Background
Adolescents often engage in risky behaviors such as smoking, drinking alcohol, using drugs, and early unprotected sexual activity [
1]. Risky behaviors might pose a threat to adolescents' future health. The adverse health consequences of these behaviors have been recognized as important public health issues [
2,
3]. When adolescents take one risk, they also tend to take other risks [
4‐
9]. The interrelationship or cluster of health risk behaviors can be labeled as "risk behavior syndrome". This occurs in different combinations in different subpopulations [
10‐
12].
The conceptual framework developed by Jessor [
13] suggests that in the assessment of adolescent risk behavior, demographic-, socio-psychological- and environmental risk factors should also be considered. Concurrent predictors of health risk behaviors include the personality but also the biological factors, the family situation, and peer influence [
14‐
17].
The population of the Lao PDR is 5.6 million and consists of 49 officially recognized ethnic groups, which have their own customs and languages. About 27.2 percent of the population lives in urban areas and 72.8 percent in rural areas [
18]. Luangnamtha province is more rural (78%) and is populated by more ethnic groups than other parts of the country. These groups include Khamu, Akha, Hmong, and Yao (Mien). Besides this, the province also consists of low land Lao, Tai Lue, Tai Neua, and Tai Dam ethnic groups [
19]. Different ethnic groups have different health risk behaviors. For example the Khamu has a higher prevalence of smoking compared to other ethnic groups in Laos [
20]. Furthermore, members of the ethnic group Akha are teaching sexual practices to adolescents when they reach puberty and certain traditional sexual customs like
"Bong Hu", which means "open the vagina" are practiced. Another custom
"Hub Khet", which means to "Welcome Guest ", is also practiced in this ethnic group and means that the village head offers guests to sleep with girls from the village [
21]. Thus, adolescents from different ethnic groups may be vulnerable to health risks such as substance use, but also the risk of being infected with sexual transmitted infections (STIs) and HIV because of unsafe sexual behavior.
Most previous studies have concentrated on risk behaviors of urban adolescents and not much is known about adolescents living in rural areas and especially not about those from ethnic minorities. For Lao adolescents, this gap in the understanding of their behavior is particularly important, since adolescents from rural areas and ethnic minorities are marginalized and more vulnerable than urban adolescents [
22]. Previous research almost exclusively focused on single risk factors while adolescents are displaying a concurrent multiple health risk behavior, which is poorly understood especially in low-income countries. The aim of this study was to estimate the prevalence of single and concurrent health risk behaviors and to explore how health risk behavior is associated with socio-demographic factors and peers' behavior in order to get a better view of the constellation of multiple risk behavior factors among ethnic minorities in northern Lao PDR.
Results
Socio-demographic background
A total of 1,360 respondents, of which 669 were boys (49.1%) were recruited into the study. The mean age of the boys was 16.7 (SD = 1.6) and that of the girls was 16.2 years (SD = 1.5). About 68.5 percent of respondents were attending school during the time of the survey although the boys were more likely to attend school than the girls (72% vs. 65%, p <.01). The main source of income was from parents (85.6%), followed by earning money while working (41.7%) (Table
1).
Table 1
Socio-demographic characteristic of adolescents aged 14-19 years old and their parents in Luangnamtha province, Lao PDR
Age
| | | | | | | <.001 |
=<15 | 447 | 32.9 | 184 | 27.5 | 263 | 38.1 | |
16-19 | 913 | 67.1 | 485 | 72.5 | 428 | 61.9 | |
Ethnicity
| | | | | | | .784 |
Lao | 504 | 37.1 | 241 | 36.0 | 263 | 38.1 | |
Akha | 249 | 18.3 | 123 | 18.4 | 126 | 18.2 | |
Khamu | 435 | 32.0 | 215 | 32.1 | 220 | 31.8 | |
Hmong & Yao | 172 | 12.6 | 90 | 13.5 | 82 | 11.9 | |
Education
| | | | | | | <.001 |
Never | 107 | 7.9 | 28 | 4.2 | 79 | 11.4 | |
Primary | 402 | 29.5 | 196 | 29.3 | 206 | 29.8 | |
Secondary & higher | 851 | 62.6 | 445 | 66.5 | 406 | 58.8 | |
Attending school
| | | | | | | .005 |
Out-of school | 429 | 31.5 | 187 | 28.0 | 242 | 35.0 | |
In-school | 931 | 68.5 | 482 | 72.0 | 449 | 65.0 | |
Source of income*
| | | | | | | |
Working | 567 | 41.7 | 244 | 36.5 | 323 | 46.7 | <.001 |
Parents | 1164 | 85.6 | 559 | 83.6 | 605 | 87.6 | .037 |
Scholarship | 18 | 1.3 | 12 | 1.8 | 6 | 0.9 | .158 |
Relative | 166 | 12.2 | 95 | 14.2 | 71 | 10.3 | .031 |
Others | 92 | 6.8 | 10 | 1.5 | 82 | 11.9 | <.001 |
Living arrangement
| | | | | | | .013 |
Other | 244 | 17.9 | 137 | 20.5 | 107 | 15.3 | |
Family | 1116 | 82.1 | 531 | 79.5 | 585 | 84.7 | |
Father's education
| | | | | | | .107 |
Illiterate | 334 | 31.0 | 163 | 29.5 | 171 | 32.8 | |
Primary | 480 | 44.7 | 242 | 43.7 | 238 | 45.7 | |
Secondary & higher | 261 | 24.3 | 149 | 26.9 | 112 | 21.5 | |
Mother's education
| | | | | | | .442 |
Illiterate | 674 | 57.2 | 335 | 56.8 | 339 | 57.6 | |
Primary | 388 | 32.9 | 190 | 32.2 | 198 | 33.6 | |
Secondary & higher | 117 | 9.9 | 65 | 11.0 | 52 | 8.8 | |
More girls than boys lived with their parents (84.7% vs. 79.5%, p = 0.013). The educational level of the parents in general was low but the fathers were better educated than the mothers. Slightly less than half (44.7%) of respondent's fathers had completed primary school, while 24.3 percent of the fathers had finished education above primary. About 32.9 percent of the mothers had a primary school education and 9.9 percent a secondary or higher education (Table
1).
Health risk behaviors
Health risk behaviors are shown in Table
2. Percentages for risky behaviors are higher in the older group for both boys and girls than the younger group, with the exception of those sexually active during the last six months, having first sex before 15 years and not using of condoms. For the younger age group, 14-15 years old, the most common single risk behavior was currently being sexually active, having the first sexual experience before the age of 15 years and not using condoms during the last sexual intercourse. Other health risks were less common. For the age group 16-19 years old, 49.8 percent drank alcohol, 12.8 percent smoked cigarettes, 55.7 percent had sex during the last six months, 44.1 percent had multiple sex partners during the last six months, and 51.7 percent did not use a condom during the last sexual intercourse.
Table 2
Prevalence of health risk behaviors among adolescents by age and sex in Luangnamtha province, Lao PDR
Current alcohol use
| 123 | 27.5 | | 455 | 49.8 | |
Boys | 39 | 21.2 | .013 | 266 | 54.8 | .001 |
Girls | 84 | 31.9 | | 189 | 44.2 | |
Current cigarette use
| 14 | 3.1 | | 117 | 12.8 | |
Boys | 14 | 7.6 | <.001 | 114 | 23.5 | <.001 |
Girls | 0 | 0 | | 3 | 0.7 | |
Current amphetamine use
| 1 | 0.2 | | 12 | 1.3 | |
Boys | 1 | 0.5 | .412 | 12 | 2.5 | .001 |
Girls | 0 | 0 | | 0 | 0 | |
Having sex during the last 6 months+
| 39 | 70.9 | | 118 | 55.7 | |
Boys | 23 | 71.9 | 1.000 | 92 | 54.1 | .391 |
Girls | 16 | 69.6 | | 26 | 61.9 | |
Age at first sex before 15 years+
| 39 | 70.9 | | 47 | 22.2 | |
Boys | 25 | 78.1 | .231 | 35 | 20.6 | .300 |
Girls | 14 | 60.9 | | 12 | 28.6 | |
Two or more partners during the last six months
| 11 | 28.2 | | 52 | 44.1 | |
Boys | 9 | 39.1 | .086 | 48 | 52.2 | .001 |
Girls | 2 | 12.5 | | 4 | 15.4 | |
Not using condoms for the last sexual intercourse++
| 27 | 69.2 | | 61 |
51.7
| |
Boys | 14 | 60.9 | .40 | 47 | 51.1 | .072 |
Girls | 13 | 81.3 | | 14 | 53.8 | |
More boys than girls reported having two or more sexual partners during the last six months. However, there was an age difference as more of the older respondents reported two or more sexual partners. At 16-19 years, a lower proportion of both sexes reported not using condoms, but the difference between the sexes was not significant (51.1% vs. 53.8%).
Co-occurrence of multiple health risk behaviors
Of the 1,360 subjects, 46.8 percent reported no risks, 39.3 percent reported one risk, 8.1 percent reported two risks, and 4.2 percent (n = 57) reported three, 1.2 percent (n = 16) reported four, and 0.4 percent (n = 5) reported five risk behaviors (Table
3). The risk behaviors of the adolescents tend to fall into specific patterns. For the boys who had two risk behaviors, the most common two risk behaviors were alcohol use and smoking, followed by being sexually active and not using condoms. For girls who had two risk behaviors, the most common two risk behaviors were being sexually active and not using condoms. Boys were more likely to report two health risk behaviors than girls (11.1% vs. 5.1%, p <.001). A small percentage of adolescents (more boys than girls) involved in more than two health risk behaviors (Table
3).
Table 3
Patterns of health risk behaviors among adolescents 14-19 years, in Luangnamtha province, Lao PDR
No risk
| - | - | <.001 |
One single risk
| - | - | |
Alcohol use | 45.6 | 39.5 | .025 |
Current smoking | 19.1 | 0.4 | <.001 |
Currently sexual active | 56.9 | 64.6 | .312 |
Having first sexual intercourse before 15 years | 29.7 | 40 | .129 |
Not using condoms during last intercourse | 63.2 | 72.3 | .231 |
Two risks
| | | |
Alcohol drinking & smoking | 14.9 | 0.3 | <.001 |
Alcohol drinking & sexual active | 9.4 | 2.0 | <.001 |
Alcohol drinking & first sex before 15 years | 2.8 | 0.9 | <.001 |
Alcohol drinking & not using condoms | 9.4 | 2.5 | <.001 |
Smoking & sexual active | 5.7 | 0.1 | <.001 |
Smoking & first sex before 15 years | 2.2 | 0 | <.001 |
Smoking & not using condoms | 7.2 | 0.1 | <.001 |
Sexually active & first sex before 15 years | 5.4 | 2.5 | <.001 |
Sexually active & not using condom | 9.6 | 4.2 | <.001 |
Three risks
| | | |
Alcohol drinking, smoking, & sexually active | 5.5 | 0.1 | <.001 |
Alcohol drinking, smoking, & first sex before 15 years | 1.5 | 0 | <.001 |
Alcohol drinking, smoking, & not using condoms | 5.5 | 0.1 | <.001 |
Sexual active, first sex before 15 years & not using condoms | 3.6 | 1.6 | <.001 |
Four risks
| | | |
Alcohol drinking, smoking, sexual active & not using condoms | 3.0 | 0.1 | <.001 |
Alcohol drinking, smoking, sexual active & first sex before 15 years | 1.2 | 0 | <.001 |
Five risks
| | | |
Alcohol drinking, smoking, sexual active, first sex before 15 years & not using condoms | 0.9 | 0 | <.001 |
Table
4 and
5 give the results of bivariate and multivariate analyses of multiple health risk behaviors by socio-demographic conditions and peer influence. The majority of adolescents had none or only one health risk. However, the prevalence of multiple risks increased with age for boys, but not for girls. Out-of-school adolescents of both sexes were more likely to have concurrent health risk behavior than in-school adolescents (p<.001). For both age groups, boys outnumbered girls in concurrent health risk behaviors.
Table 4
Bivariate analyses of concurrent multiple health risk behaviors among boys and adolescents by socio-demographic backgrounds and peer influence
Age
| | | | | <.001 | | | | | .002 |
14-15 | 184 | 62.5 | 24.5 | 13 | | 263 | 62.4 | 30.4 | 7.2 | |
16-19 | 485 | 29.7 | 46.0 | 24.3 | | 428 | 49.8 | 43.7 | 6.5 | |
Attending school
| | | | | <.001 | | | | | <.001 |
Out-of school | 187 | 24.1 | 43.3 | 32.6 | | 242 | 44.2 | 40.9 | 14.9 | |
In school | 482 | 44.4 | 38.8 | 16.8 | | 449 | 60.1 | 37.4 | 2.4 | |
Adolescent's education
| | | | | <.005 | | | | | <.001 |
Illiterate | 28 | 28.6 | 42.9 | 28.6 | | 79 | 43.0 | 29.1 | 27.8 | |
Primary | 196 | 43.9 | 29.6 | 26.5 | | 206 | 54.9 | 34.0 | 11.2 | |
Secondary & others | 445 | 37.1 | 44.5 | 18.4 | | 406 | 56.7 | 42.9 | 0.5 | |
Ethnicity
| | | | | <.001 | | | | | <.001 |
Lao | 241 | 36.5 | 43.6 | 19.9 | | 263 | 51.3 | 48.3 | 0.4 | |
Akha | 123 | 43.1 | 26.8 | 30.1 | | 126 | 52.4 | 23.8 | 23.8 | |
Hmong & Yao | 90 | 63.3 | 28.9 | 7.8 | | 82 | 76.8 | 19.5 | 3.7 | |
Khamu | 215 | 28.4 | 48.4 | 23.3 | | 220 | 51.4 | 42.7 | 5.9 | |
Living arrangement
| | | | | .338 | | | | | .582 |
Other | 138 | 33.3 | 44.2 | 22.5 | | 106 | 53.8 | 41.5 | 4.7 | |
Family | 531 | 40.1 | 39.0 | 20.9 | | 585 | 54.7 | 38.1 | 7.2 | |
Father's education
| | | | | .014 | | | | | <.001 |
Illiterate | 163 | 46.0 | 28.8 | 25.2 | | 171 | 50.9 | 32.2 | 17.0 | |
Primary | 242 | 36.4 | 43.8 | 19.8 | | 238 | 57.1 | 39.5 | 3.4 | |
Secondary & others | 149 | 38.9 | 45.0 | 16.1 | | 112 | 59.8 | 40.2 | 0 | |
Mother's education
| | | | | .029 | | | | | <.001 |
Illiterate | 335 | 43.3 | 34.6 | 22.1 | | 339 | 54.9 | 33.9 | 11.2 | |
Primary | 190 | 34.2 | 48.9 | 16.8 | | 198 | 53.5 | 45.5 | 1.0 | |
Secondary & others | 65 | 41.5 | 41.5 | 16.9 | | 52 | 53.8 | 46.2 | 0 | |
Peers using alcohol
| | | | | <.001 | | | | | <.001 |
No | 179 | 63.1 | 20.1 | 16.8 | | 226 | 73.5 | 18.1 | 8.4 | |
Yes | 490 | 29.8 | 47.3 | 22.9 | | 465 | 45.4 | 48.6 | 6.0 | |
Peers smoking
| | | | | <.001 | | | | | .009 |
No | 375 | 52.3 | 33.9 | 13.9 | | 636 | 56.0 | 37.9 | 6.1 | |
Yes | 294 | 21.4 | 48.0 | 30.6 | | 55 | 38.2 | 47.3 | 14.5 | |
Peer using drug
| | | | | .008 | | | | | .271 |
No | 643 | 39.5 | 40.2 | 20.2 | | 669 | 55.0 | 38.4 | 6.6 | |
Yes | 26 | 15.4 | 42.3 | 42.3 | | 22 | 40.9 | 45.5 | 13.6 | |
Peers being sexually active
| | | | | <.001 | | | | | <.001 |
No | 279 | 49.5 | 40.1 | 10.4 | | 586 | 58.4 | 36.9 | 4.8 | |
Yes | 390 | 31.0 | 40.0 | 29.0 | | 105 | 33.3 | 48.6 | 18.1 | |
Peers have been pregnant
| | | | | .003 | | | | | .132 |
No | 625 | 40.2 | 39.8 | 20.0 | | 647 | 55.5 | 38.0 | 6.5 | |
Yes | 44 | 18.2 | 43.2 | 38.6 | | 44 | 40.9 | 47.7 | 11.4 | |
Total | 669 | 38.7 | 40.1 | 21.2 | | 691 | 54.6 | 38.6 | 6.8 | |
Table 5
Multivariate analyses of concurrent multiple health risk behaviors among boys and girls by socio-demographic backgrounds and peer influence
Age
| | | | |
14-15 | 1 | | 1 | |
16-19 | 2.2 | 1.33 - 3.60 | 1.31 | .84 - 2.03 |
Attending school
| | | | |
Out-of school | 1 | | 1 | |
In school | 0.53 | .33 - .86 | 0.65 | .40 - 1.06 |
Adolescent's education
| | | | |
Illiterate | 1 | | 1 | |
Primary | 1.44 | .48 - 4.28 | 0.19 | .08 - .46 |
Secondary & others | 1.42 | .47 - 4.32 | 0.17 | .06 - .45 |
Ethnicity
| | | | |
Lao | 1 | | 1 | |
Akha | 2.2 | 1.04 - 4.61 | 0.88 | .40 - 1.93 |
Hmong & Yao | 0.48 | .26 - .90 | 0.38 | .18 - .80 |
Khamu | 1.56 | 1.02 - 2.38 | 0.97 | .61 - 1.54 |
Living arrangement
| | | | |
Other | 1 | | 1 | |
Family | 0.94 | .49 - 1.82 | 1.63 | .69 - 3.86 |
Father's education
| | | | |
Illiterate | 1 | | 1 | |
Primary | 1.27 | .77 - 2.10 | 0.77 | .45 - 1.29 |
Secondary & others | 1.24 | .70 - 2.20 | 0.61 | .32 - 1.16 |
Mother's education
| | | | |
Illiterate | 1 | | 1 | |
Primary | 0.92 | .59 - 1.41 | 0.92 | .56 - 1.48 |
Secondary & others | 0.72 | .37 - 1.39 | 0.97 | .46 - 2.03 |
Peers using alcohol
| | | | |
No | 1 | | 1 | |
Yes | 1.88 | 1.10 - 3.21 | 2.55 | 1.59 - 4.09 |
Peers smoking
| | | | |
No | 1 | | 1 | |
Yes | 3.11 | 2.10 - 4.60 | 1.83 | .89 - 3.73 |
Peer using drug
| | | | |
No | 1 | | 1 | |
Yes | 1.9 | .77 - 4.67 | 1.72 | .59 - 5.02 |
Peers being sexually active
| | | | |
No | 1 | | 1 | |
Yes | 1.31 | .90 - 1.92 | 2.82 | 1.65 - 4.8 |
Peers have been pregnant
| | | | |
No | 1 | | 1 | |
Yes | 1.87 | .93 - 3.77 | 0.89 | .341 - 1.96 |
In the bivariate analysis, for boys, age above 15 years and the ethnicity Akha were significantly associated with multiple health risk behaviors. Boys who had peers with health risk behaviors were more likely to have multiple risk behaviors than boys whose peers had no health risk behavior. Boys with a higher level of education, currently attending school, and having parents with some level of education were negatively associated with multiple health risk behaviors. For girls, older age, attending school, higher level of education, Khamu, Hmong and Yao, and Lao ethnicities, and parents having some level of education were associated with fewer risk behavior, while peer's involvement in health risk behaviors such as smoking, drinking alcohol and having sex were associated with multiple risk behaviors.
In the multivariate analysis, attending school (OR = .53, 95% CI = .33-.86), Hmong and Yao ethnicity (OR = .48, 95% CI = .26-.90) were the protective factor for multiple risk behaviors, while older age (OR = 2.20, 95% CI = 1.33-3.60), Akha ethnicity (OR = 2.20, 95% CI = 1.04-4.61), peers smoking (OR = 3.11, 95% CI = 2.1-4.6), and peers drinking alcohol (OR = 1.88, 95% CI = 1.1-3.21) were significantly associated with multiple risk behaviors among boys. For girls, having some education (OR = 0.17, 95% CI = 0.06-0.45) and being of Hmong and Yao ethnicity (OR = 0.38, 95% CI = 0.18-0.80) were significantly associated with fewer risk behaviors; while peers perceived drinking alcohol (OR = 2.55, 95% CI = 1.59-4.09) and peers being sexually active (OR = 2.82, 95% CI = 1.65-4.8) were associated with multiple risk behaviors.
Discussion
To our knowledge this is the first study investigating the prevalence of concurrent HRBs among adolescents and examining the associations between the risk factors for multiple HRBs in Lao PDR. Although it seems that few adolescents engaged in two or more concurrent HRBs, it is important to notice that overall risk-taking among adolescents is rather common, in particular among adolescents from minority ethnic groups.
The study revealed that more boys than girls drank alcohol and smoked tobacco in the older age group, which is consistent with findings from other studies conducted in South East Asia [
23‐
25]. Our study, however, detected higher rates of alcohol drinking among girls in younger age groups compared with boys of the same age group. The reason might be that girls are more likely to socialize with and being persuaded by friends to drink alcohol compared to boys, which was also reflected in the association between own risk behavior and peers drinking alcohol. It has also been shown elsewhere that adolescents exposed to high levels of alcohol availability are more likely to drink alcohol than adolescents not so exposed [
26]. An alternative explanation is that younger boys may drink alcohol equally or more than younger girls, but they are less likely to report. Girls in the younger age group might be more vulnerable to the aftereffects of alcohol drinking than their male counterparts because of girls' lower body-weight [
27]. The higher rates of drinking alcohol, smoking, and using amphetamine among males in the older age group are dangerous since the habit often continues into adulthood [
2,
28].
Early age at first sexual intercourse (before 15 years) was higher among younger boys than girls as have been found in previous studies [
29,
30]. In Lao PDR, most adolescents in rural areas start to have sexual intercourse at early age, which is consistent with previous research in Lao PDR [
31]. The alarming rate of sexual risk behaviors among the younger adolescents may be explained by their curiosity, experimentation with new things and hormonal change but also related to some sexual traditional customs among some ethnic groups in Luangnamtha province such as 'welcome guest', and 'open vagina'. This is consistent with previous research by Lyttleton et al [
21], who also described these traditional sexual customs that are practiced in Lunagnamtha province. Research suggests that early sexual intercourse is associated with sexually transmitted infections [
32] and early pregnancy, which might result in abortion and immature childbirth [
33,
34].
Sexual risk behaviors were more prevalent among boys than girls. Slightly more than half of older boys in this study had two or more sexual partners, which is consistent with previous research showing that about 70 percent of male students in the Republic of Korea and about 30 percent of young men in Thailand had two or more sexual partners [
35]. The higher prevalence of two or more sexual partners among older adolescents could be explained by the fact that the older age group was more sexually experienced and they might also socialize with sexually experienced friends to a higher extent than the younger counterparts.
Most adolescents in our study did not use a condom during the last sexual intercourse. Low condom use among adolescents seems to be a trend in the region. A previous study in the Lao PDR indicated that 75 percent of sexually experienced adolescents aged 15 to 25 years did not use any contraceptive method at first sexual intercourse [
36]. Similarly, a study carried out in Thailand also found that condom use during last sexual activity was 16 percent among sexually active males and 11 percent among sexually active female high school and vocational students [
37].
Another important finding is the sex difference for risk factors for multiple HRBs. Boys seemed to be more likely than girls to engage in multiple risk behaviors. This might be due to cultural acceptance for young boys to engage in alcohol use, smoking, and sexual activity. The alternative reason is social desirability reporting bias in which boys may exaggerate and girls underreport their multiple health risk behaviors. Previous studies in China [
38] show similar results with male students being more likely to report engaging in multiple risk behaviors than female students.
Our findings suggest that having some education and attending school are protective factors for both sexes considering multiple health risk behaviors. Out-of school adolescents belong to a vulnerable group for risk-taking and they are at higher risk of engaging in multiple health risks. The reason might be that they are more relaxed to socialize with many people compared to in-school youth who have more strict rules to observe. In Lao PDR, school regulations are strict and the behaviors of adolescents are controlled, which might limit health risk behaviors. Similar results have been found in the United States, Ethiopia, and China [
11,
39,
40].
Multiple risk health behaviors differed significantly between ethnicities, being highest among Akha adolescents of both sexes and lowest among Hmong and Yao adolescents. However, not much is known about Asian ethnic groups as most studies focus on African, American or Causacian adolescents. The ability to differentiate between ethnic adolescents' is limited by the lack of anthropological data about health risk behavior of ethnic groups in Lao PDR as well as in other South East Asian countries. This study has shown that adolescents from certain ethnic groups are at risk of multiple health risk behaviors, which might be due to their cultural beliefs and practices related to smoking, drinking alcohol, and sexuality. Some of the adolescents in our study seemed to have sexual freedom and started having sex at an early age, which corresponded with prior research in Luangnamtha province [
21].
Peer involvement in health risk behaviors seemed associated to adolescents' multiple health risk behaviors. Jessor and Jessor (1977) suggested that adolescents who are more connected with their peers than with their parents, especially peers with negative behaviors, were more likely to practice risky health-related behaviors [
41]. In our study, peer behavior was associated with health risk behaviors among the participants such as smoking, alcohol use and sexual activity, which corresponds with previous studies in other parts of the world [
17,
42‐
46]. Blanton (2001) also suggests that peer influences were more likely to be manifested when the target and the peer shared similar behavioral histories, which is consistent with social comparison theories [
47].
Limitations
This study has some limitations that are worth mentioning. This investigation is a cross-sectional study and thus it is not possible to determine either causality or directionality of any health risk behaviors. Co-occurrence is not necessarily a proof that one behavior causes the other. Reported use of specific drugs were not provided because there were too few who used drugs, then the estimates would have been too imprecise. Since we rely on self-reporting a potential bias caused by the questioning format and the sensitive nature of some health risk behaviors is possible. Some behaviors might thus be over reported by boys and under-reported by girls. However, there are no sexual taboos in some ethnic groups as they have some sexual ritual practices during the puberty of adolescents. We try to reduce the bias by matching the sex between interviewers and respondents.
Conclusion
This study highlighted that there are sex, age and ethnic differences in the concurrent risk behaviors. The most common concurrent risk behaviors among boys was alcohol use and smoking, followed by being sexually active and not using condoms, while alcohol use, sexually active, and not using condoms were the most common concurrent risk factor for the girls. The influencing factors on multiple HRBs are present in one's demographic background namely adolescent's education and peers influence.
Implication
The findings have important policy implications. Addressing the co-occurring risk factors in public health settings might prevent future behavioural health risks. Strategies might be to encourage young people to finish school, be selective in choosing their friends, and aimed for health attitudes and behavior. Focus on the reduction of risk should be multifactorial within the specific socio-cultural and gender specific context. Tailoring behavior change interventions to individual needs and circumstances is also essential. Interventions should target vulnerable groups such as younger adolescents, ethnic minority groups, and out of school adolescents.
Further research is required to examine to what extent these findings can be replicated in other areas of Lao PDR, especially in respect of sexual risk behaviors among ethnic minority groups. In addition, there is a need to explore in depth factors influencing adolescent's sexualities such as their safe and unsafe sexual practices and what programs are most effective and efficient in addressing multiple risk behaviors among adolescents.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
SV developed the research proposal, designed the instrument, collected data in the field sites, ran data analysis, and drafted the manuscript. EF supervised the research project and assisted via expertise in the survey instrument development, data collection and data analysis. ST contributed to the study design and helped in improving the manuscript. All authors read and approved the final manuscript.