Abstract
Objectives
We aimed to investigate the prevalence and correlates of sexual intercourse among adolescents in post-communist Albania.
Methods
The data used in this study was the Albanian Health Behavior in School-aged Children (HBSC) survey conducted in 2022. The current analysis included 1839 schoolchildren aged 15 years who reported on sexual intercourse (about 55% girls). Data on sociodemographic characteristics, family and peer support, behavioral factors, health complaints, and child maltreatment were also collected. Binary logistic regression was used to assess the association of lifetime sexual intercourse with correlates.
Results
The prevalence of lifetime sexual intercourse was approximately18%. It was around 34% in boys vs. about 4% in girls. Also, sexual intercourse was more prevalent among: adolescents residing in urban areas, those from more affluent families, adolescents who reported lifetime smoking, alcohol consumption and particularly drunkenness, those without a high family support, adolescents who reported witnessing of family violence and especially those who reported lifetime sexual abuse. In gender-pooled models where all variables were adjusted for each other, positive independent correlates of lifetime sexual intercourse included: being boy (OR = 12.6, 95%CI = 8.4–19.1), family affluence (OR = 1.4, 95%CI = 1.0–2.0), lifetime smoking (OR = 1.9, 95%CI = 1.3–2.7), lifetime drunkenness (OR = 2.3, 95%CI = 1.6–3.3) and lifetime sexual abuse (OR = 8.1, 95%CI = 3.9–16.9). Sexual abuse and smoking were consistent correlates (in both genders), in addition to family affluence and drunkenness (in boys only), and adequate exercise and witnessed family violence (in girls only).
Conclusion
There is a significant gender difference in the prevalence and correlates of lifetime sexual intercourse among Albanian adolescents. Targeted interventions should promote healthy behaviors and enhance sexual health education in Albania and similar transitional countries, where youths may face unique challenges in adopting healthy sexual behaviors.
Keywords: Adolescents, Albania, Health Behavior in School-aged Children (HBSC), schoolchildren, sexual intercourse
Introduction
About 13% of adolescents aged 12–15 years worldwide have reported their first sexual intercourse during adolescence (Smith et al., 2020). However, according to a recent population-based study including 69 low- and middle-income countries (LMICs) worldwide, the global prevalence of lifetime sexual intercourse among adolescents aged 14–15 years was estimated at about 9% (Jing et al., 2023). On the other hand, according to the last round of the Health Behavior in School-aged Children (HBSC) survey conducted in 2021–2022 including 44 countries in Europe, central Asia and Canada, the prevalence of sexual intercourse among 15-year-old adolescents was estimated at 18% (20% in boys vs. 15% in girls) (Költő et al., 2024). Yet, large cross-national differences were noted, ranging in adolescent girls from as low as ≤2% (in central Asian countries) to almost 50% (in Denmark), whereas in adolescent boys the range was from 5% (in Kyrgyzstan) to almost 40% (in Bulgaria) (Költő et al., 2024).
Sexual experiences are a natural part of human sexual development (Lee et al., 2024), but they also pose serious risks to adolescents including sexually transmitted infections (STIs) and unintended pregnancies (Lee et al., 2024; Orihuela et al., 2020). The high prevalence of risky sexual behaviors among adolescents reported in a recent population-based study conducted in many countries worldwide (Jing et al., 2023), indicates a high exposure of adolescents not only to adverse physical health outcomes (Lee et al., 2024; Orihuela et al., 2020), but also to negative mental health consequences including stress and anxiety related to the fear of pregnancy or contracting STIs (Lee et al., 2024).
Important individual correlates of initiation and engagement in sexual intercourse include several demographic characteristics of adolescents (such as age and gender) (Kebede et al., 2023; Lee et al., 2024), other health behaviors (such as smoking and alcohol consumption) (Kebede et al., 2023), knowledge on STIs and sexual education in general (Kebede et al., 2023; Lee et al., 2024), and viewing pornography (Kebede et al., 2023).
However, for several decades now, it has been convincingly shown that individual factors alone do not capture the full spectrum of adolescent sexual behaviors (DiClemente et al., 2005; Salazar et al., 2010). Instead, a comprehensive understanding of behavioral correlates requires an assessment of the interrelated contextual risk factors which influence adolescent sexual practices (DiClemente et al., 2005; Salazar et al., 2010). From this perspective, embedded in Bronfenbrenner’s ecological approach involving specific environmental systems (Bronfenbrenner, 1979), ecological frameworks have been developed to better understand how multiple levels of influence interact to shape adolescent’s sexual health behaviors (DiClemente et al., 2005; Raneri & Wiemann, 2007; Salazar et al., 2010). Taking this approach, important psycho-social influences for sexual behavior include interactions within adolescents’ families, informal social networks, family support, as well as peer support and peer norms (DiClemente et al., 2005; Raneri & Wiemann, 2007; Salazar et al., 2010). In addition, other important correlates of initiation and engagement of adolescents in sexual intercourse include socioeconomic factors and other family characteristics including parental education and income (Lee et al., 2024), parental presence, and family control (Kebede et al., 2023).
Another useful framework for understanding the multiple level shaping of adolescents’ sexual behaviors is the Dahlgren and Whitehead’s model of social determinants of health (Dahlgren & Whitehead, 2021), which provides a comprehensive framework for examining the multifaceted influences on adolescent sexual behavior by situating individual choices within broader social, economic, and environmental contexts (Dahlgren & Whitehead, 1991, 2021). This model is particularly suitable for understanding adolescents’ sexual behaviors, as it facilitates a structured exploration of correlates at multiple levels, ranging from individual characteristics (such as age, knowledge, and attitudes) to other behavioral factors (such as substance use), and extending to broader influences including peer influence, family dynamics, socioeconomic status, and cultural norms (Dahlgren & Whitehead, 1991, 2021).
Additionally, the syndemic model (Singer & Clair, 2003) offers another theoretical framework for understanding how multiple, co-occurring health and social conditions interact synergistically to exacerbate adverse outcomes, making it particularly relevant for understanding adolescents’ sexual behaviors. This model suggests a combination and interaction of health-related behaviors and an interplay of various psychosocial and structural factor, such as mental health issues, substance use, exposure to violence, and socioeconomic disadvantage, which jointly increase vulnerability to risky behaviors and deleterious sexual health outcomes (Singer & Clair, 2003).
Within the realm of ecological determinants, the quality of adolescent-parent relationship is considered crucial to adolescents’ sexual behaviors (Buhi & Goodson, 2007). From this viewpoint, parental support, as well as perceived easiness of communication with the parents are deemed important correlates of adolescents’ sexual behavior and intention (Buhi & Goodson, 2007).
The positive influence of family support has been also evidenced in HBSC surveys (Burke et al., 2018; Izdebski et al., 2025). Other important correlates of adolescents’ sexual behavior have emerged in HBSC surveys including socializing with peers and academic performance (Izdebski et al., 2025), as well as number of friends and drunkenness (Burke et al., 2018) – the latter being recently linked to a significant increase in psychosomatic symptoms among adolescents from affluent families in HBSC surveys (Buli et al., 2024).
On another note, HBSC surveys have also documented a higher prevalence of negative feelings about the timing of first sexual intercourse among adolescent girls (Moreau et al., 2019). The significant gender-difference in the perception of adolescents about the timing of first intercourse may be particularly relevant for Albania, which constitutes the most isolated post-communist country in Europe, and the only country where religious practices were legally prohibited until 1990 (Burazeri & Kark, 2011). According to the HBSC survey conducted in 2017–2018, Albanian adolescents exhibited one of the largest gender differences (40%) in the prevalence of lifetime sexual intercourse (Inchley et al., 2020). Seemingly, the internationally observed “sexual double standard” (Muehlenhard et al., 2015) is more prominent in Albania, a country which, notwithstanding freedom and transition toward a market-oriented economy in the past three decades, still represents a patriarchal society (Qirjako et al., 2021). Nonetheless, historical and traditional factors aside, in the past few decades following the breakdown of the socialist regime, other factors may have also influenced sexual behaviors among Albanian adolescents including globalization and digitalization of the society (Meherali et al., 2024), and the proliferation of online pornography (Kebede et al., 2023). Also, the country transition in the past 30 years has been linked to significant changes in health behaviors of the Albanian population (Qirjako et al., 2021), including potential changes in adolescents’ sexual practices.
According to the HBSC 2017–2018 survey, overall, the lifetime prevalence of sexual intercourse among Albanian adolescents was estimated at 26% (Inchley et al., 2020). However, little is known about the current prevalence of sexual intercourse and its correlates among adolescents in transitional Albania, a country undergoing rapid transformations (Qirjako et al., 2021), which may inevitably affect also youth’s sexual behaviors.
In these circumstances, we aimed at assessing the prevalence and correlates of sexual intercourse among Albanian adolescents. Building on the evidence from the previous HBSC round carried out in Albania in 2017–2018 (Qirjako et al., 2021), we hypothesized a higher prevalence of lifetime sexual intercourse among boys and maltreated adolescents. Based on theoretical frameworks (Buhi & Goodson, 2007; Dahlgren & Whitehead, 2021) and empirical evidence from HBSC surveys conducted internationally (Burke et al., 2018; Izdebski et al., 2025), we also hypothesized a positive association of sexual intercourse with family and peer support, as well as drunkenness.
Materials and methods
The last round of the HBSC survey (a cross-sectional study carried out every four years) was conducted in Albania in 2022.
Sample
Selection of the analytic sample is presented in Figure 1. Like the previous survey rounds and according to the international HBSC protocol, the study population consisted of a nationwide sample of schoolchildren aged 15 years (stratified multistage cluster sampling with probability proportional to size) (Duli et al., 2024). Stratification was based on prefectures (regions) of Albania, ensuring adequate representativeness at a national level. According to the international HBSC protocol, the minimum required sample size was 1550 schoolchildren aged 15 years (Duli et al., 2024). We decided to target 350 additional adolescents to increase the study power, considering also potential non-response. Hence, a nationwide sample of 1900 schoolchildren aged 15 years was targeted for inclusion. The sampling frame was available from the Albanian Ministry of Education and Sport. The sampling technique consisted of a (region-stratified) two-stage cluster sampling with PPS, with schools as the primary sampling unit and, next, selection of classes within schools. All schoolchildren from the selected classes were invited to participate in the survey (N = 1951). Of these, 74 adolescents refused participation and/or provided non-valid information (Duli et al., 2024), whereas further 38 schoolchildren (with valid data) did not report specifically on sexual intercourse. Hence, the final sample included in this analysis consisted of 1839 participants with valid data on sexual intercourse (1014, or 55.1% girls). The final response rate for the sample included in this analysis was about 94%.
Figure 1.
Sample of adolescents included in the HBSC 2022 survey conducted in Albania.
Procedure
Data collection consisted of a paper-based version of the internationally standardized HBSC instrument (Inchley et al., 2021; Qirjako et al., 2024), which is a structured self-administered and anonymous questionnaire, already validated in Albania since 2009–2010 (Duli et al., 2024; Qirjako et al., 2021). The international HBSC survey protocol provides detailed instructions for piloting, translation-backtranslation, administration of the survey and data analysis. The administration of the questionnaire was conducted in the school classrooms, with an average completion time of about 35–40 minutes (Qirjako et al., 2024).
The questionnaire included, among other aspects, assessment of sexual intercourse, family and peer support, behavioral factors, health complaints, child maltreatment, and sociodemographic factors (Inchley et al., 2021). Of note, Albania opted for inclusion of the non-mandatory “child abuse and maltreatment” module since the previous HBSC round conducted in 2017–2018 (Qirjako et al., 2021), based on public health concerns and increased recognition of child maltreatment issues in this transitional country (Qirjako et al., 2021, 2024).
Measures
Assessment of sexual intercourse, health complaints, and family and peer support is presented in detail in the “Appendix”. Measurement of sociodemographic factors, behavioral characteristics, and child maltreatment has been reported in detail elsewhere (Duli et al., 2024; Qirjako et al., 2024).
Adolescents were asked if they had ever had sexual intercourse (“yes” vs. “no”). A short explanation was provided (“Sometimes this is called ‘making love’, ‘having sex’ or ‘going all the way’”) (Inchley et al., 2021).
Measurement of family support was based on a subscale of the Multidimensional Scale of Perceived Social Support (Zimet et al., 1988) consisting of four items, each of which coded as a Likert scale. An overall score was calculated for each adolescent, which was dichotomized in the analysis into “high family support” vs. “not high family support” (Inchley et al., 2021).
Peer support was also measured on a four-item composite scale (each item coded as a Likert scale). An overall score was calculated for each participant, which was dichotomized in the analysis into “high peer support” vs. “not high peer support” (Inchley et al., 2021).
Behavioral factors included assessment of daily consumption of breakfast, daily consumption of fruit, adequate toothbrushing (≥2 times/day), engagement in adequate physical activity (≥3 times/week), lifetime smoking, lifetime alcohol consumption, and lifetime drunkenness (all dichotomized in the analysis into: “yes” vs. “no”) (Duli et al., 2024; Inchley et al., 2021).
Assessment of adolescents’ health complaints included headache, stomachache, backache, feeling low, irritability, nervousness, sleep difficulties and dizziness – all dichotomized into: “≤once a week” vs. “>once a week” (Buli et al., 2024). In further analyses, a summary score of these eight complaints was calculated and dichotomized into: “at least two complaints for more than once a week” vs. “the rest”.
Child maltreatment indices included lifetime physical abuse, emotional abuse, sexual abuse, and witnessed family violence – all dichotomized into: “never” vs. “at least once” (Duli et al., 2024; Inchley et al., 2021).
Sociodemographic factors included adolescents’ gender, place of residence, mother’s and father’s current employment status, and family affluence scale (Duli et al., 2024; Inchley et al., 2021).
Ethical aspects
The study was approved by the Ethics Committee of Tirana Medical University (approval ID: No.700/1). All schoolchildren were informed about the objectives and procedures of the study, as well as the aspects regarding the anonymity of the survey and the subsequent aggregated data analysis. Passive consent was sought from the parents through teachers from each respective school (Qirjako et al., 2024), in accordance with the HBSC protocol (Inchley et al., 2021).
Analytic approach
Fisher’s exact test was employed to compare the distribution of lifetime sexual intercourse by covariates (sociodemographic factors, family and peer support, behavioral characteristics, health complaints, and child maltreatment indices) (Tables 1–4).
Table 1.
Distribution of sexual intercourse by sociodemographic factors, family support and peer support.
| Total (N = 1839) | No sexual intercourse (N = 1512) | Sexual intercourse (N = 327) | Pb | |
|---|---|---|---|---|
| Overall sample | 1839 (100.0)a | 1512 (82.2) | 327 (17.8) | – |
| Sociodemographic factors | ||||
| Gender | <0.001 | |||
| Boys | 825 (100.0)a | 543 (65.8) | 282 (34.2) | |
| Girls | 1014 (100.0) | 969 (95.6) | 45 (4.4) | |
| Place of residence | 0.055 | |||
| Urban areas | 1279 (100.0) | 1037 (81.1) | 242 (18.9) | |
| Rural areas | 560 (100.0) | 475 (84.8) | 85 (15.2) | |
| Father employed | 0.836 | |||
| Yes | 1650 (100.0) | 1355 (82.1) | 295 (17.9) | |
| No | 176 (100.0) | 146 (83.0) | 30 (17.0) | |
| Mother employed | 0.644 | |||
| Yes | 1230 (100.0) | 1018 (82.8) | 212 (17.2) | |
| No | 583 (100.0) | 477 (81.8) | 106 (18.2) | |
| Family affluence | <0.001 | |||
| Less affluent | 859 (100.0) | 741 (86.3) | 118 (13.7) | |
| More affluent | 943 (100.0) | 740 (78.5) | 203 (21.5) | |
| Family and peer support | ||||
| Family support | 0.021 | |||
| Not high | 365 (100.0)a | 285 (78.1) | 80 (21.9) | |
| High | 1428 (100.0) | 1191 (83.4) | 237 (16.6) | |
| Peer support | 0.307 | |||
| Not high | 671 (100.0) | 561 (83.6) | 110 (16.4) | |
| High | 1136 (100.0) | 928 (81.7) | 208 (18.3) | |
Absolute numbers and their respective row percentages (in parentheses). Discrepancies in the totals are due to the missing values for the following covariates: father’s employment (n = 13), mother’s employment (n = 26), family affluence scale (n = 37), family support (n = 46), and peer support (n = 32).
P-values from Fisher’s exact test.
Table 2.
Distribution of sexual intercourse by behavioral characteristics.
| Behavioral characteristics | Total (N = 1839) | No sexual intercourse (N = 1512) | Sexual intercourse (N = 327) | Pb |
|---|---|---|---|---|
| Breakfast consumption | 0.331 | |||
| Daily | 668 (100.0)a | 560 (83.8) | 108 (16.2) | |
| Not daily | 1098 (100.0) | 900 (82.0) | 198 (18.0) | |
| Fruit consumption | 0.712 | |||
| Daily | 1005 (100.0) | 831 (82.7) | 174 (17.3) | |
| Not daily | 823 (100.0) | 675 (82.0) | 148 (18.0) | |
| Toothbrushing | <0.001 | |||
| ≥2 times/day | 1054 (100.0) | 897 (85.1) | 157 (14.9) | |
| <2 times/day | 779 (100.0) | 610 (78.3) | 169 (21.7) | |
| Physical activity | <0.001 | |||
| Adequate | 989 (100.0) | 775 (78.4) | 214 (21.6) | |
| Not adequate | 838 (100.0) | 726 (86.6) | 112 (13.4) | |
| Smoking | <0.001 | |||
| No | 1407 (100.0) | 1219 (86.6) | 188 (13.4) | |
| Yes | 383 (100.0) | 264 (68.9) | 119 (31.1) | |
| Alcohol consumption | <0.001 | |||
| No | 1064 (100.0) | 928 (87.2) | 136 (12.8) | |
| Yes | 708 (100.0) | 538 (76.0) | 170 (24.0) | |
| Drunkenness | <0.001 | |||
| No | 1368 (100.0) | 1189 (86.9) | 179 (13.1) | |
| Yes | 435 (100.0) | 300 (69.0) | 135 (31.0) |
Absolute numbers and their respective row percentages (in parentheses). Discrepancies in the totals are due to the missing values for the following covariates: smoking (n = 49), alcohol consumption (n = 67), drunkenness (n = 36), physical activity (n = 12), toothbrushing (n = 6), breakfast consumption (n = 73), and fruit consumption (n = 11).
P-values from Fisher’s exact test.
Table 3.
Distribution of sexual intercourse by health complaints.
| Health characteristics | Total (N = 1839) | No sexual intercourse (N = 1512) | Sexual intercourse (N = 327) | Pb |
|---|---|---|---|---|
| Headache | 0.316 | |||
| ≤once a week | 1354 (100.0)a | 1112 (82.1) | 242 (17.9) | |
| >once a week | 454 (100.0) | 383 (84.4) | 71 (15.6) | |
| Stomachache | 0.832 | |||
| ≤once a week | 1619 (100.0) | 1337 (82.6) | 282 (17.4) | |
| >once a week | 169 (100.0) | 141 (83.4) | 28 (16.6) | |
| Backache | 0.674 | |||
| ≤once a week | 1492 (100.0) | 1229 (82.4) | 263 (17.6) | |
| >once a week | 291 (100.0) | 243 (83.5) | 48 (16.5) | |
| Feeling low: | 0.305 | |||
| ≤once a week | 1119 (100.0) | 914 (81.7) | 205 (18.3) | |
| >once a week | 674 (100.0) | 564 (83.7) | 110 (16.3) | |
| Irritability | 0.655 | |||
| ≤once a week | 1084 (100.0) | 892 (82.3) | 192 (17.7) | |
| >once a week | 702 (100.0) | 584 (83.2) | 118 (16.8) | |
| Nervousness | 0.846 | |||
| ≤once a week | 1118 (100.0) | 922 (82.5) | 196 (17.5) | |
| >once a week | 667 (100.0) | 553 (82.9) | 114 (17.1) | |
| Sleep difficulties | 0.086 | |||
| ≤once a week | 1417 (100.0) | 1183 (83.5) | 234 (16.5) | |
| >once a week | 361 (100.0) | 287 (79.5) | 74 (20.5) | |
| Dizziness | 0.594 | |||
| ≤once a week | 1529 (100.0) | 1265 (82.7) | 264 (17.3) | |
| >once a week | 257 (100.0) | 209 (81.3) | 48 (18.7) | |
| At least two complaints (>once a week): | 0.377 | |||
| No | 933 (100.0) | 765 (82.0) | 168 (18.0) | |
| Yes | 831 (100.0) | 695 (83.6) | 136 (16.4) |
Absolute numbers and their respective row percentages (in parentheses). Discrepancies in the totals are due to the missing values for the following covariates: headache (n = 31), stomachache (n = 51), backache (n = 56), feeling low (n = 46), irritability (n = 53), nervousness (n = 54), sleep difficulties (n = 61), and dizziness (n = 53).
P-values from Fisher’s exact test.
Table 4.
Distribution of sexual intercourse by child maltreatment indices.
| Lifetime child maltreatment indices | Total (N = 1839) | No sexual intercourse (N = 1512) | Sexual intercourse (N = 327) | Pb |
|---|---|---|---|---|
| Physical abuse | 0.558 | |||
| Never | 1212 (100.0)a | 992 (81.8) | 220 (18.2) | |
| At least once | 600 (100.0) | 498 (83.0) | 102 (17.0) | |
| Emotional abuse | 0.677 | |||
| Never | 1520 (100.0) | 1249 (82.2) | 271 (17.8) | |
| At least once | 293 (100.0) | 244 (83.3) | 49 (16.7) | |
| Sexual abuse | <0.001 | |||
| Never | 1755 (100.0) | 1474 (84.0) | 281 (16.0) | |
| At least once | 68 (100.0) | 24 (35.3) | 44 (64.7) | |
| Witnessed family violence | 0.003 | |||
| Never | 1691 (100.0) | 1402 (82.9) | 289 (17.1) | |
| At least once | 128 (100.0) | 92 (71.9) | 36 (28.1) |
Absolute numbers and their respective row percentages (in parentheses). Discrepancies in the totals are due to the missing values for the following covariates: physical abuse (n = 27), emotional abuse (n = 26), sexual abuse (n = 16), and witnessed of family violence (n = 20).
P-values from Fisher’s exact test.
Binary logistic regression was used to assess the association of sexual intercourse with covariates. Initially, crude (unadjusted) models were run (Table 5 – left column), followed by multivariable-adjusted models controlling for all covariates in a stepwise backward elimination procedure with a p-value to exit set at P < 0.10 (Table 5 – right column), a procedure which is recommended when adjusting for many factors, as it avoids model overfitting and handles potential multicollinearity by trimming redundant variables (Hosmer & Lemeshow, 1989). More importantly, this approach to statistical analysis was in line with the current study’s theoretical framework and rationale regarding the assessment of a wide range of correlates of adolescents’ sexual behavior (Buhi & Goodson, 2007; Dahlgren & Whitehead, 1991, 2021; Singer & Clair, 2003). Subsequently, the analysis was stratified by gender (Table 6). Odds ratios (ORs) and their respective 95%CIs and p-values were calculated for all logistic regression models. All multivariable-adjusted logistic regression models met the Hosmer-Lemeshow criterion (Hosmer & Lemeshow, 1989).
Table 5.
Association of lifetime sexual intercourse with sociodemographic factors, support, behavioral characteristics, health complaints, and child maltreatment indices; results from binary logistic regression.
| Variable | Crude (unadjusted) models |
Multivariable-adjusted modelsb |
||||
|---|---|---|---|---|---|---|
| ORa | 95%CI | P | ORa | 95%CI | P | |
| Being boy | 11.2 | 8.0–15.6 | <0.001 | 12.6 | 8.4–19.1 | <0.001 |
| Urban residence | 1.3 | 1.0–1.7 | 0.054 | |||
| Father employed | 1.1 | 0.7–1.6 | 0.784 | |||
| Mother employed | 0.9 | 0.7–1.2 | 0.621 | |||
| More affluent | 1.7 | 1.3–2.2 | <0.001 | 1.4 | 1.0–2.0 | 0.028 |
| Non-daily breakfast consumption | 1.1 | 0.9–1.5 | 0.315 | |||
| Non-daily fruit consumption | 1.1 | 0.8–1.3 | 0.709 | |||
| Inadequate toothbrushing | 1.6 | 1.2–2.0 | <0.001 | |||
| Adequate exercise | 1.8 | 1.4–2.3 | <0.001 | |||
| Smoking | 2.9 | 2.2–3.8 | <0.001 | 1.9 | 1.3–2.7 | <0.001 |
| Alcohol consumption | 2.2 | 1.7–2.8 | <0.001 | |||
| Drunkenness | 3.0 | 2.3–3.9 | <0.001 | 2.3 | 1.6–3.3 | <0.001 |
| At least two complaints (>once a week) | 0.9 | 0.7–1.1 | 0.363 | |||
| Not high family support | 1.4 | 1.1–1.9 | 0.018 | |||
| Not high peer support | 0.9 | 0.7–1.1 | 0.302 | |||
| Physically abused | 0.9 | 0.7–1.2 | 0.546 | |||
| Emotionally abused | 0.9 | 0.7–1.3 | 0.650 | |||
| Sexually abused | 9.6 | 5.8–16.1 | <0.001 | 8.1 | 3.9–16.9 | <0.001 |
| Witnessed family violence | 1.9 | 1.3–2.8 | 0.002 | |||
Odds ratios (ORs: “sexual intercourse” vs. “no sexual intercourse”) and their respective 95%CIs and p-values from binary logistic regression analysis.
Regardless of the crude/unadjusted findings, all variables presented in the table were entered into the multivariable-adjusted logistic regression models in a stepwise backward elimination procedure with a p-value to exit set at P < 0.10. Empty cells indicate variables which were rejected from the final models.
Table 6.
Association of lifetime sexual intercourse with covariates by adolescents’ gender; results from multivariable-adjusted binary logistic regression.
| Variable | Boysb |
Girlsb |
||||
|---|---|---|---|---|---|---|
| ORa | 95%CI | P | ORa | 95%CI | P | |
| Urban residence | ||||||
| Father employed | ||||||
| Mother employed | ||||||
| More affluent | 1.5 | 1.0–2.1 | 0.051 | |||
| Non-daily breakfast consumption | ||||||
| Non-daily fruit consumption | 0.7 | 0.5–1.0 | 0.061 | |||
| Inadequate toothbrushing | ||||||
| Adequate exercise | 2.1 | 1.0–4.4 | 0.054 | |||
| Smoking | 1.9 | 1.2–2.8 | 0.002 | 2.2 | 1.0–5.0 | 0.061 |
| Alcohol consumption | ||||||
| Drunkenness | 2.8 | 1.9–4.2 | <0.001 | |||
| At least two complaints (>once a week) | ||||||
| Not high family support | ||||||
| Not high peer support | ||||||
| Physically abused | ||||||
| Emotionally abused | ||||||
| Sexually abused | 7.4 | 2.6–20.7 | <0.001 | 8.0 | 2.7–23.3 | <0.001 |
| Witnessed family violence | 2.9 | 1.1–8.0 | 0.034 | |||
Odds ratios (ORs: “sexual intercourse” vs. “no sexual intercourse”) and their respective 95%CIs and p-values from binary logistic regression analysis.
All variables presented in the table were entered into the multivariable-adjusted logistic regression models in a stepwise backward elimination procedure with a p-value to exit set at P < 0.10. Empty cells indicate variables which were rejected from the final models.
P < 0.05 was considered as statistically significant for all tests. Statistical Package for the Social Sciences (SPSS, version 19.0) was used for all the statistical analyses.
Results
The results showed that approximately 18% of the sample had had sexual intercourse (Table 1). Split by gender there was a 30% gap between boys and girls (34% vs 4%, respectively; P < 0.01). Sexual intercourse was more prevalent among the following groups: schoolchildren residing in urban areas (about 19% vs. 15% in rural areas, P = 0.06), those from more affluent families (approximately 22% vs. 14% among less affluent participants, P < 0.01), and adolescents without a high family support (22% vs. 17% among those with a high family support, P = 0.02) (Table 1); schoolchildren who reported adequate levels of physical activity (around 22% vs. 13% among less physically active adolescents, P < 0.01), those with inadequate toothbrushing practices (22% vs. 15% among adolescents with adequate toothbrushing practices, P < 0.01), those who reported lifetime smoking (31% vs. 13% among never smokers, P < 0.01), and adolescents who reported lifetime alcohol consumption (24% vs. 13% among never drinkers, P < 0.01) and drunkenness (31% vs. 13% among those who had never experienced drunkenness, P < 0.01) (Table 2). Health complaints were not significantly related to the prevalence of sexual intercourse (Table 3). On the other hand, sexual intercourse was significantly more prevalent adolescents who reported witnessing of family violence (28% vs. 17% among those who had never witnessed family violence, P < 0.01), and especially those who reported lifetime sexual abuse (almost 65% vs. 16% among schoolchildren who were never sexually abused, P < 0.01) (Table 4).
In crude/unadjusted binary logistic regression analysis (Table 5 – left column), positive correlates of lifetime sexual intercourse consisted of: being boy (P < 0.01); urban residence (P = 0.054); family affluence (P < 0.01); inadequate toothbrushing habits (P < 0.01); adequate physical activity (P≪0.01); lifetime smoking (P < 0.01), alcohol consumption (P < 0.01) and drunkenness (P < 0.01); inadequate family support (P = 0.02; lifetime witnessing of family violence (P < 0.01); and, especially, lifetime sexual abuse (P < 0.01).
In multivariable-adjusted logistic regression models (Table 5 – right column), independent significant positive correlates of lifetime sexual intercourse included: being boy (OR = 12.6, 95%CI = 8.4–19.1), a higher family affluence (OR = 1.4, 95%CI = 1.0–2.0), lifetime smoking (OR = 1.9, 95%CI = 1.3–2.7), lifetime drunkenness (OR = 2.3, 95%CI = 1.6–3.3), and lifetime sexual abuse (OR = 8.1, 95%CI = 3.9–16.9).
A gender stratified analysis (Table 6) indicated that lifetime smoking and sexual abuse were consistent correlates of sexual intercourse in both genders (smoking: OR = 1.9, P < 0.01 in boys, and OR = 2.2, P = 0.06 in girls; sexual abuse: OR = 7.4, P < 0.01 in boys, and OR = 8.0, P < 0.01 in girls). Family affluence and drunkenness were significant correlates only in boys (OR = 1.5, P = 0.051 and OR = 2.8, P < 0.01, respectively), whereas adequate exercise and witnessed family violence were significant correlates in girls only (OR = 2.1, P = 0.054 and OR = 2.9, P = 0.03, respectively).
Discussion
Main findings
In this study including a nationwide representative sample of 15-year-old Albanian schoolchildren, 34% of boys, but only 4% of girls reported lifetime sexual intercourse. After controlling for a very wide range of covariates, there was still evidence of a considerable gender gap. The strongest independent correlates of sexual intercourse included lifetime smoking, and especially lifetime sexual abuse and being boy. Notably, there was evidence of a significant gender difference in selected behavioral correlates of lifetime sexual intercourse such as drunkenness and physical activity.
Comparison with literature reports
According to a report including 44 participating countries in the last HBSC round conducted in 2021–2022 (Költő et al., 2024), the prevalence of sexual intercourse among 15-year-old adolescents was 20% in boys (which is far lower than our estimate of around 34% among Albanian boys) and 15% in girls (which is much higher than our estimate of only about 4% among Albanian girls). Notably, among all HBSC participating countries in 2021–2022, Albania exhibited the largest gender difference in the prevalence of lifetime sexual intercourse (Költő et al., 2024). This pronounced gender gap suggests that underlying cultural, societal, or behavioral factors influence differentially sexual activity by gender of Albanian adolescents, potentially reflecting stronger gender norms (Qirjako et al., 2021), disparities in sexual health education and autonomy, but also, possibly, differential reporting biases.
Across six post-communist European countries, HBSC data (2014–2022) show that sexual intercourse among 15-year-olds remains more common in boys than girls, with trends generally stable or declining, except Hungary, where rates stayed relatively high and gender gaps were narrower (Költő et al., 2024; Inchley et al., 2016, 2020).
Overall, the prevalence of lifetime sexual intercourse in our study was lower than in the previous HBSC round conducted in Albania in 2017–2018 (18% vs. 26%, respectively) (Inchley et al., 2020). A decrease in adolescent sexual initiation rates in Albania between 2018 and 2022 may reflect the impact of the COVID-19 pandemic, like the evidence obtained in many other HBSC participating countries (Költő et al., 2024; Inchley et al., 2020). As elsewhere, the pandemic led to prolonged periods of social distancing, school closures, and reduced opportunities for in-person interactions among Albanian adolescents. These restrictions may have limited the circumstances of sexual engagement among Albanian adolescents, thereby contributing to the observed decrease in sexual initiation rates during this period. Another reason may be the reduced opportunities for physical peer interaction due to increased digital screen time. Hence, greater engagement of Albanian adolescents with online platforms, including social media, gaming, or remote learning, may have displaced in-person social interactions that often facilitate sexual relationships. However, a decrease in adolescent sexual initiation rates in Albania between 2018 and 2022 may also reflect positive shifts in youth behavior or increased awareness.
According to a population-based study including 69 LMICs worldwide (only North Macedonia from Europe), the global prevalence of lifetime sexual intercourse among adolescents aged 14–15 years was estimated at 8.5% (95%CI = 7.7–9.3%) (Jing et al., 2023). This is much lower than the HBSC average based mostly on European countries (Költő et al., 2024), including also our estimate pertinent to Albanian adolescents. This difference between global estimates and the HBSC estimates highlights important contextual differences in adolescent sexual behavior patterns, influenced by cultural, social, and economic factors. Seemingly, adolescents in HBSC participating countries, mainly higher-income European and North American settings, may be initiating sexual activity earlier than their peers globally, possibly reflecting greater autonomy, different societal norms around sexuality, or better access to sexual and reproductive health services.
The association of sexual intercourse with a higher family affluence evidenced in our study is comparable with the HBSC multi-country report for boys only (Költő et al., 2024). Additionally, our findings on positive relationships between sexual intercourse and unhealthy behaviors including smoking and alcohol consumption, as well as child maltreatment are similar to previous studies conducted internationally (Kebede et al., 2023; Izdebski et al., 2025; Reis et al., 2024). Yet, our finding on a positive association of drunkenness and sexual intercourse in boys only differs from a previous report from Ireland based on HBSC data, where alcohol use/drunkenness was significantly related to sexual initiation among girls only (Burke et al., 2018). According to this study, sociodemographic factors and behavioral characteristics were stronger correlates of the age of sexual initiation among girls than boys (Burke et al., 2018). On the other hand, our finding on the association between adequate physical activity levels and sexual intercourse in girls is comparable with HBSC data from Poland (Izdebski et al., 2025).
At a broader level, our findings are in line with the ecological framework coined by Salazar et al. (2010; DiClemente et al., 2005) according to which, the factors related to adolescents’ sexual behavior represent multiple levels of influence, including individual behaviors (in our study: smoking, drunkenness, and sexual abuse) and broader social structures (in our study: gender norms, and family affluence). Also, our findings are in line with the Dahlgren and Whitehead’s model of social determinants of health (Dahlgren & Whitehead, 2021) which highlights how socioeconomic status (in our study: family affluence) and gender roles intersect to shape adolescents’ sexual behaviors, while individual risk factors like smoking and alcohol consumption contribute to poor health outcomes. The interrelated factors (in our study: smoking and alcohol use, drunkenness, and sexual abuse) create a “syndemic” of combined risks, where the overlapping social and environmental stressors increase vulnerability to early sexual initiation and subsequent health risks (Singer & Clair, 2003).
In our study, lifetime sexual abuse was a particularly strong correlate of sexual initiation in both genders which highlights the need for integrated prevention and intervention strategies that address both trauma and sexual health education. We also evidenced a significant link between witnessing family violence and sexual initiation in girls only, which may reflect sociocultural norms in Albania that place disproportionate emotional and behavioral burdens on adolescent girls in response to family violence, influencing their psychosocial development and risk trajectories differently than boys.
Limitations and strengths
Several limitations should be considered when interpreting the findings of our study. First, the study’s generalizability is restricted, as it includes only 15-year-old adolescents who were enrolled in school at the time of data collection. Adolescents who were out of school may have systematically differed from their in-school peers with respect to key characteristics such as socioeconomic status, access to health information and education, social networks, and engagement in risk behaviors, including sexual activity. Excluding this potentially more vulnerable subgroup may have introduced selection bias, hence misrepresenting the true prevalence and correlates of sexual intercourse among all 15-year-olds in Albania. Second, information bias, particularly social desirability bias, poses a substantial threat to the validity of the self-reported data. Given the strong cultural norms and taboos surrounding adolescent sexuality in Albania, participants may have either underreported or overreported their sexual experiences to conform to perceived societal expectations. This bias may differentially affect boys and girls, leading to a potential underestimation of sexual intercourse prevalence among girls (due to stigma) and an overestimation among boys (due to perceived social approval), thus inflating observed gender differences (Muehlenhard et al., 2015). Third, the cross-sectional design of the survey precludes the ability to infer temporal or causal relationships between sexual intercourse and its associated factors. Since exposure and outcome data were collected simultaneously, it is not possible to determine whether the identified correlates (e.g., family and peer support, or substance use) preceded or resulted from sexual activity, limiting the ability to infer causality.
However, our study has several strengths. Firstly, to our knowledge, this is the first systematic analysis of sexual behaviors and its correlates in Albania. Secondly, we employed a nationally representative sample of adolescents. Thirdly, our study was based on a rigorous methodology used by the HBSC network (Inchley et al., 2021).
Conclusions
Our study informs about the prevalence and important correlates of sexual intercourse among adolescents in post-communist Albania including the significant role of such sociodemographic factors as family affluence and especially gender, as well as smoking and history of sexual abuse. The most salient finding of our study consists of a substantial gender difference in Albanian adolescents, where, among all HBSC participating countries in 2021–2022, the prevalence of lifetime sexual intercourse in Albanian boys was the second highest, whereas in girls it was one of the lowest (Költő et al., 2024). The very low prevalence in girls may be seemingly attributed to the fact that Albania is a predominantly Muslim country (Burazeri & Kark, 2011). However, religion was officially banned during communism and, despite the restoration of religious freedom after 1990, there is a general disconnection from religion among the Albanian population, including adolescents. This is evidenced in the most recent edition of the Inglehart-Welzel World Cultural Map, where Albania is characterized by secular-rational values indicating a decrease in the religious influence (World Values Survey (WVS), 2023). Therefore, the low prevalence of sexual intercourse in adolescent girls may be more likely attributed to the patriarchal nature of the Albanian society (Qirjako et al., 2021).
Nevertheless, further research is needed to explore other important dimensions of sexual health among Albanian adolescents including engagement in early sex, condom and contraceptive pill use, the considerable double standard (Muehlenhard et al., 2015) observed in Albania, and especially the sexual health aspects of marginalized groups of adolescents.
Our findings underscore the need for targeted interventions to promote healthy behaviors and enhance sexual health education in Albania and similar post-communist countries and transitional societies, where youths may face unique challenges in adopting healthy sexual behaviors. Specifically for Albania, adolescents face several unique challenges concerning sexual health which are shaped by cultural, educational, and systemic factors (Qirjako et al., 2021, 2024) including especially cultural taboos and limited family dialogue on discussions about sexuality, as well as inadequate sexual education. The strict social controls, conservative norms, and censorship around sexual matters under communism led to generations with limited sexual health knowledge and weak institutional frameworks for sexual education in Albania. Notably, Albania differed considerably from other communist countries in Eastern and Central Europe, such as, e.g., Poland, Czechoslovakia and Hungary where there were quite developed schools of sexology and sexual education (Csányi, 2025; Kościańska, 2016; Lišková, 2016). The societal liberalization after 1990s exposed Albanian adolescents to new globalized cultural influences, including more liberal attitudes toward sexuality, but without a corresponding development of comprehensive, structured sexual health services or education systems. After the breakdown of the communist regime, the other post-communist European countries followed different trajectories regarding public policies around sexual health (including abortion and contraception).
Recommendations
In all cases, interventions in Albania and similar countries should address diverse backgrounds of adolescents, their different developmental stages, specific risk factors, as well as gender-specific correlates as evidenced also in our study (family affluence and drunkenness in boys and witnessed family violence in girls). In particular, there is a critical need to develop and implement targeted interventions and support systems for Albanian adolescents who have been victims of sexual abuse, as well as those who have been exposed to family violence. These young individuals are at increased risk for a range of adverse mental, emotional, and behavioral outcomes (Kebede et al., 2023; Izdebski et al., 2025; Reis et al., 2024), and require trauma-informed care, psychosocial support, and sustained engagement to promote their recovery, resilience, and overall well-being. Tailoring programs to adolescents’ specific needs may improve engagement, knowledge retention, and the adoption of safer sexual practices. Eventually, integration of targeted interventions into schools, community settings, and digital platforms can ensure broader access and long-term improvements in adolescent sexual and reproductive health outcomes. Also, the finding on a positive link between witnessing family violence and sexual initiation in girls only underscores the need for gender-responsive child protection policies in Albania that address the distinct psychosocial risks faced by adolescent girls exposed to family violence, including targeted support services, comprehensive sexual education, and trauma-informed care. On another aspect, the high prevalence of sexual intercourse among Albanian boys is concerning considering the lack of comprehensive, and structured sexual health education. This highlights an urgent need for adequate policies to promote informed, safe, and responsible sexual behavior among Albanian adolescent boys. An additional important cause of concern for Albanian adolescent boys relates to our finding on the association between sexual initiation and unhealthy behaviors such as smoking and particularly drunkenness. This calls for an urgent need for integrated public health policies in Albania that address multiple risk behaviors through coordinated adolescent health and education programs.
Yet, all interventions should be carefully designed considering that sexual initiation is not inherently risky, but can be if it occurs without maturity, consent, or protection. Portraying adolescent sexual practices merely as “risky” may unfairly blame young people and deny them the possibility to consider sex as pleasurable, health-promoting and a natural step to adulthood.
Acknowledgments
This study was conducted by the Faculty of Medicine, University of Medicine, Tirana, Albania.
Appendix. Assessment of sexual intercourse, health complaints, and family and peer support
Sexual intercourse
Schoolchildren were asked if they had ever had sexual intercourse, after providing a short explanation: “Have you ever had sexual intercourse? Sometimes this is called ‘making love’, ‘having sex’ or ‘going all the way’” (Inchley et al., 2021). Potential answers included “yes” vs. “no”.
Health complaints
Measurement of health complaints included headache, stomachache, backache, feeling low, irritability, nervousness, sleep difficulties, and dizziness. Schoolchildren were asked to report on the frequency of these eight health complaints in the last six months preceding the survey (Inchley et al., 2021).
Frequency categories for each complaint ranged from “about every day” to “rarely or never”.
In the analysis, each of these eight health complaints was dichotomized into: “≤once a week” vs. “>once a week” (Inchley et al., 2021).
Family and peer support
Family support: measurement of family support was based on a scale composed of the following four items (Inchley et al., 2021):
My family really tries to help me.
I get the emotional help and support I need from my family.
I can talk about my problems with my family.
My family is willing to help me make decisions.
Each item was coded as a Likert scale from 1 (very strongly disagree) to 7 (very strongly agree). An overall score for the family support scale was calculated by adding the items together and dividing by four. This mean score, ranging from 1 to 7 (with higher mean scores indicating higher levels of perceived family support) was dichotomized in the analysis into ≥5.5 (“high family support”) vs. <5.5 (“not high family support”) (Inchley et al., 2021).
Peer support: measurement of peer support was based on a scale composed of the following four items (Inchley et al., 2021):
My friends really try to help me.
I can count on my friends when things go wrong.
I have friends with whom I can share my joys and sorrows.
I can talk about my problems with my friends.
Each item was coded as a Likert scale from 1 (very strongly disagree) to 7 (very strongly agree). An overall score for the peer support scale was calculated by adding the items together and dividing by four. This mean score, ranging from 1 to 7 (with higher mean scores indicating higher levels of perceived peer support) was dichotomized in the analysis into ≥5.5 (“high peer support”) vs. <5.5 (“not high peer support”) (Inchley et al., 2021).
Funding Statement
This study was funded by the following agencies: the United Nations Population Fund (UNFPA) Office in Albania, the United Nations Children’s Fund (UNICEF) Office in Albania, and the Swiss Development and Cooperation (SDC) Agency through the project “Schools for Health” implemented in Albania.
Authors’ contributions
IM, MK, GQ and GB contributed to the study conceptualization and design, analysis and interpretation of the data and writing of the article. ER commented comprehensively on the manuscript. All authors have read and approved the submitted manuscript.
Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Data availability statement
The data presented in this study is available upon reasonable request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data presented in this study is available upon reasonable request from the corresponding author.