scenarios in other countries worldwide [70, 71]. A previous study in a coastal area of Indonesia also indicated that good knowledge and attitudes did not guarantee good practice. Their research demonstrated a good knowledge of HIV/AIDS in coastal areas and that attitudes toward the disease are adequate, yet it cannot be assumed that people will behave safely. In this study, some participants still had premarital sexual intercourse, did not use condoms, had sexual activities with prostitutes, had multiple sexual partners, and had ongoing STI symptoms during the survey [72]. Our findings did not support Bloom’s taxonomy theory (1956) of educational learning objective, in which practice is influenced by knowledge and attitude because knowledge is a necessary precondition for putting skills and abilities into practice [70, 71]. However, if we view this phenomenon from the recent theory of reasoned action and planned behaviour (TPB), we would get a broader perspective that the practice or behaviour aspect is a complex framework and not merely determined by a good knowledge score and attitude [68]. The lack of correlation between knowledge and attitude towards practice might be due to uncaptured or unidentified confounding factors that may influence these phenomena [73]. In the TPB, there are three main backgrounds of contributing confounding factors, such as personal background (i.e., personality, mood, emotion, intelligence, values, stereotypes, general attitudes, and experiences); social environment (i.e., education, age, gender, income, religion, race, ethnicity, and culture); and availability information (knowledge, media, and intervention) [68]. These background factors interact with each other to produce three proximal constructs: attitudes toward the behaviour (positive or negative outcomes of the behaviour), subjective norms (perceived social pressure to engage or disengage in the behaviour), and perceived behavioural control (perceived ability to perform the behaviour). It is considered that the practice/behaviour and intention are directly related. The intention to engage in a practice/behaviour is believed to be influenced by attitudes, subjective norms, and perceived behavioural control. In this model, individuals will begin to engage in certain practices or behaviours once they have gained the awareness, knowledge, and desire to do so; thus, although knowledge and attitude levels were already satisfying, as long as the participants did not have good awareness and willingness regarding its practice, non-correlation is expected [70, 71].

To exemplify the application of TPB, we found that people tend to respond negatively to the practice of using and giving condoms. It is possible because, in Eastern culture, condoms are often associated with free premarital sex behaviour, which is not following Indonesian values and norms. In our study, 32% of respondents said that they used condoms; a similar rate was observed in urban people in India (24.5%) [74] and Kenya (29.0%) [19] but contrasted with a Nigerian study on urban communities (79.3%) [22] and a Malaysian study on students (63.8%) [17]. The fact that more respondents to our study were married and therefore believed that condoms were less valuable than when they were single contributed to the reduced rate of condom use. Giving advice or condoms to friends is also uncommon in our society because it is closely tied to stigmatisation. An earlier study in the same municipality confirmed the lack of condoms in East Jakarta primary care, which found that using a condom only occurred in 14.1% of STI patients in the polyclinic [4]. Most reasons are unpleasant feelings, an embarrassment to buying condoms, and cost-related issues [4]. These results may provide stakeholders with information to continue their efforts to promote frequent condom use, particularly for the targeted high-risk group, as the key to decreasing STI transmission with the purpose of prevention over stigma, religion, norms, or personal subjectivity concerns [58].

As for abstinence practice, there were not many positive responses because most respondents were married; hence, abstinence may not be their best option to prevent STIs. We also found that knowledge and attitude were not strong enough to influence the practice of avoiding PLWHA. However, in the bivariate analysis, there was a tendency that good knowledge (OR 1.846, p=0.694) and a positive attitude (OR 3.148, p=0.399), is slightly giving a better understanding to the community that HIV patients are not to be shunned, stigmatised, or even isolated from social life. Although a good understanding of the practice of avoiding PLWHA was seen in this study, and most of our respondents did not avoid PLWHA, we should admit that Indonesia still faces challenges in stigmatisation toward PLWHA [75]. Similar to Indian society, it is evident that STIs are strongly linked to social condemnation, disgrace, and rejection in Indonesia [76]. Sexuality and its health implications continue to be widely stigmatised. Although their rights and needs may be accepted in principle and practice, they nonetheless face numerous impediments when trying to get assistance in actual life. With extensive knowledge and a positive attitude, eventually, an understanding that STIs and HIV patients will not be stigmatised or isolated from society will develop [77-80]. Aligned with this, a study in China also showed a relationship between education and attitude, whereby the higher the level of education a person had, the more positive their attitude and acceptance of PLWHA [81]. Inversely, a lack of HIV-related knowledge can lead to misconceptions regarding disease transmission [82]. In overcoming this issue, mass media information is essential for society to understand STI-related, HIV-related, and stigmatisation attitudes and information [83, 84]. However, much neglect is given to media information about HIV, which reduces understanding and impacts stigmatisation attitudes. A previous study on the stigmatisation attitude of people showed a correlation with ignorance of information on transmission, prevention, and treatment of HIV [81].

Negative labelling, ignorance of HIV, fear of contracting the disease, personal values, religious beliefs, and sociocultural norms and values are all identified as catalysts or enablers of HIV-related stigma and discrimination in Indonesia [85]. In families, communities, and healthcare facilities, attitudes toward the undervalued attribute frequently result in prejudice, stereotyping, and discrimination toward PLWHA [86, 87]. At the community level, examples of stigmatisation and discrimination include refusing to sit close to PLWHA, changing seats away from PLWHA, being afraid to physically interact with PLWHA [87], PLWHA dropping out of school, not being allowed to play together, and not eating with peers [88]. There was still a lack of tolerance toward people with STIs and HIV/AIDS, thus encouraging stigmatisation. Several Indonesian studies related to HIV/AIDS stigmatisation revealed that 56% of household heads demonstrated high stigmatisation of PLWHA [89], more than half (71.63%) of youths stigmatised PLWHA [90], and younger people were 1.19 times more likely to discriminate against people with HIV [91].

Interestingly, the highest prevalence of stigmatising attitudes was on the island of Java (59.82%), particularly in the urban areas, compared to other regions in Indonesia [75]. A further impact of discrimination on PLWHA is worrisome, such as the loss of jobs, social status, and family and community support hence developing a tendency to avoid proper treatment [75]. Stigmatisation and discrimination that result in a reluctance to seek treatment for PLWH will worsen their health condition and increase their prevalence due to undetected spread. According to a study [75], younger people are more likely to discriminate against people with HIV, and thus we should focus on female participants at a younger age. Youths do not understand and realise their stigmatisation and discrimination and their effects on people with HIV [75].

The lack of correlation between knowledge and attitudes with practice might reflect that some preceding factors may need to be improved, which is how to apply these two aspects to actual practice. Our findings are an alarm and highlight substantial dysfunction in the Indonesian educational system, where the focus should not only be on improving knowledge and attitude but also on improving the actual practice of young people regarding STIs. Moreover, to better understand STIs, it is essential to involve the parents in sexual and reproductive health education before children reach puberty. The preciousness and usefulness of parent-child interactions for the prevention of STIs were highlighted in 2010 by Deptula et al. [92] who discovered that supportive parent-child interactions are linked to decreased rates of unprotected sex, unwanted pregnancies, and adolescent STIs. Unfortunately, the parent’s role in educating their children about reproductive health remains lacking in Indonesia. Indonesian women, in this context, are characterised as a more closed-personality who are uncomfortable discussing sexual issues with their partner(s), children, family, or even parents [27]. The women’s lack of reproductive health knowledge was a significant cause of such risky behaviour. Indeed, prior qualitative studies demonstrate how Indonesian parents and youth avoid discussing puberty and sexuality because they perceive it to be irrelevant and taboo [27]. It should be encouraged that parental communication is vital for shaping sexual health knowledge and attitudes [80].

Due to the fact in this study that 74% of respondents were mothers, our study is calling out Indonesian women to improve their KAP towards STI and reproductive health to play a better role as educators for their children later. This message should also be directed to the 26% of women who were not childbearing and/or unmarried. Women should be fully provided with adequate KAP on reproductive health to prevent STIs and related problems. Since the need for sex education for young people and women has been articulated, we should also emphasise the need to strengthen the role of community health centres in Indonesia, particularly in urban communities. General practitioners, midwives, clinical psychologists, and nurses must be trained to conduct health counselling about STIs. In more extended action, trained healthcare workers in community health centres could train teachers at school, mothers, peer support, and other volunteers on how to adequately talk about sexuality to their children [77-79].

This study elucidated the KAP of STIs among women of reproductive age at an urban community health centre in Jakarta, Indonesia. The association between the level of education and knowledge was impressive. The higher the educational attainment, the higher the participants’ knowledge about STIs-related issues. It has also been confirmed that the level of knowledge and attitudes related to STIs is correlated and gives a high probability of having a positive attitude when the baseline of knowledge is good. However, there was no statistically significant relationship between knowledge and attitudes towards behaviours assessed in this study (abstinence, using and giving recommendations about condoms, and stigmatisation of PLWHA). It was discovered that better practice tends to result from promoting good knowledge and positive changes in attitudes. Existing educational policies should integrate into sex education and modify message delivery to improve the knowledge and attitude, but also emphasise the proper applicable practice in preventing STIs.

In order to combat constrictive and prejudiced STI norms, our findings also suggest that public health initiatives should target not only reproductive-age women, but also their societal surroundings (such as parents, adolescents, teachers, and community members) [94]. It is imperative to support women in their reproductive years in their crucial roles as mothers or future mothers who will play a significant role in educating their children about sexuality and reproductive health and as wives who should be aware of their reproductive health. To address underlying societal norms in urban cities that cause women to be reluctant, multi-component and multi-level interventions are requires [95]. The aforementioned suggested interventions can be implemented while promoting more extensive structural reforms and collaborating with families, cross-sectoral groups, and community health centres.

HW and MH were the principal investigators of this study. HW acquired funding, controlled the decision to publish, and accepted full responsibility for the overall content of the work. MH conceptualised the study, investigated, designed the methodology, provided the resources, collected the data and did the project administration. HW and MH contributed to the analysis and drafted the paper. MH was entirely responsible for software utilisation, data cleaning, and visualisation of research findings. HW, FK, KHN, TDA, TWU, ADP, and DMS supervised the study process thoroughly and validated all data analyses. All authors critically revised the manuscript for important intellectual content, and all authors gave final approval for the version to be published.