Advertisement

BMC Public Health

, 19:1101 | Cite as

Sexual behaviors and seroprevalence of HIV, HBV, and HCV among hill tribe youths of Northern Thailand

  • Tawatchai ApidechkulEmail author
Open Access
Research article
Part of the following topical collections:
  1. Health behavior, health promotion and society

Abstract

Background

Sexual behaviors reflect the degree of exposure to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), especially in people in sexually active stages, such as youths. Hill tribe people have their own cultures, beliefs and lifestyles related to their behaviors, including sexual behaviors, which may lead to HIV, HBV, and HCV infections, especially among youths. The study aimed to examine sexual behaviors and assess the seroprevalence of HIV, HBV, and HCV among hill tribe youths.

Methods

A cross-sectional study was conducted. The participants were recruited from 60 randomly selected hill tribe villages in Chiang Rai Province, Thailand. A validated questionnaire and 5 mL blood specimens were used to collect data. Data were collected by a self-reporting method. Rapid immunochromatographic tests were used to detect hepatitis B surface antibody (anti-HBs), hepatitis B surface antigen (HBsAg), hepatitis C antibody (anti-HCV), and human immunodeficiency virus antibody-I and- II (anti-HIV-1 and -2). Chi-square and Fisher’s exact test were used to detect the associations between variables.

Results

A total of 1325 participants were recruited for the analysis. The majority were females (60.5%) and aged 15–17 years (58.9%). A total of 14.5% smoked, 22.4% drank alcohol, 14.2% were tattooed, and 61.4% had their ears pierced. Among the 30.3% who had sexual experience, 42.0% experienced one-night stands, 26.9% had sexual contact with a prostitute within 1 year prior to the study, 18.9% used alcohol prior to having sexual intercourse, and 15.7% had been tested for HIV/AIDS previously. Among males, 11.5% were males who had sex with males (MSM), and 4.6% were bisexual. Among females, 83.0% were females who had sex with males, and 5.0% were females who had sex with females. Different sexes and tribes were found to have significantly different risk behaviors and sexual behaviors, such as overall males having a greater proportion of sexual experience than females, and Lahu, Akha and Hmong had a higher proportion of sexual experience, having sexual experience with one-night stands, and having sexual experience with a prostitute 1 year prior to the study than others. Among the 836 obtained blood samples, none were positive for anti-HIV-I and -II, 6.4% were positive for anti-HBs, 1.9% were positive for HBsAg, and 0.2% were positive for anti-HCV.

Conclusion

Hill tribe youths in Thailand are at risk of STIs such as HBV and HCV infections according to their risk behaviors and sexual behaviors, which differ between sexes and tribes. Effective behavioral interventions should be promoted among hill tribe youths to minimize the risk for these diseases in the future.

Keywords

Sexual behaviors HIV HBV HCV Seroprevalence Hill tribe Youths 

Abbreviations

AIDS

Acquired immunodeficiency syndrome

Anti-HBs

Antibody to hepatitis B surface antigen

Anti-HCV

Antibody to hepatitis C virus

Anti-HIVI&II

Antibody to human immunodeficiency I&II

HBsAg

Hepatitis B surface antigen

HBV

Hepatitis B virus

HCV

Hepatitis C virus

HIV

Human immunodeficiency virus

ID

Identification card

IOC

Item-objective congruence technique

MSM

Men who have sex with men

NPV

Negative predictive value

STIs

Sexually transmitted infections

WHO

World Health Organization

Background

Individual sexual behaviors reflect the degree of risk for sexually transmitted infections (STIs) [1], which are caused by more than 30 different bacteria, viruses and parasites known to be transmitted through sexual contact, particularly human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), which are identified as major human health threats today [2]. Expressions of sexual behaviors are influenced by both internal and external factors [3, 4, 5]. Internal factors include age, sex, hormones, etc., which stimulate the interest in or expression of sexual activities in humans [4, 5]. Sexual behaviors also depend on the stage of physical and mental development [6, 7]. Several studies have reported that sociocultural factors act as external factors to express or suppress some human-related sexual behaviors [8, 9, 10]. Some communities widely accept sexual-related behaviors in public areas, while others condemn this behavior [11]. Some communities accept polygamy, while others do not [12]. Sex workers are legal and allowed in some countries, whereas they are not allowed in others [13, 14]. However, reproduction and genetic continuation are the major factors driving sexual behaviors in all species, including humans [15].

Different communities have different levels of social acceptance or suppression of the expression of their sexual behaviors [16, 17]. Sexual behaviors in different communities or groups of people are also dominated by their economy, culture, lifestyle, etc. [18]. Moreover, the patterns or preferences of sexual behaviors are also different from person to person and community to community, including people living in Thailand [19, 20, 21]. Many communities have already accepted the differences in human sexual behaviors or sexual patterns, such as male-to-female sexual intercourse and male-to-male sexual intercourse. [22, 23]. In addition, sexual behaviors are influenced by other factors, such as alcohol, drugs, the media, etc. [5, 8, 19, 24]. The use of alcohol or substances in different groups or different communities of people depends on various factors, including personal characteristics, education level, social status, culture, income, etc. [19, 20, 24]. Different sexual behaviors lead to different levels of exposure to HIV, HBV, and HCV [25, 26]. The United Nation defines that those people aged 15–24 are youths [27]. Youths are also defined as the sexually active stage [28]. Therefore, from several studies mentioned above [3, 4, 5, 8, 9, 10, 19, 24], youths aged 15–24 years are at the sexually active stage of life; as a result, they become one of the most vulnerable populations for drug and alcohol use and, consequently, at high risk of HIV, HBV, and HCV infections.

In 2017, the World Health Organization (WHO) reported that HIV/AIDS, HBV, and HCV were major global communicable diseases for humankind in this era with a large population of infected persons. Approximately 35 million are HIV-infected [29], 257 million are HBV-infected [30], and 71 million have chronic hepatitis C infections globally [31]. Currently, these diseases are widely recognized as major public health problems worldwide with significant impacts on human health and human life, particularly among those people who are living in highly epidemic areas, including Thailand [29].

Thailand has one of the highest HIV, HBV and HCV burdens in the world [32, 33], particularly among those with low socioeconomic status, including the hill tribe people [32]. Hill tribes are a group of people who have their own cultures, beliefs and lifestyles [34]. They migrated from the south of China and have settled in the border regions of Thailand-Myanmar-Laos over the past centuries [34]. In 2017, approximately 3.5 million hill tribe people lived in Thailand, and 300,000 hill tribe people lived in Chiang Rai Province [35] located in the northernmost part of Thailand. They are classified into six main tribes: Akha, Lahu, Hmong, Yao, Lisu, and Karen [35]. Each tribe has their own culture, lifestyle, and level of acceptance for the use of alcohol and substances in their communities [36]. Most hill tribe people are of low socioeconomic status, and some of them do not possess Thai identification cards (ID cards), which are used for free access to all public services, including education and health care systems [37]. Today, the hill tribe people who live in Thailand are the second and third generations of the first hill tribe generation that had moved to and settled in Northern Thailand in the early twentieth century [34]. Many hill tribe people still practice their own traditions, cultures and lifestyles, including sexual behaviors, particularly sexual intercourse in their early age, use alcohol before having sex, etc. [37]. Some tribes accept monogamy, and others accept polygamy. Akha accepts polygamy, while Lahu accepts getting married in younger age, less than 15 years [38]. Under globalization and urbanization, many have changed their sexual behaviors. They often work with or are exposed to people outside their community and have integrated with a new society with advanced communication technology, population migration, rapid economic growth, and a mixture of cultures, resulting in a risk of HIV, HBV, and HCV infection. Moreover, many factors may influence their sexual behaviors and practices, particularly among those in the sexually active stage of life and those aged 15–24 years.

There is limited scientific information available on sexual behaviors and HIV, HBV, and HCV among hill tribe youths. Therefore, this study aimed to understand the context of sexual behaviors and estimate the prevalence of HIV, HBV, and HCV among hill tribe youths aged 15–24 years. The study also aimed to assess several risk behaviors that could be associated with STIs between sexes and tribes among hill tribe youths.

Methods

Study design

A cross-sectional study was conducted to elicit information from the participants.

Study setting

In 2016, there were 749 hill tribe villages in Chiang Rai, which included 316 Lahu villages, 243 Akha villages, 63 Yao villages, 56 Hmong villages, 36 Karen villages, and 35 Lisu villages. In 2016, a total of 41,366 hill tribe families lived in Chiang Rai Province [35].

The 60 hill tribe villages in Chiang Rai, Thailand were the study setting. Ten villages of each tribe were randomly selected from a list of hill tribe villages based on data from 2017.

Study population

The study populations were hill tribe youths aged 15–24 years.

Inclusion and exclusion criteria

Inclusion criteria include being a hill tribe youth from one of the six hill tribe populations, aged 15–24 years old at the date of data collection, and fluent in Thai. Those selected samples who had a physical or mental condition resulting in the inability to provide essential information regarding the study protocols were excluded from the study.

Sample size

The sample size was calculated based on the following formula, which was developed by Daniel in 1999 [39], to find the minimum number for the study that was used while we did not know a certain number of the study population. The sample size was calculated based on the prevalence from previous or pilot studies.
$$ \mathrm{n}=\left[{{\mathrm{Z}}^2}_{\upalpha /2}\mathrm{PQ}\right]/{\mathrm{e}}^2 $$

Where n is the sample size required. Z was set at 1.96. P was assumed to be 0.17, which was the prevalence of HBsAg based on a study by Pichainarong et al. [40], which was a very important number for obtaining the best precision of the findings; then, the Q was 0.83. The accepted error or type one error in this study was set at e = 0.05, and the confidence interval was 95%. At least 1301 participants were required for the analysis. Then, we used the same number of participants in all six tribes.

Research instruments

A questionnaire and 5 mL blood specimens were used for data collection. A questionnaire was developed from a literature review, and an in-depth interview with 12 selected participants (six men and six women) aimed to ensure that all relevant information regarding sexual behaviors of the hill tribe youths was included in the questionnaire. It was then tested for validity using the item-objective congruence (IOC) technique, which was performed by three external experts in relevant fields. A pilot study was conducted with 20 selected samples (ten men and ten women) who had similar characteristics to the study participants to assess the reliability and feasibility of the questionnaire.

The questionnaire consisted of six parts. The first part consisted of 13 questions used to collect the participants’ general information, such as sex, age, tribe, marital status, income (referred to the money getting from work, not included having daily or weekly allowance from parents), etc. The second part consisted of 10 questions used to collect the participants’ health behaviors, such as smoking, alcohol use, and methamphetamine use. Three answer choices were provided for each question: yes, no, and quit using it. The third part consisted of 15 questions used to collect information on the participants’ sexual behaviors such “Do you have a partner?”, “Have you had sexual experience?”, “Did you use condom while having sex?”, “How many partners?”, “Have you ever been tested for HIV?”, “Have you been tested for HIV in the past 6 months? (from the interview date)”, etc.

The fourth part consisted of 8 questions used to collect information on the history of STIs, such as “Did you experience genital discharge?”, “Did you have itching in your genital organs?”, “Did you have bad smell from your genitals?”, etc. For these questions, the two answer choices were “yes” and “no”.

The fifth part contained 6 questions that were used to collect information regarding their experiences in receiving information regarding STIs and sources of information. The last part consisted of questions used to detect the knowledge and attitude of risk of STIs. For the knowledge questions, the answers were “correct” “not sure”, and “incorrect”. For the attitude section answers, the answers were “agree” “neutral” and “disagree”. In the last two parts of the questionnaire, there were questions in relation to the experience of information regarding STIs and the knowledge and attitude of risk of STIs. However, after analysis, there was no outcome of interest from questions part five and six; then, they were omitted from the results.

Laboratory analysis

Rapid immunochromatographic tests were used to detect hepatitis B surface antibody (anti-HBs), hepatitis B surface antigen (HBsAg), hepatitis C antibody (anti-HCV), and human immunodeficiency virus antibody-1 and-2 (anti-HIV-1 and -2). The Wondfo Diagnostic Kit® was used to detect anti-HBs, which showed a sensitivity of 97.3% and a specificity of 99.2%. The Wondfo One Step HBsAg Serum/Plasma Test® was used for HBsAg detection, which showed a sensitivity of 96.2% and a specificity of 99.3%. The Quick Hepatitis C Virus Serum/Plasma Test was used to detect antibodies to HCV, which showed a sensitivity of 96.6% and a specificity of 99.5%. Finally, the Wondfo Diagnostic Kit for HIV-1 and -2 Antibodies® was used to detect the antibodies of HIV-1 and HIV-2, with a sensitivity of 100.0%.

Process of data gathering

Access to villages was granted by district government officers. All selected village headmen were contacted 2 days before approaching the participants for data collection. All youths who were living in the selected villages were listed by the village headman. Those who met the inclusion and exclusion criteria were invited to participate in the study and were informed by the village headman regarding the research objectives and protocols through the village broadcast system.

Upon reaching the village, participants were provided all essential information, and informed consent was obtained on a voluntary basis form before completing the questionnaire by a self-administered method in a private and confidential room at the village. Five milliliter blood specimens were collected. Blood specimens were packed and kept in a temperature-controlled box and were delivered to the laboratory for analysis the same day at the Mae Fah Laung University Medical Laboratory Center.

Statistical analysis

Data were double entered into an Excel sheet. Before analysis, the data were cleaned. No missing data were found. Data were analyzed by SPSS version 24, 2016 (SPSS, Chicago, IL). Descriptive and inferential statistics were used for analysis and interpretation of the results. A chi-square test or Fisher’s exact test was used to detect the associations between variables at the alpha = 0.05 significance level.

Ethical consideration

All research proposals, protocols and consents to participate were approved by the Mae Fah Luang University Research Ethics Committee on Human Research (REH-60030). Interviews for data collection and blood specimen collections for laboratory testing were conducted after all participants received oral and written explanations regarding the study objectives and procedures, including any possible risks for physical and mental harm; participants voluntarily agreed by signing on the consent form. Parental consent was obtained from the parent/guardian of participants aged less than 18 years after given the explanations by a village headman and their child (participants). After completion of the analysis, all completed questionnaires were destroyed properly. All relevant data files were kept on a personal computer with secure passwords. A small gift (a piece of towel that was less than 2$US) was provided to all participants to show appreciation for their cooperation.

Results

In total, 1325 participants were enrolled in the study. The majority were females (60.5%), aged 15–17 years (58.9%), and single (94.3%). More than half were Buddhist (56.1%) and lived with their parents (59.8%). A total of 72.5% graduated high school, and 90.0% had no income (Table 1).
Table 1

Demographic characteristics of the participants

Characteristics

n (%)

Total

1325 (100.0)

Sex

 Male

524 (39.5)

 Female

801 (60.5)

Age (year)

 15–17

780 (58.9)

 18–20

398 (30.0)

 21–24

147 (11.1)

Tribe

 Akha

449 (33.9)

 Lahu

207 (15.6)

 Hmong

215 (16.2)

 Yao

177 (13.4)

 Karen

160 (12.1)

 Lisu

117 (8.8)

Marital status

 Single

1250 (94.2)

 Married

65 (5.0)

 Separated

10 (0.8)

Religion

 Buddhism

743 (56.1)

 Christianity

574 (43.3)

 Islam

8 (0.6)

Education

 Illiterate

47 (3.5)

 Primary school

52 (3.9)

 High school

960 (72.5)

 Vocational school

248 (18.7)

 University

18 (1.4)

Occupation

 Unemployed

114 (8.6)

 Student

1058 (79.8)

 Farmer

39 (2.9)

 Laborer

104 (7.8)

 Merchant

10 (0.8)

Income

 No

1192 (90.0)

 Yes

133 (10.0)

Living place

 Own house

935 (70.6)

 Dormitory

331 (25.0)

 Relative’s house

51 (3.8)

 Other

8 (0.6)

Living with

 Alone

97 (7.3)

 Parents

793 (59.8)

 Father

31 (2.3)

 Mother

98 (7.4)

 Relative

106 (8.0)

 Brother

59 (4.5)

 Friends

98 (7.4)

 Partners

41 (3.1)

 Employer

2 (0.2)

Participants used different substances in different proportions: 14.5% smoked, 22.4% drank alcohol, 2.6% used methamphetamines, and 4.5% used marijuana. In addition, 14.2% had tattoos, 61.4% had ear piercings, 12.2% had a history of medical surgery, 4.0% had experienced injection from illegal practitioners, and 2.0% had experienced acupuncture (Table 2).
Table 2

Comparison of risk behaviors between the sexes

Characteristics

Total

n

%

Male

Female

χ2

p-value

n

%

n

%

Total

1325

100.0

524

39.5

801

60.5

N/A

N/A

Smoking

 Yes

192

14.5

165

85.9

27

14.1

202.12

< 0.001*

 No

1133

85.5

359

31.7

774

68.3

  

Alcohol use

 Yes

297

22.4

205

69.0

92

31.0

139.12

< 0.001*

 No

1028

77.6

319

31.0

709

69.0

  

Methamphetamine use

 Yes

35

2.6

29

82.9

6

17.1

28.20

< 0.001*

 No

1290

97.4

495

38.4

795

61.6

  

Heroin use

 Yes

23

1.8

19

82.6

4

17.4

18.15

< 0.001*

 No

1302

98.2

505

38.8

797

61.2

  

Crystal methamphetamine use

 Yes

20

1.5

15

75.0

5

25.0

10.67

0.001*

 No

1305

98.5

509

39.0

796

61.0

  

Opium use

 Yes

21

1.7

17

81.0

4

19.0

15.30

< 0.001*

 No

1304

98.4

507

38.9

797

61.1

  

Marijuana use

 Yes

60

4.5

54

90.0

6

10.0

66.91

< 0.001*

 No

1265

95.5

470

37.2

795

62.8

  

Tattooed

 Yes

188

14.2

119

63.3

69

36.7

51.69

< 0.001*

 No

1137

85.8

405

35.6

732

64.4

  

Ear piercing

 Yes

813

61.4

193

23.7

620

76.3

219.91

< 0.001*

 No

512

38.6

331

64.6

181

35.4

  

History of blood transfusion

 Yes

50

3.8

20

40.0

30

60.0

0.004

0.947

 No

1275

96.2

504

39.5

771

60.5

  

History of organ transplant

 Yes

11

0.8

8

72.7

3

27.3

5.10

0.024*, a

 No

1314

99.2

516

39.3

798

60.7

  

History of medical surgery

 Yes

161

12.2

81

50.3

80

49.7

8.88

0.003*

 No

1164

87.8

443

38.1

721

61.9

  

Injection from illegal practitioners

 Yes

53

4.0

33

62.3

20

37.7

11.91

0.001*

 No

1272

96.0

491

38.6

781

61.4

  

Acupuncture

 Yes

26

2.0

16

61.5

10

38.5

5.36

0.021*

 No

1299

98.0

508

391

791

60.9

  

Shared a toothbrush

 Yes

267

20.2

99

37.1

168

62.9

0.85

0.356

 No

1058

79.8

425

40.2

633

59.8

  

History of hepatitis B vaccination

 Yes

116

8.8

42

63.2

74

63.8

3.17

0.366

 No

476

35.9

192

40.3

284

59.7

  

 Not sure

433

32.7

161

37.2

272

62.8

  

 Unknown

300

22.6

129

43.0

171

57.0

  

Family history of hepatitis B

 Yes

31

2.3

12

38.7

19

61.3

0.79

0.850

 No

797

60.2

315

39.5

482

60.5

  

 Not sure

185

14.0

78

42.2

107

57.8

  

 Unknown

312

23.5

119

38.1

193

61.9

  

Work experience outside the village

 Yes

143

17.1

82

57.3

61

42.7

29.56

< 0.001*

 No

693

82.9

230

33.2

463

66.8

  

Work experience abroad

 Yes

10

1.2

4

40.0

6

60.0

0.31

0.860a

 No

826

98.8

308

37.3

518

62.7

  

*Significance level at α =0.05

aFisher’s exact test

While making comparisons between sexes regarding risky behaviors, 14 behaviors or variables were significantly different between the sexes: smoking, alcohol use, methamphetamine use, heroin use, crystal methamphetamine use, opium use, marijuana use, tattoos, ear piercings, a history of organ transplants, a history of medical surgery, a history of drug injection from illegal practitioners, acupuncture, and experience working outside the village. The male sex made up a greater proportion of all variables except ear piercing, which was greater in females (Table 2).

In total, 402 persons (30.3%) reported having sexual experience (average age of first sexual intercourse was 16.7 years, with a minimum of 12 years and maximum of 23 years). Both males and females had similar proportions of having girlfriends (38.5%) and boyfriends (38.2%). 80.6% reported having sexual experience with their current boyfriend or girlfriend. Among those who had sexual experience, 42.0% had experienced one-night stands, 26.9% had sexual experience with prostitutes (commercial sex workers) within 1 year prior to the study, 36.0% had regular sexual partners, and 18.9% used alcohol prior to having sexual intercourse. Sixty-three (15.7%) participants had previously experienced testing for HIV/AIDS. However, only 5.0% had been tested for HIV/AIDS within the 6 months prior to the study (Table 3).
Table 3

Comparison of sexual behaviors between sexes

Characteristics

n

%

Male

Female

χ2

p-value

n

%

n

%

Having boyfriend/girlfriend

 Yes

509

38.4

202

39.7

307

60.3

0.01

0.935

 No

816

61.6

322

39.5

494

60.5

  

Number of boyfriends/girlfriends

 Only one

489

96.1

187

38.2

302

61.8

10.84

0.001*

 More than one

20

3.9

15

75.0

5

25.0

  

Sexual experience

 Yes

402

30.3

194

48.3

208

51.7

18.31

< 0.001*

 No

923

69.7

330

35.8

593

64.2

28.76

 

Sexual experience with current boyfriend/girlfriend

 Yes

324

80.6

141

43.5

183

56.5

15.02

< 0.001*

 No

78

19.4

53

67.9

25

32.1

  

Sexual experience with one-night stand

 Yes

169

42.0

99

58.6

70

41.4

12.43

< 0.001*

 No

233

58.0

95

40.8

138

59.2

  

Sexual experience with a prostitute 1 year prior to the study

 Yes

108

26.9

61

56.5

47

43.5

3.99

0.046*

 No

294

73.1

133

45.2

161

54.7

  

Having a regular partner

 Yes

145

36.0

50

34.5

95

65.5

17.23

< 0.001*

 No

257

64.0

144

56.0

113

44.0

  

Use alcohol or drugs prior to having sexual intercourse

 Yes

76

18.9

40

52.6

36

47.4

1.24

0.536

 Sometimes

18

4.5

10

55.6

8

44.4

  

 No

308

76.6

144

46.8

164

53.2

  

HIV testing experience

 Yes

63

15.7

30

47.6

33

52.4

0.01

0.912

 No

339

84.3

164

48.4

175

51.6

  

HIV testing 6 months prior to the study

 Yes

43

5.0

23

53.5

20

46.5

0.52

0.468

 No

359

73.1

171

47.6

188

52.4

  

HIV testing 6 months to 1 year prior to the study

 Yes

41

10.2

22

53.7

19

46.3

0.53

0.465

 No

361

89.8

172

47.6

189

52.4

  

*Significance level at α =0.05

In the comparison of sexual behaviors between males and females, six variables were found to be significantly different between sexes: number of boyfriends or girlfriends, sexual experience, sexual experience with current boyfriends or girlfriends, sexual experience with one-night stands, sexual experience with a prostitute within 1 year prior to the study, and having a regular partner. These variables were found to be more common among boys than girls. However, there were no significant differences between sexes regarding testing for HIV (Table 3).

Regarding the risk behaviors between the tribes, four variables were statistically significant: smoking, alcohol use, hepatitis B vaccination in family members, and work experience outside the village (Table 4). However, some variables could not be analyzed due to the small sample size in cells.
Table 4

Comparison of risk behaviors among tribes

Characteristics

Akha

Lahu

Hmong

Yao

Karen

Lisu

χ2

p-value

n

%

n

%

n

%

n

%

n

%

n

%

Total

449

33.9

207

15.6

215

16.2

177

13.4

160

12.1

117

8.8

N/A

N/A

Smoking

 Yes

64

33.3

44

22.9

20

10.4

14

7.3

28

14.6

22

11.5

21.45

0.001*

 No

385

34.0

163

14.4

195

17.2

163

14.4

132

11.7

95

8.4

  

Alcohol use

 Yes

84

28.3

57

19.2

35

11.8

38

12.8

49

16.5

34

11.4

20.58

0.001*

 No

365

35.5

180

17.5

180

17.5

139

13.5

111

10.8

83

8.1

  

Methamphetamine use

 Yes

18

51.4

4

11.4

4

11.4

1

2.9

6

17.1

2

5.7

N/A

N/A

 No

431

33.4

203

15.7

221

16.4

176

13.6

154

11.9

115

8.9

  

Heroin use

 Yes

10

43.5

7

30.4

4

17.4

0

0.0

1

4.3

1

4.3

N/A

N/A

 No

439

33.7

200

15.4

211

16.2

177

13.6

159

12.2

116

8.9

  

Crystal Methamphetamine use

 Yes

10

50.0

4

20.0

3

15.0

0

0.0

2

10.0

1

5.0

N/A

N/A

 No

439

33.6

203

15.6

212

16.2

177

13.6

158

12.1

116

8.9

  

Opium use

 Yes

9

42.9

5

23.8

3

14.3

0

0.0

3

14.3

1

4.8

N/A

N/A

 No

440

33.7

202

15.5

212

16.3

177

13.6

157

12.0

116

8.9

  

Marijuana use

 Yes

25

41.7

8

13.3

6

10.0

10

16.7

9

15.0

2

3.3

5.90

0.306

 No

424

33.5

199

15.7

209

16.5

167

13.2

151

11.9

115

9.1

  

Tattooed

 Yes

74

39.4

36

19.1

23

12.2

24

12.8

16

8.5

15

8.0

8.37

0.137

 No

375

33.0

171

15.0

192

16.9

153

13.5

144

12.7

102

9.0

  

Ear piercing

 Yes

285

35.1

134

16.5

131

16.1

100

12.3

92

11.3

71

8.7

4.65

0.460

 No

164

32.0

73

14.3

84

16.4

77

15.0

68

13.3

46

9.0

  

History of blood transfusion

 Yes

18

36.0

12

24.0

5

10.0

1

2.0

8

16.0

6

12.0

N/A

N/A

 No

431

33.8

195

15.3

210

16.5

176

13.8

152

11.9

111

8.7

  

History of organ transplants

 Yes

6

54.5

4

36.4

0

0.0

0

0.0

1

9.1

0

0.0

N/A

N/A

 No

443

33.7

203

15.4

215

16.4

117

13.5

159

12.1

117

8.9

  

History of medical surgery

 Yes

48

29.8

30

18.6

27

16.8

16

9.9

20

12.4

20

12.4

6.29

0.278

 No

401

34.5

177

15.2

188

16.2

161

13.8

140

12.0

97

8.3

  

Injection from illegal practitioners

 Yes

23

43.4

12

22.6

3

5.7

5

9.4

3

5.7

7

13.2

10.72

0.057a

 No

426

33.5

195

15.3

212

16.7

172

13.5

157

12.3

110

8.6

  

Acupuncture

 Yes

6

23.1

8

30.8

4

15.4

1

3.8

3

11.5

4

15.4

7.91

0.161a

No

443

34.1

199

15.3

211

16.2

176

13.5

157

12.1

113

8.7

  

Shared a toothbrush

 Yes

88

33.0

31

11.6

48

18.0

42

15.7

35

13.1

23

8.6

5.88

0.318

 No

361

34.1

176

16.6

167

15.8

135

12.8

125

11.8

94

8.9

  

History of hepatitis B vaccination

 Yes

44

37.9

12

10.0

19

16.4

16

13.8

14

12.1

11

9.5

16.02

0.381

 No

174

36.6

71

14.9

70

14.7

67

14.1

52

10.9

42

8.8

  

 Not sure

136

31.4

66

15.2

81

18.7

48

11.1

60

13.9

42

9.7

  

 Unknown

95

31.7

58

19.3

45

15.0

46

15.3

34

11.3

22

7.3

  

Family history of hepatitis B

 Yes

8

25.8

8

25.8

8

25.8

7

22.6

0

0.0

0

0.0

34.23

0.003*

 No

3000

37.6

115

14.4

112

14.1

109

13.7

91

11.4

70

8.8

  

 Not sure

60

32.4

28

15.1

33

17.8

22

11.9

21

11.4

21

11.4

  

 Unknown

81

26.0

56

17.9

62

19.9

39

12.5

48

15.4

26

8.3

  

Work experience outside the village

 Yes

50

35.0

29

30.3

13

9.1

14

9.8

25

17.5

12

8.4

17.94

0.003*

 No

201

29.0

81

11.7

119

17.2

122

17.6

105

15.2

65

9.4

  

Work experience abroad

 Yes

3

3.0

3

30.0

0

0.0

0

0.0

0

0.0

4

40.0

N/A

N/A

 No

248

30.0

107

13.0

132

16.0

136

16.5

130

15.7

73

8.8

  

N/A No statistical analysis available

*Significance level at α =0.05

aFisher’s exact test

Regarding sexual behaviors between the tribes, six variables were found to have statistical significance: having a boyfriend/girlfriend, number of boyfriends or girlfriends, sexual experience, HIV testing experience, HIV testing within 6 months prior to the study, and HIV testing within 6 months to 1 year prior to the study. These variables of having a boyfriend/girlfriend, number of boyfriends or girlfriends, and sexual experience were found to be more common among the Akha, Lahu, and Hmong than other tribes (Table 5).
Table 5

Comparison of sexual behaviors between tribes

Characteristics

Akha

Lahu

Hmong

Yao

Karen

Lisu

χ2

p-value

n

%

n

%

n

%

n

%

n

%

n

%

Having boyfriend/girlfriend

 Yes

149

29.3

88

17.3

107

21.0

63

12.4

56

11.0

46

9.0

19.79

0.001*

 No

300

36.8

119

14.6

108

13.2

114

14.0

104

12.7

71

8.7

  

Number of boyfriends/girlfriends

 Only one

147

30.1

76

15.5

104

21.3

63

12.9

55

11.2

44

9.0

20.28

< 0.001*

 More than one

2

10.0

12

60.0

3

15.0

0

0.0

1

5.0

2

10.0

  

Sexual experience

 Yes

111

27.6

84

20.9

68

16.9

41

10.2

53

13.2

45

11.2

25.69

< 0.001*

 No

338

36.6

123

13.3

147

15.9

136

14.7

107

11.6

72

7.8

  

Sexual experience with current boyfriend/girlfriend

 Yes

93

28.7

64

19.8

56

17.3

37

11.4

42

13.0

32

9.9

6.98

0.222

 No

18

23.1

20

25.6

12

15.4

4

5.1

11

14.1

13

16.7

  

Sexual experience with one-night stand

 Yes

46

27.2

36

21.3

28

16.6

25

14.8

20

11.8

14

8.3

8.70

0.122

 No

65

27.9

48

20.6

40

17.2

16

6.9

33

14.2

31

13.3

  

Sexual experience with a prostitute 1 year prior to the study

 Yes

33

30.6

22

20.4

15

13.9

18

16.7

9

8.3

11

10.2

10.10

0.072

 No

78

26.5

62

21.1

53

18.0

23

7.8

44

15.0

34

11.6

  

Having a regular partner

 Yes

42

29.0

34

23.4

26

17.9

12

8.3

17

11.7

14

9.7

2.66

0.751

 No

69

26.8

50

19.5

42

16.3

29

11.3

36

14.0

31

12.1

  

Used alcohol or drugs prior to having sexual intercourse

 Yes

18

23.7

16

21.1

12

15.8

9

11.8

7

9.2

14

18.4

9.46

0.489

 Sometime

5

27.8

2

11.1

2

11.1

3

16.7

3

16.7

3

16.7

  

 No

88

28.6

66

21.4

54

17.5

29

9.4

43

14.0

28

9.1

  

HIV testing experience

 Yes

13

20.6

18

28.6

13

20.6

0

0.0

11

17.5

8

12.7

12.84

0.025*

 No

98

28.9

66

19.5

55

16.2

41

12.1

42

12.4

37

10.9

  

HIV testing 6 months prior to the study

VYes

3

7.0

21

48.8

11

25.6

0

0.0

5

11.6

3

7.0

33.31

< 0.001*

 No

108

30.1

63

17.5

57

15.9

41

11.4

48

13.4

42

11.7

  

HIV testing 6 months to 1 year prior to the study

 Yes

4

9.8

15

36.6

12

29.3

0

0.0

6

14.6

4

9.8

19.58

0.001*

 No

107

29.6

69

19.1

56

15.5

41

11.4

47

13.0

41

11.4

  

*Significance level at α =0.05

According to the sexual patterns of males, 11.5% were MSM, and 4.6% were bisexual. For females, 5.0% preferred to have sex with females, and 12.0% were bisexual. One-third met their boyfriend or girlfriend through Facebook, and another one-third met them as classmates at school. Among those who had sexual experience, 88.1% reported having their first intercourse with a boyfriend or girlfriend, and more than half did not use a condom. Almost one-third (26.9%) of participants had sex with a prostitute 1 year prior to the study, and 8.0% engaged in commercial sex (Table 6).
Table 6

Sexual patterns among the participants who had sexual experience

Characteristics

n

%

Total

1325

100.0

Male sexual orientation (n = 524)

 Males who have sex with males (MSM)

60

11.5

 Males who have sex with females

440

84.0

 Males who have sex with both males and females (Bisexual)

24

4.6

Female sexual orientation (n = 801)

 Females who have sex with males

665

83.0

 Females who have sex with females

40

5.0

 Females who have sex with both males and females

96

12.0

Channel of meeting boyfriend/girlfriend

 Facebook

172

33.8

 Line

2

0.4

 Phone

40

7.9

 Night club

14

2.8

 Work together

12

2.4

 Classmate

171

33.6

 Live in the same village

98

19.3

First sexual intercourse with (n = 402)

 Boyfriend/girlfriend

354

88.1

 Spouse

41

10.2

 Prostitute

2

0.5

 One-night stand

5

1.2

Used condom while having first sexual intercourse (n = 402)

 Yes

193

48.0

 No

190

57.2

 Cannot remember

19

4.8

Had a sexual experience as a male having sex with males (n = 181)

 Yes

52

28.8

 No

129

71.2

Had sex with a prostitute 1 year prior to the study (n = 402)

 Yes

108

26.9

 No

294

73.1

Participated in sexual swinging (n = 402)

 Yes

7

1.7

 No

338

84.1

 No answer

57

14.2

Worked as a sex worker (n = 402)

 Yes

32

8.0

 No

370

92.0

Had a sexual experience with a foreigner (n = 402)

 Yes

37

9.2

 No

365

90.8

Regarding STIs, 78.1% of females had known STIs, 47.7% had pelvic pain, 8.6% had a bad smell, 0.2% had discharge, 1.2% had vaginal ulcers, and 1.7% had lymphadenitis in the groin area. In males, 63.5% had known STIs, 3.4% had discharge, 12.0% had pain during urination, and 4.4% had lymphadenitis in the groin area. There was a significant difference in the proportion of those who had known STIs, discharge (a condition in which fluid drained from the genital area as a result of a bacterial, viral or yeast infection), pain during urination, and lymphadenitis in the groin area between both sexes (Table 7).
Table 7

STI symptoms among the participants

Characteristics

Female (Total = 801)

Male (Total = 524)

χ2

p-value

n

%

n

%

Known STIs

 Yes

626

78.1

333

63.5

40.89

< 0.001*

 No

100

12.5

135

25.8

  

 Not sureb

75

9.4

56

10.7

  

Pelvic pain

 Yes

382

47.7

N/A

N/A

N/A

N/A

 No

340

42.4

N/A

N/A

N/A

N/A

 Not sureb

79

9.9

N/A

N/A

N/A

N/A

Discharge

 Yes

2

0.2

18

3.4

22.61

< 0.001*,a

 No

773

96.6

470

89.7

  

 Not sureb

26

3.2

36

6.9

  

Bad smell from vagina

 Yes

69

8.6

N/A

N/A

N/A

N/A

 No

642

80.1

N/A

N/A

N/A

N/A

 Not sureb

90

11.3

N/A

N/A

N/A

N/A

Pain during urination

 Yes

51

6.4

63

12.0

14.93

< 0.001*

 No

700

87.4

407

77.7

  

 Not sureb

50

6.2

54

10.3

  

Vaginal ulcer

 Yes

10

1.2

N/A

N/A

N/A

N/A

 No

759

94.8

N/A

N/A

N/A

N/A

 Not sureb

32

4.0

N/A

N/A

N/A

N/A

Lymphadenitis in groin area

 Yes

14

1.7

23

4.4

9.31

< 0.002*

 No

756

94.4

452

86.3

  

 Not sureb

31

3.9

49

9.3

  

Vaginal itching

 Yes

109

13.6

N/A

N/A

N/A

N/A

 No

601

75.0

N/A

N/A

N/A

N/A

 Not sureb

91

11.4

N/A

N/A

N/A

N/A

*Significance level at α =0.05

aFisher exact test

bThese row numbers were not included in the analysis

From a total of 1325 participants, 836 blood specimens (63.1%) were voluntarily obtained. Among those who allowed blood specimen collection, nobody was positive for anti-HIV-I and -II, 6.4% were positive for anti-HBs, 1.9% were positive for HBsAg, and 0.2% were positive for anti-HCV. Only 3 participants (3.5%) reported having been vaccinated for hepatitis B and were positive for anti-HBs (Table 8).
Table 8

Prevalence of human immunodeficiency virus antibody-I and-II, hepatitis B surface antibody, hepatitis B surface antigen, hepatitis C antibody among the participants

Characteristics

n (Total = 836)

%

Human immunodeficiency virus antibody- I and-II

 Positive

0

0.0

 Negative

836

100.0

Hepatitis B surface antibody

 Positive

85

10.2

 Negative

751

89.8

Hepatitis B surface antigen

 Positive

25

2.9

 Negative

811

97.1

Hepatitis C antibody

 Positive

2

0.2

 Negative

834

99.8

Discussion

Several risk behaviors and sexual behaviors related to HIV, HBV, and HCV infections were detected among hill tribe youths in Thailand, such as having number of boyfriends or girlfriends, having sexual experience, sexual experience with one-night stands, sexual experience with a prostitute within 1 year prior to the study, etc. A large proportion of hill tribe youths have pierced ears, use alcohol, use a shared toothbrush, have work experience outside the village, smoke and have tattoos. However, less than 10.0% had a history of hepatitis B vaccination. Regarding sexual experience, almost one-third had boyfriends or girlfriends, and most of them had already had sexual intercourse with their partners. A large proportion had sexual experience with one-night stands and prostitutes with 1 year prior to the study. Only 15.7% had a history of HIV testing.

The seroprevalence of HIV and HCV was low; however, the prevalence of HBV was high (2.9% for HBsAg and 10.2% for anti-HBs). UNAIDS reported that in 2017, the HIV prevalence among people aged 15 and older was 0.2–0.4% [41]. However, in our study, among 836 blood specimens obtained from the participants, none were positive for HIV. Leroi et al. [42] reported that the seroprevalence of HBsAg in Thailand was 5.1%, which is greater than that found in our study. In a recent study on the seroprevalence of HCV in the Thai population, Wasitthankasem, et al. [43] reported a seroprevalence of 0.9%, which was greater than that in the hill tribe youths from our study at 0.2%.

Several studies have reported the impact of sociocultural factors on risk behaviors and sexual behaviors in different communities [5, 10, 11, 12]. A study on culture and sexual behaviors among Iranian and New Zealand women found that sexual behaviors and sexual desire and pleasure were related to community culture, beliefs and past experiences regarding sexual activities [44]. A change in the social context or diversity of socialization led to a change in risky behaviors and sexual behaviors among youths in Ghana [45]. Moreover, a study by Mpondo et al. [46] reported that apart from culture, parenting styles and school curriculum affected risk behaviors, including sexual behaviors, of youths. A study in Nordic countries demonstrated that cultural and socioeconomic factors were associated with substance use among youths [47]. This was supported by a study in the United States that was conducted in different minority high school children with different cultural backgrounds, and it demonstrated that there were different risk behaviors, including sexual behaviors, particularly related to HIV infection [48]. This finding coincides with our study, which found that some behaviors, including sexual behaviors, are different between sexes and tribes, such as ear piercing, alcohol use, smoking, sexual experience, number of sexual partners, etc., which might be affected by the participants’ cultures and socioeconomic statuses. For instance, Akha people accept polygamy, while ear piercing is common in Lisu females [35, 49]. Moreover, Lahu males accept starting drinking alcohol in young age [50].

Many studies conducted in different countries, regions, and populations have demonstrated the associations of risk behaviors, sexual behaviors, and HIV, HBV, and HCV prevalence among youths [8, 14, 18]. They clearly showed that several risk behaviors and sexual behaviors impacted individual and community health in both developed and developing countries. A study of youths’ risky behaviors in the United States in 2017 showed that sex, race/ethnicity, and number of partners, including substance use among youths, were associated with youths’ health, particularly regarding HIV and HBV infections [51]. A systematic review on the prevalence of drug use, sexual activities, tattooing, and piercing from 2007 to 2017 included 9303 publications from around the world and reported that these behaviors were associated with HIV, HBV, and HCV [52]. A study in Nigeria reported that sharing items, tattooing, and a history of surgery were highly associated with HBV infection [53]. Ssewanyana et al. [54] conducted a systematic review and meta-analysis on health risk behaviors among adolescents in sub-Saharan Africa and found that the adolescents in the area had unprotected sexual intercourse with boyfriends or girlfriends leading to HIV and HBV infection. Moreover, a study in Beijing, China in 2018 reported that illegal drug use, number of sexual partners, and condom use were predictors of HIV infection among MSM aged 15–14 years [55]. Tran et al. [56] also reported that substance use and sexual intercourse with sex workers were associated with HIV infection among ethnic minority youths in Vietnam. In addition, a study in China by Pei et al. [57] on rural ethnic minority youths found that working outside the village and illiteracy were risk behaviors associated with HIV infection. In our study, there were several risk behaviors and sexual behaviors for HIV, HBV, and HCV infections among the hill tribe youths in Thailand, such as ear piercing, using alcohol, using a shared toothbrush, working outside the village, smoking, tattooing, sexual experience at an early age, and having a large number of sexual partners.

One interesting finding from our study was that the hill tribe youths in Thailand were highly vulnerable to HIV, HBV, and HCV infections due to their own behaviors, poor health education, low socioeconomic status, exposure to people outside the village, and low coverage of vaccination. In addition, the degree of behavioral expression and sexual behavior among the tribes and between the sexes were also different. This means that the different sexes and different tribes have different levels of exposure to HIV, HBV, and HBV. This coincides with some studies conducted in Thailand [20, 21, 24].

Some limitations were found in this study that could impact the analysis of the findings. Of those who participated in the study, 36.9% were not willing to provide blood specimens for HIV, HBV, and HCV marker detection. Two characteristics were significantly different between those who submitted blood specimens and those who did not: sex and tribe (see Appendix). Females were more willing to submit blood specimens than males, and Akha and Lahu participants were less willing to submit blood specimens than the others. However, the remaining number of participants who voluntarily allowed their blood specimens to be obtained was enough to be representative of the seroprevalence of HIV, HBV, and HCV among hill tribe youths in Thailand. Another factor that could impact the results is recall bias, such as the questions on number of partners, history of HBV vaccination, etc. An advantage of the cross-sectional design, which demonstrated the seroprevalence of the diseases, is that the results can be used in public health policy development, especially for resource allocation. This study also provided information on risk behaviors and sexual behaviors among the minority who are highly vulnerable to HIV, HBV, and HCV infections, which could be used for developing effective public health interventions for certain populations in the future.

Conclusions

A large proportion of the hill tribe youths in Thailand engage in various risk behaviors and sexual behaviors related to HIV, HBV and HCV infections, such as substance use, using a shared toothbrush, injection with illegal substances, and working outside the village. Additionally, they had a low rate of HBV vaccination and a high rate of ear piercing, which had a significantly high prevalence rate in females. Hill tribe youths are also exposed to sexual experience at an early age, many sexual partners, prostitutes, and one-night stands, but most of them are not regularly tested for HIV. Under the conditions of economic constraints and poor education, many hill tribe youths desire to work outside the community and improve their families’ economic status; as such, they become a new vulnerable population for HBV, HCV and HIV infections. Providing a national-specific policy and strategy to improve the school attendance rate and create jobs with reasonable wages for hill tribe youths is urgently required to prepare and maintain them in their home setting, while effective health education and risk and sexual behavior change interventions are also needed.

Notes

Acknowledgements

The author would like to thank all the participants and hill tribe village headmen for their great participation in the project. The author also would like to extend the appreciation to the research assistants from the center of excellence for the hill tribe health research for helping in collecting data in the fields. Finally, the author would like to thank Mae Fah Luang University, and WHO-Thailand for technical support throughout the project.

Author’s contributions

TA designed the study, collected data, analyzed, drafted and finally approved the manuscript.

Funding

The study was funded by the National Research Council of Thailand (NRCT) and Mae Fah Luang University, Thailand (Grant no. 60207020106). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Ethics approval and consent to participate

All research proposal, protocol and consent to participate were approved by the Mae Fah Luang University Research Ethics Committee on Human Research (REH-60030). Interview for data collection and drawing blood specimen for laboratory testing were conducted after all participants received oral and written explanation regarding the study objectives and procedures including any possible risk for physical and mental harms, and obtaining their voluntary agreement by signing on the consent form. The parental consent was obtained from the parent/guardian for participants under 16 years old by written which was agreed by the ethic committee. After completion of the analysis, all completed questionnaires were destroyed properly. All relevant data files were kept with security passwords in a personal computer. A small gift was provided to all participants to appreciate their cooperation.

Consent for publication

Not applicable.

Competing interests

The author declares that he has no competing interests.

References

  1. 1.
    Centers for Disease Control and Prevention (CDC). Sexual risk behaviors; HIV, STD, &Teen pregnancy prevention. 2018. https://www.cdc.gov/healthyyouth/sexualbehaviors/ Google Scholar
  2. 2.
    World Health Organization (WHO). Sexually transmitted infections (STIs); Key facts. 2018. http://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis).Google Scholar
  3. 3.
    Elton C, Alicia OC, Elizabeth CG, Jennifer VF. Factors perceived to fluence risky sexual behaviors among university students in United Kingdom: a qualitative telephone interview study. BMC Public Health. 2014;14:1055.  https://doi.org/10.1186/147-2458-14-1055.CrossRefGoogle Scholar
  4. 4.
    Katherine A, Sarah K. Factors influencing adolescents girls’ sexual behaviors: a secondary analysis of the 2011 youths risk behaviors survey. Issues Ment Health Nurs. 2015;36(3):217–21.CrossRefGoogle Scholar
  5. 5.
    Esther AE, Anke VK, Prisca Z, Ayuba IZ. Exploring the factors influencing adolescents’ sexual behaviors in plateau state Nigeria. Am J Med Med Sci. 2017;7(1):1–6.Google Scholar
  6. 6.
    Lui PSC, Dunne MP, Baker P, Isom V. Adverse childhood experiences, mental health, and risk behaviors among men in the Solomon Island. Asia Pac J Public Health. 2018.  https://doi.org/10.1177/1010539518792911.PubMedCrossRefGoogle Scholar
  7. 7.
    Grant JE, Redden SA, Laut K. Chamberland Nonmedical use of stimulants is associated with riskier sexual practices and other forms of impulsivity. J Addict Med. 2018.  https://doi.org/10.1097/ADM.0000000000000448.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Martins-Fonteyn E, Loquiha O, Baltazar C, Thapa S, Boothe M, Raimundo I, et al. Factors influencing risky sexual behaviors among Mozambicam miners; a socio-epidemiological contribution for HIV prevention framework in Mozambique. Int J Equity Health. 2017;16(1):179.  https://doi.org/10.1186/s12939-017-0674-z.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Footer KHA, Lim S, Brantley MR, Sherman SG. Structure risk and limits on agency among exotic dancers: HIV risk practices in the exotic dance club. Cult Health Sex. 2018;20(3):321–34.PubMedCrossRefGoogle Scholar
  10. 10.
    Berger R, Benatov J, Cuadros R, VanNattan J, Gelkopf M. Enhancing resiliency and promoting prosocial behaviors among Tanzanian primary-school students: a school-based intervention. Transcult Psychiatry. 2018.  https://doi.org/10.1177/1363461518793749.PubMedCrossRefGoogle Scholar
  11. 11.
    Yaya S, Bishwajit G. Age at first sexual intercourse and multiple sexual partnerships among women in Nigeria: a cross-sectional analysis. Front Med (Lausanne). 2018;5(171).  https://doi.org/10.3389/fmed.2018.00171.
  12. 12.
    Cirakoglu A, Benli E, Yuce A. Polygamy, sexual behaviors in a population under risk for prostate cancer diagnostic: an observational study from the Black Sea region in Turkey. Int Braz J Nurol. 2018;44(4):704–8.CrossRefGoogle Scholar
  13. 13.
    Mutagoma M, Kayitesi C, Gwiza A, Ruton H, Koleros A, Gupta N, et al. Estimation of the size of the female sex workers populations in Rwanda using three different methods. Int J STD AIDS. 2015;26(11):810–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Wanyenze RK, Musinguzi G, Kiguli J, Nuwaha F, Mujisha G, Arinitwe J, et al. “When they know that you are a sex worker, you will be the last person to be treated”: perceptions and experiences of female sex workers in accessing HIV services in Uganda. BMC Int Health Hum Rights. 2017;17(1).  https://doi.org/10.1186/s12914-017-0119-1.
  15. 15.
    Anna G, Metin AG, George PS, Claudia GM, Paul FV. Sexual and reproductive health: a matter of life and death. Lancet Sex Reprod Health. 2006;368(9547):1595–607.Google Scholar
  16. 16.
    Woodford MR, Kulick A, Sinco BR, Hong JS. Contemporary heterosexism on campus and psychological distress among LGBT students: the mediating role of self-acceptance. Am J Orthop. 2014;84(5):519–29.CrossRefGoogle Scholar
  17. 17.
    Mousavi MS, Shahriari M, Salehi M, Kohan S. Gender identity development in the shadow of socialization: a grounded theory approach. Arch Womens Ment Health. 2018.  https://doi.org/10.1007/s00737-018-0888-0.PubMedCrossRefGoogle Scholar
  18. 18.
    Mwalabu G, Evans C, Redsell S. Factors influencing the experience of sexual and reproductive healthcare for female adolescents with perinatally-acquired HIV: a qualitative case study. BMC Womens Health. 2017;17(1):125.  https://doi.org/10.1186/s12905-017-0485-9.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Sitanan S, Siriorn S, Ameporn R, Chukiat V. Factors influencing sexual behaviors among Thai adolescents. J Popul Soc Stud. 2017;25(3):171–93.CrossRefGoogle Scholar
  20. 20.
    Teeranee T, Niphon D, Sureeporn P, Patou MM, Bhekumusa W, Christiana E, et al. Changes in sexual behavior and attitudes across generation and gender among a population-based probability sample from an urbanizing province in Thailand. Arch Sex Behav. 2016;45:367–82.CrossRefGoogle Scholar
  21. 21.
    Wilaialk O. Social and cultural dimensions of adolescents sexual relationships in Thailand. Procedia Soc Behav Sci. 2015;171:606–12.CrossRefGoogle Scholar
  22. 22.
    Glick SN, Cleary SD, Golden MR. Brief report: increasing acceptance of homosexuality in the United States across racial and ethnic subgroups. J Acquir Immune Defic Syndr. 2015;70(3):319–22.PubMedCrossRefGoogle Scholar
  23. 23.
    Pachankis JE, Hatzenbuehler ML, Berg RC, Fermandez-Davila P, Mirandola M, Marcus U, et al. Anti-LGBT and anti-immigrant structure stigma; an intersectional analysis of sexual minority men’s HIV risk when migrating to or within Europe. J Acquir Immune Defic Syndr. 2017;76(4):356–66.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Karl P, Supa P. Prevalence and social correlates of sexual intercourse among school-going adolescent in Thailand. Sci World J. 2011;11:1812–20.CrossRefGoogle Scholar
  25. 25.
    Suvirya S, Shukla M, Pathania S, Singhal AK, Agarwal J. Clinico-epidemiological profile and high-risk sexual behavior among clients attending sexually transmitted infection clinic at a tertiary care hospital in North India. Indian J Sex Transm Dis AIDS. 2018;39(1):38–43.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Wendland EM, Horvath JDC, Kops NL, Bessel M, Caierao J, Hohenberger GF, et al. Sexual behavior across the transition to adulthood and sexually transmitted infections: findings from the national survey of human papillomavirus prevalence (POP-Brazil). Medicine (Baltimore). 2018;97(33):e17758.CrossRefGoogle Scholar
  27. 27.
    United Nations. Definition of youth. Available from: http://www.un.org/esa/socdev/documents/youth/fact-sheets/youth-definition.pdf. Assessed 26 Aug 2018.
  28. 28.
    Pringle J, Mills KL, Mateer J, Jepson R, Hogg E, Anand N, et al. The physiology of adolescent sexual behavior: a systematic review. Congent Soc Sci. 2017;3(1):1368858.Google Scholar
  29. 29.
    World Health Organization (WHO). HIV/AIDS: Key facts. 2018. http://www.who.int/news-room/fact-sheets/detail/hiv-aids Google Scholar
  30. 30.
    World Health Organization (WHO). Hepatitis B: Key facts. 2018. http://www.who.int/news-room/fact-sheets/detail/hepatitis-b Google Scholar
  31. 31.
    World Health Organization (WHO). Hepatitis C: Key facts. 2018. http://www.who.int/news-room/fact-sheets/detail/hepatitis-c Google Scholar
  32. 32.
    Thailand-World Health Organization. Thailand national strategy on STIs prevention and control, 2017-2021. 2018. http://www.searo.who.int/thailand/areas/thailand-national-strategy-sti-prevention-2017-2021-eng.pdf Google Scholar
  33. 33.
    Taweesap S, Sumet O, Patchara B, Wiwat P, Mukta S. The impact of Thailand’s public health response to the HIV epidemic 1984–2015: understanding the ingredients of success. J Virus Erad. 2016;2(Sup 4):7–14.Google Scholar
  34. 34.
    Princess Maha Chakri Siridhorn Anthropology Center. Hill tribe. 2018. http:// www.sac.or.th/main/index.php Google Scholar
  35. 35.
    The hill tribe welfare and development center, Chiang Rai province. Hill tribe population. The hill tribe welfare and development center. Chiang Rai: Ministry of Interior; 2016. p. 22–31.Google Scholar
  36. 36.
    Detpitukyon S, Apidechkul T, Sunsern RS, Anuwatnonthakate A, Sinkhorn O, Putsa B, et al. Patterns and perception of alcohol drinking among the Lahu people, northern Thailand. J Health Res. 2018;32(3):185–97.CrossRefGoogle Scholar
  37. 37.
    Department of Provincial Administration, Ministry of Interior, Thailand. Act on the card 2011. 2018. http://www.moi.go.th/portal/page?_pageid =814,1036627,814_1036665&_dad=portal&_schema= PORTAL.Google Scholar
  38. 38.
    Apidechkul T, Wongnuch PW, Sittisarn S, Ruanjai T. Health status of Akha hill tribe in Chiang Rai province, Thailand. J Pub Health Dev. 2016;14(1):77–97.Google Scholar
  39. 39.
    Peter B, Leslie EW, Mark RS, Charles EM. Ethic and sample size. Am J Epidemiol. 2005;161(2):105–10.CrossRefGoogle Scholar
  40. 40.
    Pichainarong N, Chaveepojkamjorn W, Luksamijarulkul P, Sujirarat D, Keereekamsuk T. Hepatitis B carrier among married hill tribe women in northern Thailand. Southeast Asian J Trop Med Public Health. 2003;34(1):114–9.PubMedGoogle Scholar
  41. 41.
    UNAIDS. Thailand: HIV and AIDS estimates. 2018. http://www.unaids.org/en/regionscountries/countries/thailand].Google Scholar
  42. 42.
    Leroi C, Adam P, Khamduang W, Kawilapat S, Neo-Giang-Huong, Ongwandee S, et al. Prevalence of chronic hepatitis B virus infection in Thailand: a systematic review and meta-analysis. In J Infect Dis. 2016;51:136–43.Google Scholar
  43. 43.
    Wassitthankasem R, Posuwan N, Vichaiwattana P, Theamboonlers A, Klinfueng S, Vuthitanachot V, et al. Decreasing hepatitis C virus infection in Thailand in the past decade: evidence from the 2014 national survey. PLoS One. 2016;11(2):e0149362.CrossRefGoogle Scholar
  44. 44.
    Abdolmanafi A, Nobre P, Winter S, Tilley PJM, Jahromi RG. Culture and sexuality: cognitive-emotional determinants of sexual dissatisfaction among Iranian and New Zealand women. J Sex Med. 2018;15(5):687–97.PubMedCrossRefGoogle Scholar
  45. 45.
    Gyan SE. Exploring the causes of change in adolescents girls’ sexual behavior in Begoro, Ghana. Afr J Reprod Health. 2017;21(2):55–63.PubMedCrossRefGoogle Scholar
  46. 46.
    Mpondo F, Ruiter RAC, Schaafsma D, van den Born B, Reddy PS. Understanding the role played by parents, culture and the school curriculum in socializing young women on sexual health issues in rural South Africa communities. Sahara J. 2018;15(1):42–9.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Pedersen MU, Thomsen KR, Heradstveit O, Skogen JC, Hesse M, Jones S. Externalizing behavior problems are related to substance use in adolescents across sex samples from Nordic countries. Eur Child Adolesc Psychiatry. 2018.  https://doi.org/10.1007/s00787-018-1148-6.CrossRefGoogle Scholar
  48. 48.
    Rasberry CN, Lowry R, Johns M, Robin L, Dunville R, Pampati S, et al. Sexual risk behaviors differences among sexual minority high school students-United States, 2015 and 2017. MMWR Morb Mortal Wkly Rep. 2018;67(36):1007–11.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Apidechkul T. A 20-year retrospective cohort study of TB infection among the hill tribe HIV/AIDS populations, Thailand. BMC Infect Dis. 2016;16:72.  https://doi.org/10.1186/s12879-016-1407-4.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Singkorn O, Apidechkul T, Putsa B, Detpettukyon S, Sunsern R, Thutsanti P, et al. Factor associated with alcohol use among Lahu and Akha hill tribe youths, northern Thailand. Subst Abuse Treat Prev Policy. 2019;14:5.  https://doi.org/10.1186/s13011-019-0193-6.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Kann L, Mcmanus T, Harris WA, Shaklin SL, Flint KH, Queen B, et al. Youths risk behaviors surveillance-United States, 2017. MMWR Surveill Summ. 2018;67(8):1–114.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Moazen B, Saeedi MS, Silbernagl MA, Lotfizadech M, Bosworth RJ, Alammehrjerdi Z, et al. Prevalence of drug infection, sexual activity, tattooing, and piercing among prison inmates. Epidemiol Rev. 2018;40(1):58–69.PubMedCrossRefGoogle Scholar
  53. 53.
    Ezeilo MC, Engwa GA, Iroha RI, Odimegwu DC. Seroprevalence and associated risk factors of hepatitis B virus infection among children in Enugu metropolis. Virology (Auckl). 2018;9:1178122X18792859.Google Scholar
  54. 54.
    Ssewanyana D, Mwangala PN, van BA, Newton CR, Abubakar A. Health risk behavior among adolescents living with HIV in sub-Saharan Africa: A systematic review and meta analysis. Biomed Res Int. 2018;7375831.  https://doi.org/10.1155/2018/7375831.CrossRefGoogle Scholar
  55. 55.
    Yin L, Zhao Y, Peratikos MB, Song L, Zhang X, Xin R, et al. Risk prediction score for HIV infection: development and internal validity with cross-sectional data from men who have sex with men in China. AIDS Behav. 2018;22(7):2267–76.PubMedCrossRefGoogle Scholar
  56. 56.
    Tran BX, Mai HT, Fleming M, Do HN, Nguyen TMT, Vuong QH, et al. Factors associated with substance use and sexual behaviors among drug users in three mountainous provinces of Vietnam. Int J Environ Res Public Health. 2018;15(9).  https://doi.org/10.3390/ijerph15091885.PubMedCentralCrossRefGoogle Scholar
  57. 57.
    Pei R, Ji-Ke C, Yang S, Nan L, Wang Q, Zhang S, et al. Risk factors for HIV infection among 15 to 25-year-old rural unmarried Yi adolescents in an ethnic minority region of China. Medicine (Baltimore). 2018;97(36):e12279.CrossRefGoogle Scholar

Copyright information

© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  1. 1.Center of Excellence for the Hill tribe Health ResearchMae Fah Laung UniversityChiang RaiThailand
  2. 2.School of Health ScienceMae Fah Luang UniversityChiang RaiThailand

Personalised recommendations