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E-publishing of this PDF file has been approved by the authors. Healthc Low-resour S 2025 [Online ahead of print] To cite this Article: Abidah SN, Salim LA, Hartini N, Safitri YI. Sexual assertiveness as a predictor of premarital sexual behavior among female adolescents: a cross-sectional studyIran. Healthc Low-resour S doi: 10.4081/hls.2025.13886 ©The Author(s), 2025 Licensee PAGEPress, Italy Note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries should be directed to the corresponding author for the article. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Submitted: 11 April 2025 Accepted: 11 November 2025 Early access: 11 December 2025 https://www.pagepressjournals.org/index.php/hls/index https://www.pagepress.org/site 2 Sexual assertiveness as a predictor of premarital sexual behavior among female adolescents: a cross-sectional study Siska Nurul Abidah,1 Lutfi Agus Salim,2 Nurul Hartini,3 Yati Isnaini Safitri4 1Doctoral Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya; 2Department of Epidemiology, Biostatistics, Population Studies and Health Promotion, Faculty of Public Health, Universitas Airlangga, Surabaya; 3Department of Psychology, Faculty of Psychology, Universitas Airlangga, Surabaya; 4Department of Midwifery, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya, Surabaya, East Java, Indonesia Correspondence: Siska Nurul Abidah, Doctoral Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia. E-mail:siska.nurul.abidah-2023@fkm.unair.ac.id Key words: adolescents; assertiveness; behavior; premarital sex. Contributions: SNA conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; LAS conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; NH and YIS, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research procedure receivedethics from the research ethics Lembaga Chakra Brahmanda Lentera Institute No. 24.1/07/V/EC/KEP/LCBL/2024. Patient consent for publication: the research involved human participants. We obtained informed consent from respondents before collecting the data. Funding: this research did not receive external funding. mailto:siska.nurul.abidah-2023@fkm.unair.ac.id 3 Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: we would like to thankful Universitas Airlangga and Universitas Nahdlatul Ulama Surabaya, Indonesia for their valuable support. Abstract Adolescence is a critical phase of life that needs extra attention. One common issue among adolescents is engaging in premarital sex, which can have serious negative effects, especially for girls. Girls need to develop the ability to firmly say no to premarital sexual activity, which is known as sexual assertiveness. This study aimed to examine the influence of sexual assertiveness on premarital sexual behavior in adolescents. This was an observational study using a cross-sectional design. The independent variable was the sexual assertiveness and the dependent variable in this research was premarital sexual behavior. This research was conducted in June – August 2024 in classroom settings at UNUSA. The sample in this study consists of 92 female students who have a boyfriend. The sampling technique used purposive sampling technique. Data collection in this study was carried out face to face through interviews and questionnaires. The instruments used were the sexual behavior scale and the Sexual Assertiveness Questionnaire (SAQ). Analysis used a simple linear regression test. The results of the statistical test show a value of ρ = 0,000 (p < 0,05), which means there is an influence of sexual assertiveness on premarital sexual behavior in adolescents. Adolescents with strong sexual assertiveness are better able to avoid engaging in premarital sexual activities, helping them steer clear of its negative consequences. The results of this study are expected to be the basis for designing interventions or educational programs aimed at improving sexual assertiveness skills as a form of self-protection in maintaining adolescent reproductive and mental health. Introduction Premarital sexual behavior among teenagers is a growing problem. One aspect of this behavior is dating, which has become quite common among young people. A study revealed that 88% of teenagers in the UK have dated.1 Similarly, a survey showed that 81% of Indonesian teenagers have 4 dated.2 Research shows that many individuals start dating for the first time during adolescence, around 33.3% of girls start between the ages of 15 and 17, while 34.5% of boys start before the age of 15.2,3 During this time, teenagers begin to feel attracted to the opposite sex and look for ways to fulfill their sexual urges.4 These findings indicate that the rate of dating among teenagers is quite high. However, in practice, dating also has the potential to be a gateway to sexual behavior that is not in accordance with norms and is not yet the right time to do, namely premarital sex. Premarital sexual behavior is very likely to occur among teenagers because of their increasing curiosity during this stage of development. As they grow, teenagers often feel the desire to explore new experiences. They begin to develop an interest in the opposite sex and learn about love and affection.5 Research shows that the higher the intensity and closeness in a dating relationship, the more likely teenagers are to engage in sexual activity.6 The level of dating that involves physical touch, intense emotional closeness, and pressure from partners often makes it difficult for teenagers to set healthy boundaries in relationships.7 When dating is carried out without sufficient understanding of sexual risks and boundaries, the chances of premarital sex increasing significantly.8 A report from the National Population and Family Planning Agency (BKKBN) shows that the prevalence of premarital sexual behavior among teenagers continues to increase from year to year.9 Basic Health Research (Riskesdas) data also shows that some teenagers have engaged in sexual activity before marriage, for various reasons ranging from love, pressure from partners, to environmental influences.10 This phenomenon is even more worrying when combined with the lack of understanding of adolescents about reproductive health and the low ability to reject sexual pressure from partners. Adolescents often feel that sex is a form of "proof of love" in a relationship, even though this decision can have long-term implications for their physical, mental health, and future.11 Unintended pregnancies, illegal abortions, and sexually transmitted infections are some of the impacts that can occur due to premarital sex.12 To mitigate these adverse outcomes, it is essential for adolescents to develop sexual assertiveness skills. Sexual assertiveness skills are an important factor that can help adolescents to reject unwanted sexual advances, set boundaries, and make healthy and responsible sexual decisions.13 Sexual assertiveness refers to an individual's ability to openly, honestly, and firmly express their desires, including rejecting or accepting sexual activity based on their own will, without pressure from others.14 Adolescents with low levels of sexual assertiveness tend to be more easily influenced by pressure from partners or the environment to have premarital sex, even though they feel uncomfortable or not ready.15 This is supported by research who found that assertiveness technique 5 training for adolescents significantly increased adolescents' ability to reject sexual advances in dating.16 Sexual assertiveness is the ability of an individual to express desires, rejections, and boundaries in the context of sexual relationships honestly and firmly. This ability is very important for adolescents to have, considering that they are in a period of developmental transition with a high level of exploration but are still vulnerable to environmental influences and peer pressure.17 Research on premarital sex has been widely conducted, but has not yet discussed in depth the internal factors, one of which is psychological, so researchers currently want to develop predictors of the causes of premarital sex related to adolescent psychology, namely the ability of sexual assertiveness possessed by adolescents. Based on this phenomenon, this study aims to examine the influence of sexual assertiveness on the likelihood of engaging in premarital sexual behavior among adolescents. Currently, many teenagers are still unable to express agreement or rejection assertively, so they are at higher risk of engaging in unwanted premarital sexual behavior. Therefore, this study is important to strengthen the understanding of how sexual assertiveness plays a role in preventing premarital sexual behavior in adolescents. This study is expected to be the basis for designing interventions or educational programs aimed at improving sexual assertiveness skills as a form of self-protection in maintaining adolescent reproductive and mental health. Materials and Methods Research design This study employed a quantitative, observational design with a cross-sectional approach. The research was conducted to examine the relationship between sexual assertiveness and premarital sexual behavior among female adolescents. Participants The study population consisted of female undergraduate students enrolled in the Midwifery Program at Universitas Nahdlatul Ulama Surabaya. This research was conducted in June – August 2024 in classroom settings at Universitas Nahdlatul Ulama Surabaya. The sample in this study was 92 adolescents who met the inclusion and exclusion criteria, namely inclusion criteria: unmarried, currently in a relationship, aged 18-23 years, willing to be respondents and exclusion criteria: adolescents who did not fill out the questionnaire completely, adolescents who withdrew (dropped out) from the questionnaire filling process before completion. The sampling technique used in this 6 study was purposive sampling, which is a sampling technique based on certain considerations or criteria that are in accordance with the objectives of the study. Data collection and instruments This study was granted by ethical clearance from Lembaga Chakra Brahmanda Lentera Institute No. 24.1/07/V/EC/KEP/LCBL/2024. Data collection in this study was done face-to-face through interviews and using questionnaires. Before filling out the questionnaire, each participant was given a complete explanation of the objectives, procedures, benefits, and potential risks of the study. Participants were then asked to sign an informed consent form as a form of conscious and voluntary agreement to participate in this study. The independent variable in this study is sexual assertiveness and the dependent variable is premarital sexual behavior. Sexual assertiveness It was defined as the ability to express sexual boundaries clearly, including the confidence to refuse unwanted sexual advances. Measured using an 18-item scale. Sexual assertiveness was adopted from Sexual Assertiveness Questionnaire (SAQ) by Loshek dan Terrell.18 Reliability of this instrument was Cronbach's Alpha = 0.890, demonstrating adequate. Premarital sexual behavior: Defined as sexual activities conducted outside of marriage, including physical intimacy such as kissing, touching, and intercourse. Measured using a 16-item favorable scale. The instrument premarital sexual behavior scale was developed by researchers. The validity of this instrument showed correlation coefficients ranged from 0.410 to 0.883 (significance level of 5% = 0.278). Reliability of the instrument was Cronbach's Alpha = 0.906, indicating high reliability. Each item on both scales was rated using a 4-point Likert-type response format. Higher scores on the assertiveness scale indicate stronger sexual assertiveness, while higher scores on the sexual behavior scale indicate more frequent engagement in premarital sexual activities. Data analysis The study aim of this study was to examine the influence of sexual assertiveness on premarital sexual behavior involvement among adolescents. We used SPSS program. Descriptive statistic was used to measure the descriptive statistic of variable and simple linear regression was used to measure the role of sexual assertiveness and premarital sexual behavior among adolescents with statistical significance (p<0.05). 7 Results Table 1 shows an F value of 78,531 with a test significance of 0.000 < 0.05. This shows that there is a linear relationship between sexual assertiveness (X) and premarital sexual behavior in adolescents (Y). This shows that the regression model can be used. Table 2 shows the results of the t-test with a significance value of 0.000 smaller than 0.05 so that it can be concluded that Ho is rejected and Ha is accepted, thus it can be concluded that the sexual assertiveness variable (X) has a significant influence on premarital sexual behavior in adolescents (Y). The regression equation obtained is Y = 99.447-1.124X+e, from this equation it can be concluded that from each additional 1 unit of the independent variable, namely sexual assertiveness (X), the value of the dependent variable, namely premarital sexual behavior in adolescents (Y) will decrease by -1.124. Discussion The results of this study indicate that there is a significant influence of sexual assertiveness on premarital sexual behavior in adolescents. Based on simple linear regression analysis, a significance value of <0.05 was obtained, indicating that sexual assertiveness has a statistically significant relationship with premarital sexual behavior. The negative regression coefficient of -1.124 indicates that the higher the level of adolescent sexual assertiveness, the lower the tendency of adolescents to engage in premarital sexual behavior. This finding is in line with previous research stating that adolescents with good sexual assertiveness are better able to reject invitations or pressure to engage in unwanted sexual activity.19 Sexual assertiveness reflects the ability of adolescents to clearly state sexual needs and boundaries, and to maintain decisions that are in accordance with personal values and beliefs. When adolescents have self-control and the courage to say "no" to sexual pressure, their chances of engaging in premarital sex can be minimized.20 These results are also in line with previous studies showing that adolescents who have the confidence to reject sexual advances tend not to engage in risky sexual behavior, thus the importance of adolescents having sexual assertiveness skills as self-protection.21 Adolescence is a period of psychological development that requires emotional maturity.22 This study also supports the theory that sexual behavior is not solely influenced by biological drives, but also by psychosocial factors, one of which is assertiveness. In the context of adolescence, the transition from childhood to adulthood is often marked by the search for identity and pressure from the social environment, including peers.23 Sexual assertiveness is an important skill to help adolescents maintain their boundaries in such situations. This highlights the need for consistent assertiveness to help adolescents refuse, thereby reducing the risk of premarital sexual behavior.24,25 8 The results of this study also obtained a determination coefficient value (R square) of 0.384 indicating that premarital sexual behavior was 38.4% influenced by sexual assertiveness while the remaining 61.6% was likely influenced by other variables not examined in this study, such as self- control, peer influence, religiosity, family norms, access to sexual information, and use of social media. However, although the influence of sexual assertiveness is moderate (38.4%), it is necessary to understand that sexual behavior is the result of a complex interaction between psychological, social, cultural, and environmental factors. Therefore, interventions to prevent premarital sexual behavior in adolescents need to be carried out holistically by involving various approaches, including comprehensive sexual education, improving interpersonal communication skills, and support from family and the school environment.26 Limitations in this study include the use of a cross-sectional design that cannot show a direct cause- and-effect relationship. In addition, data were obtained through questionnaires, which allow for social bias in filling in answers by respondents. Therefore, further research is recommended to use a longitudinal approach and consider other mediator or moderator variables, such as self-control, subjective norms, or quality of relationships with parents. Practically, the results of this study provide important implications for the development of adolescent sexual education programs. This study is expected to strengthen the understanding of how sexual assertiveness plays a role in preventing premarital sexual behavior in adolescents. So that it can be a basis for designing interventions or educational programs that aim to improve sexual assertiveness skills as a form of self-protection in maintaining adolescent reproductive and mental health. Interventions that focus on increasing sexual assertiveness can be one of the preventive strategies in preventing premarital sexual behavior in adolescents. Educators, counselors, and health workers are expected to integrate assertiveness skills training into reproductive health education provided to adolescents as a reinforcement of positive values in adolescents so that they are able to make healthy and responsible sexual decisions. The results of this study also provide an understanding to adolescents that having good sexual assertiveness is a form of self-protection against the risk of premarital sexual behavior. Assertiveness allows adolescents to set boundaries in relationships, reject unwanted sexual advances, and make decisions based on personal values and beliefs.27 Thus, increasing sexual assertiveness needs to be part of the educational process and character formation of adolescents, especially in dealing with pressure from the social environment and dating relationships. 9 Conclusions This study confirms a strong relationship between sexual assertiveness and premarital sexual behavior. The results of this study can encourage adolescents to realize the importance of having the ability to refuse unwanted sexual advances and to make sexual decisions consciously, responsibly, and not based on pressure or fear of losing a partner. This study supports the importance of equipping oneself with sexual assertiveness skills to avoid risky sexual behavior. The results of this study are expected to increase self-awareness and self-control in adolescents so that they can avoid premarital sexual behavior. In addition, health workers and teachers can be more sensitive to adolescents who show signs of low assertiveness, such as difficulty refusing, tending to follow peer pressure, or not daring to talk about discomfort in relationships. Thus, earlier intervention can be given through a supportive approach. References 1. Fox CL, Corr M-L, Gadd D BI. Young teenagers’ experiences of domestic abuse. J Youth Stud 2014;17:510–26. 2. Demographic and Health Survey (SDKI). Adolescent Reproductive Health. Jakarta: National Population and Family Planning Agency (BKKBN); 2017. 3. Ohee C, Purnomo W. The influence of relationship status on risky dating behavior in Papuan migrant students in Surabaya City. Indonesian J Public Health 2018;13:268–80. 4. Zani B, Cicognani E. Sexuality and intimate relationships in adolescence. Handbook of adolescent development. Psychology Press; 2020. 200–22 p. 5. Nugroho E, Shaluhiyah Z, Purnami CT, Kristawansari K. Counseling model development based on analysis of unwanted pregnancy case in teenagers. J Kesehat Masy 2017;13:137–44. 6. Olivia Yudi RS, Darminto D. Sexual behavior in adolescents in Malang City reviewed from self-control. National Seminar Information Systems 2018;2:225–31. 7. Ajayi AI, Odunga SA, Oduor C, et al. “ I was tricked”: understanding reasons for unintended pregnancy among sexually active adolescent girls. Reproductive Health 2021;18:1–11. 8. Rong Z, Wen Z, Maoxu L, et al. Relationship between childhood sexual abuse and attitudes toward premarital sexual permissiveness among middle school students in Luzhou, China. BMC Public Health 2022;22:71–5. 9. National Population and Family Planning Agency. Indonesian population and family profile 2021. BKKBN; 2021. 10. Kementerian Kesehatan RI. National report of Basic Health Research (Riskesdas) 2018. Jakarta: Health Research and Development Agency; 2018. 10 11. Taquette SR MD. Causes and consequences of adolescent dating violence: A systematic review. J Injury Violence Res 2019;11:137. 12. Shrestha RB. Premarital sexual behaviour and its impact on health among adolescents. J Heal Promot 2019;7:43–52. 13. Kim M, Choi J-H. A study on sexual behavior, sexual knowledge, and sexual assertiveness among Korean college students. Indian J Sci Technol 2016;9:1–8. 14. Haider SI, Burfat FM. Improving self-esteem, assertiveness and communication skills of adolescents through life skills based education. JSSH 2018;26:2. 15. Widman L, Choukas-Bradley S, Helms SW, Prinstein MJ. Adolescent susceptibility to peer influence in sexual situations. J Adolescent Health 2016;58:323. 16. Amaliyah K, Filliani R, Hidayat DR. The effect of assertive training techniques to increase assertiveness towards sexual behavior in dating. J Guidance Counseling 2020;4:77–88. 17. Couture S, Fernet M, Hébert M, etbal. “I just want to feel good without making you feel bad”: sexual assertiveness negotiation in adolescent romantic relationships. Arch Sexual Behavior 2023;52:3063. 18. Loshek E, Terrell. The development of the Sexual Assertiveness Questionnaire (SAQ): a comprehensive measure of sexual assertiveness for women. J Sex Res 2014;0:1–11. 19. Afriani R, Mahrita D, Wahyuni S. The Relationship between sexual assertiveness and premarital sexual behavior in adolescents. J Reproductive Health 2021;8:123–30. 20. Alvarado SLL, Van Parys H, Jerves E, Enzlin P. Development of sexual assertiveness and its function for human sexuality: a literature review. Interamerican J Psychol 2020;54:948. 21. Struckman-Johnson C, Anderson PB, Smeaton G. Predictors of female sexual aggression among a US MTurk sample: The protective role of sexual assertiveness. J Contemporary Criminal Justice 2020;36:499–519. 22. Ozdemir A, Utkualp N PA. Physical and psychosocial effects of the changes in adolescence period. Int J Caring Sci 2016;9:717–23. 23. Santrock JW. Adolescence (16th ed.). New York: McGraw-Hill Education; 2018. 24. Widman L, Golin CE, Kamke K, et al. Sexual assertiveness skills and sexual decision- making in adolescent girls: Randomized controlled trial of an online program. Am J Public Health 2018;108:96–102. 25. Kristanti I, Poerwandari EK, Pohan LD, Primasari I. Cognitive-behavioral intervention to enhance sexual assertiveness in women who exhibit premarital sexual compliance in the greater Jakarta Area, Indonesia. Pertanika J Soc Sci Humanit 2019;27:2. 26. Okah PS, Onalu CE, Aghedo GU, et al. Factors associated with the premarital sex among 11 adolescents and the need for introduction of functional sex-education in secondary schools in Ebonyi state, Nigeria. Cogent Soc Sci 2023;9:1. 27. López-Alvarado S, Van Parys H, Cevallos-Neira A, Enzlin P. Latin American women's beliefs, views and ideas about sexual assertiveness: a focus group study in Cuenca (Ecuador). J Sex Res 2020;57:307–21. Table 1. Anova Table Model Sum of Squares df Mean Square F Sig. 1 Regression 2481.887 1 2481.887 78.531 .000(a) Residual 2307.097 73 31.604 Total 6466.467 91 a. Predictor: (Constant), sexual assertiveness b. Dependent Variable: premarital sexual behavior Table 2. Simple Linear Regression Calculation Results Model Unstandardized Coefficients Standardized Coefficients t Sig. B Std. Error Beta 1 (Constant) 99.447 8.512 11.682 .000 Sexual assertivene ss -1.124 .150 -.620 -7.487 .000 a. Dependent Variable: premarital sexual behavior