Sexual health, risky sexual behavior and condom use among adolescents young adults and older adults in Chiang Mai, Thailand: findings from a population based survey
Pinyopornpanish et al. BMC Res Notes
Sexual health, risky sexual behavior and condom use among adolescents young adults and older adults in Chiang Mai, Thailand: findings from a population based survey
Kanokporn Pinyopornpanish 0
Sanhapan Thanamee 0
Wichuda Jiraporncharoen 0
Kanittha Thaikla 2
Jessica McDonald 1
Apinun Aramrattana 0
Chaisiri Angkurawaranon 0
0 Department of Family Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai 50200 , Thailand
1 Thai Health Promotion Foundation , Bangkok 10120 , Thailand
2 Research Institute for Health Sciences, Chiang Mai University , Chiang Mai 50200 , Thailand
Background: Sexual health is one of the key dimensions of health across all ages. Understanding risky sexual behaviors remains an important area of public health research. This study aimed to explore sexual health, risky sexual behaviors and factors associated with recent condom use as condom use is considered a main intervention proven to reduce negative health consequences of risky sexual behaviors, specifically related to sexually transmitted infections and unintended pregnancies. A stratified two-stage cluster sampling technique survey was conducted in Chiang Mai, Thailand. Information was obtained about age of first sexual intercourse, sexual activity, condom use, number of partners and history of drug/alcohol use prior to sexual activities within the past 3 months. A weighted analysis was performed to account for data clustering. Results: It is estimated that most men (93%) and women (86%) in Chiang Mai have engaged in sexual intercourse. More than 70% of the people in Chiang Mai over age 30 remained sexually active in the past 3 months, even for populations over age 50. Eight percent of male teenagers reported having more than one sexual partner in the past 3 months. Regular condom use was reported in less than 5% of the population (6.6% men and 3.1% women). Conclusions: Our study demonstrated that sexual health is an important public health issue across all age groups. Condom use has been promoted as one way to minimize and prevent unintended consequences of sexual behavior but overall use remains low.
Sexual health is one of the key dimensions of health
across all ages. Understanding risky sexual behaviors
remains an important area of public health research [
Risky sexual behaviors can lead to many negative health
related consequences and public health issues, especially
sexually transmitted infections (STIs) and unintended
]. High risk sexual behaviors include
younger age at first sexual intercourse (SI), having
multiple partners or casual partners, inappropriate use
of contraception, and drug and alcohol use before sexual
Unsafe sex was found to be one of the leading risk
factors related to the global burden of disease over the
past decade [
]. Many global and local public health
policies promote sexual education and encourage safe
sexual practices instead of prohibiting them. However,
unintended pregnancy and STIs are still ongoing
problems. While more effective methods are used to prevent
pregnancy, STIs can be effectively prevented with male
condom. Higher incidence of STIs than in the past is
reported in the United States and the United Kingdom,
not only in adolescents, but also in middle-aged adults
and elderly populations [
]. Thus, sexual health and
high-risk sexual behavior is an important public health
issue across all age groups.
Sexual behavior is affected by cultural values and
public health policies that are different in each country and
setting. Furthermore, cultural values and health
policies have changed over time [
]. As a result, the sexual
norms in most parts of the world are experiencing
cultural transitions, including Thailand. It has been reported
that while Thai people are aware of the possible
transmission of human immunodeficiency virus (HIV) through
sexual intercourse, risky sexual behavior are continually
]. These risky behaviors include younger age
at first intercourse, multiple partners, and low rate of
condom use with casual partners. Data from 2012
suggested that STIs were increasing in many age groups in
This study aimed to assess sexual health and risk
behaviors among individuals across different age groups among
those living in Chiang Mai, which has the second
highest prevalence in STIs in Thailand [
] Prior studies
conducted in Thailand focused mostly on adolescents [
] while a very limited amount of research has been
conducted among other age groups [
]. In addition,
the study aimed to explore factors associated with recent
condom use as condoms are considered a main
intervention intended to reduce negative health consequences
associated with risky sexual behaviors, specifically related
to STIs [
Study setting and design
This population-based survey was conducted in Chiang
Mai province, the largest province in the Northern region
of Thailand, in 2014. The targeted populations were
those who have lived in Chiang Mai for at least 3 months
between ages 15 and 64. Data was collected by trained
field researchers using face-to-face structured interviews
and questionnaires that were developed from
questionnaires used in Thailand National Health Examination
] and the Thai National Sexual Behavior
Sampling and sample size calculations
The Thai census estimated that there were 713,053
households and approximately 1.6 million people
living in Chiang Mai in 2014. Approximately 1.2 million
people were between 15 and 64 years of age. A stratified
two-stage cluster sampling technique was done. The
enumeration areas (EAs) were sub-districts in Chiang Mai
and were considered the primary sampling units.
Households were the secondary sampling units. Thirty-six EAs
were randomly selected using probability proportional to
the size of the population in each unit. Twenty-four EAs
were in urban areas and 12 were in rural areas. Twenty
households per cluster were randomly selected in the
second stage. Allowing for an 80% response rate and
a design effect of 1.5, it was estimated that 1888 people
could represent the targeted population.
Measurements and variable definitions
In addition to general demographic data, the survey
obtained information on age at first sexual intercourse,
sexual activity and number of partners within the past
3 months along with history of drug or alcohol use before
sexual intercourse in the past 3 months. To assess
condom use, participants were asked, “In the past 3 months,
how often do you use (male) condoms to prevent STIs”?
Participants could choose from four choices: never,
sometimes, most of the time and all the time. Those who
answered the latter two options were considered regular
condom users. For the study, other high risk behaviors
were defined as, having more than one partner (multiple
partners) within the past 3 months and using drugs or
alcohol prior to SI within the past 3 months.
Other factors of interests in the study survey included
highest education, which was classified into four
categories: primary school, early secondary school, late
secondary school and Bachelors degree. Monthly income was
categorized into four categories. Marital status was
categorized into three categories: single, married/partner or
separated/divorced/widowed. Urbanicity of living
location was also documented as urban or rural.
Descriptive statistics were used to describe the
sampled population in terms of age and gender distribution,
marital status and urban or rural dwelling locations. To
infer back to the source population, weighted analysis
were conducted to account for a clustering effect using
the survey commands in STATA 13. Prevalence of risky
sexual behaviors were estimated and stratified by age
and sex. Univariable and multivariable logistic regression
were used to explore factors associated with regular
condom use among those who have been sexually active in
the past 3 months. Age and sex were considered a priori
when identifying confounders in multivariable analysis.
Participants were given an informed consent form prior
to each interview. If participants were less than 18 years
of age, consent was obtained from legal guardian(s). The
study was approved by an Ethics Committee from Chiang
Mai University (No 62/2014).
A total of 1744 participants were enrolled in the present
study and a 92.4% response rate was obtained (92.8%
response in urban areas and 91.7% response in rural
areas). The sample represented the source population
well in terms of age and sex distributions (Additional
file 1: Table S1). The sample consisted of 936 women and
808 men. The mean age of the study sample was 43.3 for
women and 43.9 for men, although, about 40% were over
50 years of age. About half were educated beyond
primary school (52.5%). Most were partnered (70.7%) and
living in urban areas (66.1%). Approximately 70–80% of
the population over the aged of 30 were married or
partnered (Additional file 1: Table S2). The weighted
estimates of demographic characteristics in the Chiang Mai
population were similar to that of the sample (Table 1).
It was estimated that the majority of men (92.7%) and
women (86.0%) in Chiang Mai have engaged in sexual
intercourse (SI). Stratified by current age group, nearly 30%
of male teenagers and 20% of female teenagers have engaged
in SI. By age 30, almost all (95%) participants reported
engaging in previous SI (Table 2). The estimated mean ages
of first SI amongst those with a history of SI were 20.5 and
20.9 years of age for men and women, respectively.
Overall, nearly two-thirds of the population in Chiang
Mai have engaged in sexual intercourse over the past
3 months. Stratified by age group, approximately 13%
of teenagers and 51% of adults between ages 20 and 29
had SI in the past 3 months. This prevalence increased
after age 30. Over 75% of men between 30 and 59 years
old and more than 65% of men 60 and over were sexually
active. While women reported having less recent sexual
encounters than men, the trend in prevalence remained
similar to men such that over 75% of women in their
thirties and forties reported recent sexual intercourse. This
number dropped to 63% among women in their fifties
and approximately 40% among those age 60 and over
UW unweighted results, W weight results, 1 US dollar approximately 35 baht in 2014
N = 936
Percent (%) who regularly used condoms in the past 3 monthsa, b (95% CI)
SI sexual intercourse, CI confidence interval
a Regular condom used defined as having used condom most of the time and all of the time in past 3 months
b The data analyzed amongst those who had experienced SI
While recent sexual activity was common, regular
condom use within the past 3 months was scarce, at less than
5% for the population. Men reported regular condom
use more often than women, at 6.6 and 3.1% respectively.
Stratified by age groups, higher prevalence of
regular condom use was reported among male and female
teenagers and early adult males, at approximately 20%
(Table 2). Among those who reported prior SI, nearly
90% of women over 19 years of age reported that their
partner never used a condom in the past 3 months while
over 90% of men age 30 and older also reported never
using condoms over the past 3 months (Table 3).
Other risky sexual behaviors
Among those who have engaged in SI, 8% of male
teenagers reported having more than one sexual partner in the
past 3 months, while approximately 1.5% of men in their
twenties and thirties reported having more than one
sexual partner in the past 3 months. Among women, having
multiple partners in the past 3 months was rare. Overall,
it is estimated that 0.7% of men and 0.2% of women who
reported a history of sexual intercourse had more than
one sexual partner in the past 3 months (Table 3). Within
the past 3 months, around 1–1.5% of women across all
age groups reported using drugs or alcohol before SI.
However, the prevalence is over 10 times higher among
men. Up to 20% of male teenagers reported using drugs
or alcohol prior to sexual intercourse (Table 3).
Factor associated with regular condom use
Among those who were sexually active in the past
3 months, there were many factors associated with
regular condom use. In a crude analysis, increasing age was
associated with declining condom use. Males reported
more condom use compared to females. Respondents
without a partner were more likely to use condoms than
those who identified as attached. Higher education and
higher income were associated with condom use. People
with multiple partners or drug use before having SI were
also more likely to report regular condom use over the
past 3 months (Table 4).
The direction of associations in an adjusted analysis
was similar to those of the crude analysis. In the
multivariable analysis, results showed that being single and
having an above average income was associated with
Proportion (per 1000) with more than 1 sexual partner in past 3 months (95% CI)
Percent (%) who used alcohol/drugs before SI in past 3 months (95% CI)
CI confidence interval
Analysis conducted among those who had a history of having had sexual intercourse in the past 3 months. Regular condom used defined as having used condom
most of the time and all of the time in past 3 months: * overall p value using likelihood ratio test
regular condom use. Regular condom use was more
commonly reported among those with multiple partners and
those who used drugs or alcohol prior to SI. For age, the
adjusted analysis found that teenagers were less likely to
use condoms compared to older age groups (Table 4).
This study indicates that more emphasis should be placed
on sexual health in Chiang Mai as the majority of study
participants reported past sexual activity. Moreover, it is
estimated that over half of the population in Chiang Mai,
over age 20, reported having SI in the past 3 months. In
addition, many of those who engaged in SI reported low
rates of condom use. On a global scale, condom use is
promoted as a primary method to prevent undesirable
health outcomes, specifically sexually transmitted
]. However, low rates of condom use were
found among the study population, which enhances the
need for further investigation into a lack of condom use
in Chiang Mai, Thailand.
The average age at first SI reported by the study
population was approximately 20 years of age. This finding is
similar to results from the 2006 Thai National Survey of
Sexual Behavior which revealed the average age at first SI
was 19 for men and 20 for women [
]. With a
cumulative effect, it was not surprising that increasing age was
associated with increasing percentage of ever having SI
throughout lifetime. Moreover, 90% of the population
over age 30 had already engaged in SI. This finding
supports that sex education should be provided during
teenage years prior to the onset of sexual activity.
In line with the previous study from Thailand by Ford
and Chamratrithirong [
], our study shows declining
prevalence of recent sexual activity in aging people. This
may be due to their general health conditions, emotional
desire, partner characteristics and family context [
However, our data demonstrates that the majority of the
people living in Chiang Mai, over age 30, still remain
sexually active, even for populations over age 50. The
proportion who remain sexually active in older populations
were similar to a US study, which found that 73% of
participants aged 57–64 years were still sexually active .
This information supports that health education on safe
sexual practices and family planning for men and women
who are of reproductive age should be continuously
promoted throughout their lifetime.
In Thailand, many public health campaigns exist to
promote condom use. In 1989, Thailand launched the
100% condom campaign, which targeted sex workers and
their clients [
]. Later campaigns have targeted condom
use for the general population, heavily targeting
teenagers in order to prevent teenage pregnancies [
However, our research indicates low levels of condom use
in Chiang Mai across all age groups. This was similar to
results from the 2006 Thai National Survey which found
that approximately 6.6% of Thai men routinely use
condoms with their regular partners [
In particular, our study demonstrated that older age
groups, between 30 and 50 years of age, remain sexually
active but also had low levels of condom use. It is possible
that they are more likely to be married and/or have
regular partners thus resulting in lower regular condom use
or no condom use. However, there is still a risk of
transmitting STIs to regular partners if prior exposure was a
factor with previous partners. A previous survey found
that among older Thai nationals, one quarter married
their first sexual partner and the majority of Thai men
had casual partners or more than one partner in their
]. While currently less common, in previous
decades, high levels of extramarital sex has been reported
particularly with sex workers [
]. Our data also suggest
that while the majority of men over the aged of 30 are
married or partnered, approximately 1% have had more
than one sexual partner in the past 3 months.
In the present study, men were more likely than women
to report condom use. A previous study from Northern
Thailand by Tangmunkongvorakul [
] found that men
were more likely to have non-regular sexual partners and
likely to report more condom use, in order to prevent
STIs from those casual partners. The study also reported
that some women were unable to negotiate protected
sex with their partner because they respected the man’s
decision or had prior uncomfortable experiences after
asking their partner to use condom. This finding could
reflect Thai cultural values in that men have authority
and women appear less concerned about their own risks
and are more likely to accept sexual risk factors to avoid
negative feedback from their partner [
condom use rates are associated with higher education in
our study and in previous studies [
]. In Thailand as
sex education is offered in school, those with higher
education could be more aware of reproductive health issues
. However, increasing sexual education to general
population across age groups, especially in reproductive
women, could help reduce the risk of STIs and unwanted
]. Innovative strategies driven by
nongovernment organizations such as peer youth education
programs may be useful [
We found that those involved in other risky
behaviors, such as, SI with multiple partners and drug/alcohol
use prior to SI, were more likely to report condom use
than those who did not report risky sexual behaviors.
Another study reported that alcohol was associated
with an increased risk of engaging in sexual activities
and an increased number of multiple or casual partners
]. Our findings could potentially reflect respondent
awareness about high risk sexual behaviors but this issue
needs to be further investigated. However, as the
overall prevalence of regular condom use among high risk
groups remains low, promotion and prevention policies
targeting this group are still needed.
The present study highlights other factors that may
be associated with condom use, specifically showing no
significant difference in condom use between rural and
urban populations. However, differences in personal
income were significantly associated with condom use.
Personal income was a major confounding factor in the
association between age and condom use. This reflects
that condom price could be one of the key barriers to
regular condom use in Thailand as seen in other developing
]. The Thai policy for access to free condoms
] should be expanded and highlighted to improve
accessibility to condom and increase the use in Thailand.
A major strength of the present study was proper
sampling and analysis, which is representative to the targeted
population. Population surveys are useful in reflecting the
current situation and to help guide future public health
interventions and preventive strategies. There were also
a number of limitations, including the cross-sectional
design limit causal interpretation. Our categorization of
regular condom use included those who reported using
condoms most of the time. Furthermore, we could not
assess proper use of condoms such as whether there
were no slippages or no early removals. These limitations
will effect the implications of our findings as it may not
result in effective prevention of STIs. Due to the nature
of the survey, difficult to access and vulnerable
populations for high-risk sexual behaviors such as sex workers,
injected drug users and high risk youths are unlikely to
be captured in the survey and thus likely to be
underrepresented in the present study. Face-to-face interviews
may have also generated some response bias. Both
aforementioned issues were likely to result in an
underestimation of high-risk sexual behaviors. Further subgroup
analysis were not possible as the study did not collect
detailed data on type of sexual partner (regular or
casual), sexual orientation and personal history of STIs. Due
to limited sample size, we could not assess condom use
amongst those with more than one partner within the
past 3 months. Further studies are needed to explore the
detailed barriers and perceptions of condom use among
different ages, gender and socioeconomic status in order
to guide effective condom policies in Thailand.
In conclusion, our study demonstrated that sexual
health and risky sexual behavior is an important
public health issue across all age groups. Condom use has
been promoted as one way to minimize and prevent
unintended consequences of sexual behavior but
overall use remains low even among high-risk populations
in Chiang Mai, Thailand. Our study suggests that
condom price may be a barrier to condom use and that
sex education in Thailand should focus on the risks of
unprotected sexual activity and tackle social, gender
and cultural perceptions that may inhibit condom use.
Thailand recently launched its new National Condom
Strategy for 2015–2019 [
]. Some of the strategies are
aimed to tackle such issues by providing free condoms
during Valentine’s day or cheap condoms in public
events and in public areas such as department store and
hotel restrooms. The National Condom Strategy also
includes mass media campaigns to promote safe sex and
positive perceptions about condom use. Evaluation is
still needed to estimate the effectiveness of such policies
Additional file 1: Table S1. Characteristics of sampled population and
source population. Table S2. Relationship status by age group and sex.
EAs: enumeration areas; HIV: human immunodeficiency virus; SI: sexual
intercourse; STIs: sexually transmitted infections.
KP, WJ, CA were responsible for the conception of the study. KT and AA were
responsible for the design and acquisition of data. KP and CA analyzed the
data and wrote the first draft of the manuscript. All authors (KP, ST, WJ, KT, JM,
AA, CA) contributed to interpretation of the data, revised the manuscript. All
authors read and approved the final manuscript.
We would like to thank Dr. Suparerk Suerungruang and Mr. Kongprai
Tunsuchart for their advice and help during the preparation phase. We are grateful
to all field staff who helped collect the data and to all participants who
participated in our study.
The authors declare that they have no competing interests.
Availability of data and materials
Data set are available from the corresponding author on request.
Consent for publication
Ethics approval and consent to participate
Participants were given an informed consent form prior to each interview. If
participants were less than 18 years of age, consent was obtained from legal
guardian(s). The study was approved by an Ethics Committee from Chiang Mai
University (No 62/2014).
The study was funded by the Thai Health Promotion Foundation. The funder
had no role in the study design, analysis, interpretation and decision to
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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