Exploring prevalence of risky sexual behaviour among adolescents in high schools: A systematic review

Abstract

Background:

Adolescents’ engagement in risky sexual behaviours poses a significant risk to their sexual and reproductive health, particularly in low- and middle-income nations. Risky sexual behaviour includes actions that heighten the risk of sexually transmitted infections and unintended pregnancies. This study aims to identify strategies for managing risky sexual behaviours among adolescents, focusing on understanding their prevalence, risk factors, consequences and effective interventions.

Methods:

A systematic review was performed following the PRISMA 2020 guidelines. We searched electronic databases (PubMed, Cochrane Library, Web of Science, Science Direct, Google Scholar) for English-language studies published between January 2012 and May 2024, using keywords and MeSH terms related to ‘risky sexual behaviour’, ‘adolescents’, ‘high school students’, ‘prevalence’, ‘factors’, ‘consequences’ and ‘interventions’. The review involved identification, screening, eligibility assessment and data extraction, with methodological quality assessed using Joanna Briggs Institute checklists, guided by inclusion and exclusion criteria.

Results:

A total of 26 studies showed global risky sexual behaviour prevalence ranging from 7.6% in Uganda to 85.1% in Indonesia. Key risky behaviours included multiple partners and inconsistent condom use. Influencing factors were socioeconomic status, substance use, peer/media influence, family dynamics and individual traits. Consequences included sexually transmitted infections, unintended pregnancies and school dropouts. Peer pressure and inadequate parental involvement were identified as major drivers of high-risk activities.

Conclusion:

Effective strategies identified include sexual education, healthcare, family support and policy changes. A multifaceted approach involving education, parental involvement and peer engagement is essential for reducing adolescent risky sexual behaviour and promoting healthier outcomes for youth.

Keywords

risky sexual behaviour adolescents sexual health high schools

Background

Adolescence is a period of profound transition marked by significant physical, cognitive, and psychological development.¹ This stage involves the formation of identity, including sexual identity, and is characterised by increasing sexual curiosity and arousal.² Likewise, there are significant differences in their sexual and reproductive health requirements among three distinct ethnicities, cultures and religions. These developments occur within diverse cultural and social contexts, leading to varied sexual and reproductive health needs among adolescents, who are typically defined as individuals aged 10–19 years.³

Within this complex developmental period, risky sexual behaviour (RSB) emerges as a serious threat to health and well-being, posing a particular challenge in low- and middle-income countries (LMICs).⁴ For this review, RSB is conceptualised as any sexual activity that increases the risk of negative health outcomes, such as contracting HIV/STIs or experiencing an unintended pregnancy.⁵ This includes unprotected sex, early sexual debut, having multiple sexual partners and engaging in anal sex due to the higher susceptibility of anal tissues to infection.⁶ Globally, the trend towards earlier sexual initiation exacerbates these risks, a pattern notably observed across Africa, where early sexual debut predisposes adolescents to the consequences of RSB.⁷

In Zimbabwe, the prevalence of RSB among school-going adolescents is a visible concern. Behaviours such as attendance at ‘VUZU’ parties, engagement in unprotected intercourse, early sexual activity and exposure to pornography are commonly reported.⁸ These activities have drawn concern from media, government and child protection advocates due to their association with negative outcomes and the erosion of protective social norms, promoting a culture of excess and peer pressure.⁹ A survey by Amnesty International reported that 40% of adolescents in Zimbabwe become sexually active before the age of 18, a development which compromises their health.⁹ The survey blames some inconsistent laws and cultural sexual taboos for putting the health and future of adolescents at risk.⁴

Adolescents are known to be an adventurous group and often engage in risky behaviours such as smoking, drinking alcohol, using drugs and early unprotected sexual activity.¹⁰ Practices such as homosexuality, lesbianism and sexual orgies are indulged in just for the reason of experimentation and peer influences, owing to a wealth of uncensored information they are exposed to, through an intensifying wave of westernisation, the Internet and electronic media.¹¹ These revelations justify the need for the current study. A primary driver of RSB is a lack of accurate information and guidance, leaving adolescents vulnerable to exploitation and health risks.⁴ Lack of information and guidance about sex and sexuality makes adolescents vulnerable to disease, physical, emotional and economic exploitation as the adolescents unknowingly engage in RSBs that might expose them to negative effects.¹² The 2015 Demographic Health Survey (DHS) indicated declining knowledge of HIV prevention among adolescents, while evidence confirms that adolescents who receive age-appropriate information are less likely to engage in RSB.¹³ It is against this backdrop that this systematic review was conducted to synthesise evidence to inform strategies for managing RSB among adolescents. The following specific objectives guided this study

To assess the prevalence of RSBs among adolescents.

To identify the factors influencing RSB among adolescents.

To analyse the consequences of RSB in adolescence.

To review intervention strategies aimed at reducing RSB among adolescents.

Methodology

Methods of review

This study employed a systematic review methodology, guided by the PRISMA 2020 statement. This approach involves the systematic identification, selection, critical appraisal and synthesis of existing research to answer a defined research question. The review only considered articles published within the 12 years preceding the review (2012–2024).

Literature sources

A comprehensive search of electronic databases was conducted, with a preference for sources offering readily available full-text articles, though not exclusively limited to open-access journals. The databases searched included Google Scholar, Science Direct, PubMed, Cochrane Library and Web of Science for relevant studies published from January 2012 to May 2024. To locate additional relevant literature, a snowballing technique was applied by reviewing the reference lists of retrieved articles. Academic theses were also incorporated to provide a broader understanding of the research landscape.

The search strategy utilised a combination of keywords and Medical Subject Headings (M eSH). The following search string was employed in PubMed on May 30, 2024, and adapted for other databases: (‘risky sexual behaviour’[MeSH Terms] OR ‘sexual behaviour’[MeSH Terms] OR ‘unsafe sex’[MeSH Terms] OR ‘risky sexual behaviour’ OR ‘sexual risk’) AND (‘adolescent’[MeSH Terms] OR ‘teen’ OR ‘youth’ OR ‘young people’ OR ‘high school student’ OR ‘secondary school student’) AND (‘prevalence’[MeSH Terms] OR ‘epidemiology’[MeSH Subheading] OR ‘factor’[Title/Abstract] OR ‘determinant’ OR ‘correlate’ OR ‘consequence’ OR ‘effect’ OR ‘impact’ OR ‘intervention’ OR ‘strategy’ OR ‘prevent’ OR ‘mitigation’) AND (‘global’ OR ‘worldwide’ OR ‘country’ OR ‘nation*’) Filters: Publication date from 2012/01/01 to 2024/05/30; English. The final search term (‘global’ OR ‘worldwid’ etc.) was included to ensure a wide geographic scope of studies was captured. The retrieved records were managed using Rayyan, a literature review application, to facilitate the screening process and de-duplication.

Inclusion and exclusion criteria

The inclusion and exclusion criteria were applied to identify the most relevant studies. We included original research studies (e.g. scoping reviews, cross-sectional, cohort, qualitative and quantitative studies) that examined the prevalence, factors, consequences or interventions related to RSB in adolescents (aged 10–19 years), published in English between January 2012 and May 2024. The review targeted literature from major databases such as Web of Science, PubMed and ScienceDirect. Studies were excluded if they were published in languages other than English, focused on adults or children outside the adolescent age range or examined interventions or exposures not directly related to RSB.

Data extraction and synthesis

Articles were identified through the searched databases, with the search limited to the period 2012–2024 and those with titles or abstracts in English. Citations and references were managed using an EndNote library. Two authors independently screened titles/abstracts and subsequently full texts against the eligibility criteria. Any disagreements during the screening process were resolved through discussion with a senior colleague available to act as a third reviewer if consensus could not be reached. Data from included studies were extracted by one reviewer and cross-checked by a second using a standardised, pre-piloted extraction form. Extracted data included: author, year, country, study design, sample size, participant characteristics, prevalence data, key factors, consequences, interventions and main findings.

Quality assessment

Quality control was maintained through several steps. Rayyan software was used to automatically detect duplicates and to screen all the articles for possible inclusion or exclusion. Only published sources were used. The methodological quality of included studies was assessed independently by two reviewers using the appropriate Joanna Briggs Institute (JBI) critical appraisal checklists for prevalence studies and cross-sectional studies.¹⁴ For the quality assessment of our study, the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA 2020) framework was used (refer to Table 1). This guideline provides a comprehensive checklist to ensure that all relevant aspects of the systematic review process are transparently reported.

Table 1.

Prevalence of risky sexual behaviours among adolescents across the world.

Country	Sexually active	Risky sexual prevalence	Reference
Gabon, Sierra Leone	19.8% male 84.5% female	Multiple partners	[15]
Benin, Mozambique, Namibia, Seychelles, and Tanzania	43.5% have had sexual intercourse	20.9% have multi sex partners	[16]
Saharan Africa, Asia, and central Asia, while in Latin America and the Caribbean	More girls than boys are sexually active	Do not use protection	[17]
Uganda	7.6% have had sexual intercourse	90% of which were not using any protection	[18]
Kenya	62% had ever had sexual intercourse	Among individuals who had been sexually active, 11.4% disclosed a history of participating in high-risk sexual behaviours. The occurrence of high-risk sexual behaviours was reported to be less common in men compared to women	[19]
Tanzania	30.3% sexually active individuals were sexually active	Out of the group, 41.7% reported having multiple sexual partners, 10.5% indicated having concurrent sexual partners, and 41.1% stated they did not use a condom during their last sexual encounter	[20]
Indonesia	85.1% sexually active	One-fourth of them engage in non-risky behaviour (14.9%)	[21]
Tanzania	The percentage is greater for males (32.15%) compared to females (10.92%).		[22]
Ethiopia	23.7% reported having engaged in sexual intercourse. Among them, 110 individuals (98.2%) had sexual contact before the age of 18, and just 68 individuals (60.8%) chose to initiate their first sexual experience voluntarily	In total, 97 individuals (19.6%) engaged in risky sexual behaviours. The incidence of risky sexual behaviour among adolescents aged 15 to 19 years was identified to be 17.2%. A significant proportion of youths (37.1%) reported having multiple partners	[23]
Zimbabwe	Out of the 910 students, 314 (34.6%) were sexually active	Two in every ten adolescents had engaged in risky sexual behaviour 171 (18.8%)	[24]
South Africa	High prevalence of sexual intercourse	Participation in risky sexual activities was significant, showing little difference between young females and males in South Africa	[25]
USA	It is estimated that 11.6 million teenagers between the ages of 13–19 have had sexual intercourse	The majority of them do not use protection	[15]
Cameroon	54.0% reported being sexually active	71.4% often engage in unprotected sexMultiple sex partners	[26]

Data analysis

A narrative synthesis approach was utilised to thoroughly analyse the data that had been extracted from various studies. Due to the significant variation in definitions and measurement methods of RSB across the different research works, conducting a meta-analysis proved to be impractical. As an alternative, the findings were organised and synthesised thematically, focusing on key objectives of the review: the prevalence of RSB, the factors that influence it, its potential consequences and interventions that are recommended to address the behaviour. To facilitate a clearer understanding, the data were tabulated and summarised, allowing for the identification of notable patterns and trends that emerged across the various studies and different geographical contexts.

Results

The initial database search yielded 1174 records. After removing duplicates, 974 records were screened by title and abstract. Of these, 98 full-text articles were assessed for eligibility. A total of 26 studies met the inclusion criteria and were included in the final systematic review. The study selection process is detailed in the PRISMA flow diagram (Supplemental Figure 1). The included studies comprised cross-sectional surveys (n = 22), cohort studies (n = 2) and qualitative studies (n = 2). Geographically, the studies were from sub-Saharan Africa (n = 18), Asia (n = 2), North America (n = 3) and multi-regional analyses (n = 3).

Prevalence of RSB

Thirteen (13) research studies across multiple countries documented the prevalence of RSBs among adolescents. Key findings indicate significant variation in sexual activity rates, with figures ranging from 7.6% in Uganda to over 85% in Indonesia. Commonly reported risky behaviours include having multiple sexual partners, inconsistent or non-use of condoms and early sexual debut. The data also reveal notable gender disparities, with some regions like sub-Saharan Africa and Asia showing higher activity among girls, while other countries, like Tanzania, reported higher rates among boys. The overall evidence points to a high global prevalence of adolescent sexual risk-taking, underscoring a critical public health concern (refer to Table 1).

Influencing factors

Ten (10) studies identified a range of factors influencing RSB among adolescents. These factors have been classified into major themes: socioeconomic and environmental factors (e.g. poverty, place of residence); substance use (e.g. alcohol, cigarettes and drugs); peer and media influence (e.g. peer pressure, pornography and unreliable information); family dynamics (e.g. parental neglect, lack of control and poor attachment); and individual characteristics (e.g. academic profile, perception of risk). This multifaceted analysis suggests that adolescent sexual behaviour is shaped by a complex interplay of individual, relational and community-level factors (refer to Table 2).

Table 2.

Factors influencing risky sexual behaviour among adolescents.

Country	Factors influencing risky sexual behaviour	Reference
Gabon, Sierra Leone	• Place of residence• Poverty• School	[15]
Benin, Mozambique, Namibia, Seychelles, and Tanzania	• Smoking cigarettes• Alcohol and substance abuse (marijuana and amphetamine)	[16]
Indonesia	• Peer influence• watching pornography• internet mass media
South Africa	• Community and personal-level factors played a significant role in clarifying the elements linked to risky sexual behaviour	[25]
USA	• Exposure to sex in the media• A very influential peer group transmits unreliable and inaccurate information (this misinformation, which contributes to the increase in sexual activity, has not been offset by safe, cautious messages from parents, religion, and the schools)	[27]
Ethiopia	• Poor social support• Living out of the family• Experiencing parental neglect• Drinking alcohol	[28]
Brazil	• Sociodemographic factors (such as community, educational institution, and social circle), family dynamics, and the existence of additional risky behaviours in adolescents	[29]
Canada	• A less secure attachment to parents was linked to having multiple partners as well as to irregular use of condoms	[30]
Cameroon	• Lack of parental control• Religion• Academic profile• Poverty• Place of residence• Perception of risk of HIV infection	[26]

Consequences

Four (4) studies outlined the severe consequences of RSB during adolescence. The primary outcomes identified include health complications such as sexually transmitted infections (STIs), including HIV, and adverse maternal outcomes; reproductive health issues, including unintended adolescent pregnancies, stillbirths and infant mortality; and broader social and educational impacts such as school dropout. The data indicate that these consequences significantly contribute to the global burden of disease and may have long-term harmful effects on adolescents’ lives. (refer to Table 3).

Table 3.

Consequences of risky sexual behaviour in adolescence.

Country	Consequence	Reference
Developing countries	• Adolescent pregnancies represent 23% of the total burden of disease (measured in disability-adjusted life years) related to pregnancy and childbirth for women of all ages• Death due to birth complications• school dropout• suicide and homicide• stillbirths and deaths of infants in the first week and first month	[31]
USA	• Sexually transmitted infections	[32]
Saharan Africa, Asia, and central Asia, while in Latin America and the Caribbean	• Beginning sexual activity at a young age raises the likelihood of contracting sexually transmitted infections, such as HIV, and may lead to unplanned pregnancies and early motherhood	[23]
Cameroon	• About 27 (8.7%) had been pregnant or impregnated their sexual partner, while 143 (45.6%) used condoms consistently	[33]

Recommendations

Ten (10) studies proposed various recommendations to combat risky adolescent sexual behaviour. These mitigation strategies have been grouped into key themes: education and awareness (e.g. enhanced sex education, educational programming and awareness campaigns); improved healthcare access (e.g. better access to barrier methods and school health services); strengthening family systems (e.g. fostering good parenting and effective parent–adolescent communication); policy and environmental interventions (e.g. policy reviews, controlling alcohol access); and comprehensive public health approaches that target multiple risk factors concurrently. The recommendations advocate for a multi-sectoral approach to effectively address this complex issue (refer to Table 4).

Table 4.

Recommendations to combat risky sexual behaviour.

Country	Mitigation	Reference
Gabon, Siera Leone	Educational initiatives and services enhance accessibility to barrier methods	[15]
Benin, Mozambique, Namibia, Seychelles, and Tanzania	Effective communication on sexual health issues between adolescents and their parents	[16]
Uganda	A tailored public health strategy that simultaneously addresses various risk factors could prove beneficial for adolescents engaging in both sexual and non-sexual risk-taking behaviours	[18]
Indonesia	Good parenting	[21]
Tanzania	Education and services related to health in schools focus on initiatives aimed at reducing psychosocial stress and preventing access to sexually explicit content to help curb the transmission of HIV and other sexually transmitted infections	[22]
South Africa	Policy review of sexual risk reduction for each gender	[25]
USA	Increased sex education in the schools	[32]
Ethiopia	Regulation of alcoholic drinks among young people aged 15–19 needs to be strengthened, and efforts should be made to raise awareness about its negative effects	[28]
Canada	Improving the quality of parental attachment	[30]

Discussion

The research revealed that the prevalence of RSB in adolescents varies depending on the context, with rates varying widely from 7.6% to 85.1%. This heterogeneity can be attributed to cultural, socioeconomic and methodological differences across studies. Nearly 11.4% of teenagers in Uganda’s pastoralist communities reported having engaged in high-risk sexual activities in the past, according to a comprehensive analysis.³⁴ However, a different study of teenagers enrolled in school in five countries in sub-Saharan Africa found that there were more concurrent risky behaviours, which linked sexual activity to substance use and other risky behaviours.²⁴ Additionally, according to a different study, 7.6% of very young adolescents (those under 15) had sex, with concerning data showing a deficiency in preventative measures.³⁵ A study carried out in Gabon and Sierra Leone revealed that 19.8% males and 84.5% females are sexually active.¹⁵ In countries such as Benin, Mozambique, Namibia, Seychelles and Tanzania, adolescents indulge in sexual intercourse with multiple sexual partners.^16,18

The identified factors influencing high-risk behaviours align with the ecological model of health behaviour, demonstrating influences at multiple levels. Parental involvement is crucial to lowering teens’ dangerous behaviour. Parents who are active and conversational about their children’s sexual health can significantly reduce their dangerous sexual behaviour.^20,36 Conversely, parents’ lack of knowledge about adolescent reproductive health (ARH) is linked to more RSB.³⁷ Peer pressure has a significant impact on adolescents’ decision-making, representing the social/peer-level influence. Research shows that teenagers often imitate their friends’ actions, especially when it comes to using drugs and having sex.²¹ As teenagers try to fit in with their social groups, this peer dynamic frequently promotes taking risks. One important predictor of RSB is increased access to pornography. Risky sexual activities are more common among adolescents who are regularly exposed to such content than among those who are not.²² Socioeconomic factors like poverty and residence further compound these risks, creating an environment where RSB is more likely to flourish.

The consequences of RSB are severe and multifaceted, extending beyond immediate health risks to long-term social and educational trajectories. Many teenagers have long-term psychological and social repercussions, such as elevated prevalence of STIs and unwanted pregnancies, anxiety, sadness and stigma related to has effects that go beyond short-term health consequences.³⁸ A qualitative study revealed mothers’ worries about the shame and stigma associated with talking about sexual health, which frequently results in their daughters receiving insufficient support and education.³⁹ Additionally, these issues are made worse by the combination of RSB with other risky behaviours, like substance misuse, which results in a compounded risk profile for teenagers.¹⁶

Comprehensive sexual health programs that address the reality of teenage sexuality and offer correct information should be implemented in schools, directly countering misinformation from peers and the media. To reinforce messages, educational activities should be culturally responsive and involve parents,⁴⁰ thereby addressing the family-level factor. Parents can be better equipped to talk to their kids about sexual health by improving their parenting abilities and understanding of ARH.²⁰ Programs that encourage parent–child communication may help reduce the dangers related to RSB. Addressing myths and encouraging safe practices among peers, peer-led campaigns can effectively engage adolescents in a relatable context.⁴¹ Policy-level interventions, such as controlling alcohol access, aim to modify the broader environment in which these behaviours occur. In the context of Zimbabwe and similar settings, these findings suggest that effective programming must be multicomponent. School-based sex education is necessary but insufficient on its own. It must be coupled with initiatives that empower parents to communicate effectively with their children, community campaigns that address stigma, and policies that restrict adolescents’ access to substances and explicit materials.

This review presents several promising directions for future research that aim to deepen our understanding of RSB. One key recommendation is the development of standardised definitions and measurement tools for RSB, which would significantly enhance the comparability of findings across different studies. Additionally, there is a pressing need for longitudinal research designs that can more effectively establish causal relationships between identified risk factors and outcomes related to RSB. Moreover, it is crucial to expand the scope of research to include out-of-school adolescents, who may face unique challenges and risk factors, as well as to incorporate studies conducted in languages other than English to mitigate both selection and language biases. Lastly, future investigations should focus on the effectiveness and practical implementation of multifaceted intervention strategies.

Limitations

This study focused on papers written on RSB among adolescents in schools, only it did not consider those out of school. The omission of studies not published in English may have led to language bias, possibly leaving out important findings from specific areas. The significant heterogeneity in how RSB was defined and measured across studies limits the comparability of prevalence estimates and precludes a meta-analysis. Also, the cross-sectional design of most studies limits our ability to infer causality between the identified factors and RSB outcomes.

Conclusion

This research highlights the differing rates of RSB among adolescents across various contexts; hence, highlighting a major public health issue. The findings reveal that a considerable number of adolescents participate in high-risk activities, influenced by factors such as peer pressure, parental involvement and access to pornography. The long-term consequences of RSB extend beyond immediate health risks, affecting adolescents’ psychological and social well-being, and often leading to issues such as STIs, unwanted pregnancies and mental health challenges. To effectively address these concerns, comprehensive sexual health education programs are vital. These programs should focus on culturally responsive content that actively engages parents, empowering them to have open discussions about sexual health. Furthermore, peer-led initiatives can create a supportive environment that promotes safe practices and reduces the stigma surrounding sexual health. Ultimately, a multifaceted approach that combines education, parental engagement and peer involvement is essential for mitigating the risks associated with adolescent RSB and fostering healthier outcomes for young people.

Supplemental Material

sj-docx-1-smo-10.1177_20503121251413045 – Supplemental material for Exploring prevalence of risky sexual behaviour among adolescents in high schools: A systematic review

Supplemental material, sj-docx-1-smo-10.1177_20503121251413045 for Exploring prevalence of risky sexual behaviour among adolescents in high schools: A systematic review by Refiloi Ndlovu and Perez Livias Moyo in SAGE Open Medicine

Footnotes

ORCID iD

Perez Livias Moyo

Ethical considerations

Ethical approval for this systematic review was obtained from the National University of Science and Technology Institutional Review Board (Ref: NUST/IRB/2025/75).

Consent to Participate

Not applicable.

Author contributions

RN conceptualised the research idea and authored the initial draft of the manuscript. PLM coordinated the manuscript writing process, provided guidance throughout the writing and contributed to the revision of the draft. All authors have reviewed and approved the final version of the manuscript.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Author’s information

RN is currently pursuing a Master of Science in Environmental Health at the National University of Science and Technology in Zimbabwe. This article forms part of the research project that fulfils a requirement for the MSc in Environmental Health degree. PLM holds a Master of Science in Environmental Health from the same institution and serves as a Lecturer in the Department of Environmental Health within the Faculty of Environmental Science at the National University of Science and Technology. PLM provided supervision for RN’s research.

Supplemental material

Supplemental material for this article is available online.

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