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Posted: September 1st, 2022
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.
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.
The papers from the search were retrieved and read to ascertain if the eligibility criteria for the systematic review were met.
Inclusion criteria were:
Exclusion criteria were:
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
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