Knowledge, Attitudes and Behaviors of the Adolescent Reproductive Health Triad

uberty is experienced by every teenager which is characterized by the maturity of the reproductive organs thus triggering the sexual impulse. If the sexual drive in adolescents is not controlled then it is at risk to the Adolescent Reproductive Health Triad. The purpose of the study was to determine the relationship between knowledge and attitudes with the behavior of the Reproductive Health Triad at SMK Duta Pratama Indonesia Tasikmalaya City in 2021. This type of research is an analytical survey using a cross sectional design. The population and sample of this study are all students of SMK Duta Pratama Indonesia based on inclusion criteria. The instrument uses Gform and the data are analyzed univariately and bivariately. The results showed that the average knowledge score was 4.54, the average attitude score was 17.21, and the average behavior score was 5.51. There is no relationship between knowledge and behavior of the Adolescent Reproductive Health Triad p value = 0.135, and there is a relationship between attitudes and behavior of the Adolescent Reproductive Health Triad p value = 0.043. From the results of the study, it can be concluded that there is no relationship between knowledge and behavior of the Adolescent Reproductive Health Triad and there is a relationship between attitudes and behaviors of the Adolescent Reproductive Health Triad. It is hoped that the school can instill spiritual values and provide adolescent reproductive health education in preventing risky behaviors in students.


Introduction
Every year the population of productive age in Indonesia continues to increase. This is known from the data of Indonesian Youth Statistics in 2019, that 1 in 4 Indonesians are youth (64.19 million people) [1]. Indonesia in 2030-2040 is predicted to experience a demographic bonus, which means that the number of people of productive age (aged 15-64 years) is greater than the unproductive age (under 15 years and over 64 years). Meanwhile, the population of adolescents aged 10-24 years who are not married in Indonesia is more than 57 million people [2]. Planning Agency (BKKBN), the age range of adolescents is 10-24 years and unmarried [5].
Adolescence is a period of very rapid growth and development, both physical, psychic and intellectual. The transition period from childhood to adulthood is passed with many changes such as the Page | 21 maturity of the reproductive organs and the emergence of attraction to the opposite sex. The characteristics of adolescents who like new things and a high sense of curiosity encourage adolescents to act to reach them regardless of the risks they will bear. Sexual desire that arises if not controlled can attract adolescents to have premarital sex who may experience unwanted pregnancies, abortions, sexually transmitted diseases (STDs), and drugs. As a young generation, of course, they do not want to be damaged by things that can interfere with the future, so teenagers need to be nurtured and filled with positive things to avoid risky behaviors.
Adolescent Reproductive Health is a healthy condition that concerns the social, function and reproductive processes possessed by adolescents, not only means being free from disease or disability, but also mentally and socio-culturally [4]. Three threats to Adolescent Reproductive Health otherwise known as the KRR Triad that can lead adolescents to risky behaviors include Sexuality (premarital sex, Ref. [4] stated that targets 28% of adolescents to access PIK-R, but only 17% of adolescents access PIK-R. The lack of participation and access of adolescents to government programs related to adolescent reproductive health shows that there is still a lack of information, which affects adolescents' knowledge and attitudes about the KRR Triad. The lack of knowledge and attitudes of adolescents towards adolescent reproductive health is a factor behind the emergence of Triad KRR risky behaviors in adolescents. A person's behavior is formed from knowledge and attitudes. If knowledge and attitudes tend to be positive, then the behaviors that arise will tend to be positive and vice versa. Ref. [5] said, the higher the information (knowledge) possessed, the more positive the attitude. The more positive the attitude will lead a person to behave positively. Action is the implementation of the knowledge and attitude of a real deed [6].
SMK Duta Pratama Indonesia is one of the high schools located in Tasikmalaya City. Based on a preliminary survey that has been carried out by researchers at SMK DPI Tasikmalaya City, by interviewing the school and student representatives, it is known that the school has never been exposed to material related to the Adolescent Reproductive Health Triad, both socialization from health agencies such as Puskesmas and from the school itself to its students. In addition, it has been found that students who have experienced unwanted pregnancies and have been expelled from school. With regard to existing backgrounds and problems, researchers are interested in conducting research to find out The Relationship of Knowledge and Attitudes with the Behavior of the Adolescent Reproductive Health Triad in Students of SMK Duta Pratama Indonesia (DPI) Tasikmalaya City in 2021.
Based on the existing background, it is necessary to study the relationship between knowledge and attitudes with the behavior of the Adolescent Reproductive Health Triad in students of SMK Duta Pratama Indonesia (DPI) Tasikmalaya City in 2021. This study provides benefits on scientific upgrading with direct research, especially in knowing the picture of knowledge and attitudes about the KRR Triad and its relationship with the behavior of the KRR Triad in school adolescents. Apart from being a basis for school policy development and program development for puskesmas in promoting programs and socialization of adolescent reproductive health , one of which can collaborate with educational institutions in providing guidance to students to prevent adolescents from the threat of the KRR Triad.

A. Research Context
This study is an analytical survey study using a cross-sectional design, where independent variables and dependent variables are only identified once at the same time as the study. The dependent variables in this study are the behavior of the KRR Triad, while the independent variables are knowledge and attitudes. This research was conducted at SMK Duta Pratama Indonesia (DPI) Tasikmalaya City located in Mangkubumi District, and the data collection time was carried out on June 14, 2021.

B. Population and Sample
The population in this study was students of SMK Duta Pratama Indonesia, Tasikmalaya City grade 10 and 11 as many as 81 students, while grade 12 did not include respondents because it was no longer effective in studying after school exams. The sampling technique in this study used total sampling where all members of the population were sampled in the study.

C. Research Instruments
Hasil test validity of valid questions as many as 19 question items. The reliability test obtained nilai r obtained for each variable is 0.574 for the knowledge variable, 0.667 for the attitude variable, and 0.630 for the behavior variable. The code given is also at the same time a scoring of the answers given by the respondent.

D. Data Analysis
Univariate analysis was carried out on each research variable, namely knowledge, attitudes, and behavior, by displaying the mean score (average), minimum score, maximum score, and standard deviation of each variable. Bivariate analysis was performed to see the relationship between independent variables and dependent variables. The statistical test used in the bivariate analysis is the Spearman Rank test.

E. Ethical Clearance
Informed consent as a form of respondents' willingness to participate by clicking on the Google Form link that explains the purpose and purpose. The information needed by the researcher is the right Page | 23 of the respondent so that confidentiality needs to be maintained using a number code. Respondents who are willing to provide information are entitled to receive a reward in the form of a GenRe keychain.

A. Characteristics of Respondents
Theattribution of respondents based on age in students of SMK DPI Tasikmalaya City can be seen in

B. Univariate Analysis
The results of the analysis can be seen in the following table 4.3.

Source : Primary Data
The distribution of respondents' attitudes based on the questions given can be seen in the table below. The distribution of respondents' behavior based on the questions given can be seen in the table below. The results showed that as many as 52.8% of respondents with knowledge scores above the average score. To find out the level of knowledge in respondents, a cut off is needed, which is based on the knowledge score by comparing the mean value of knowledge. If the knowledge score ≥ average, it can be categorized as a good level of knowledge, while if the knowledge score < the average, it can be categorized as a lack of knowledge level [7]. The average knowledge is 4.54 with a minimum score of 2 and a maximum value of 6, so it can be known that as many as 52.8% of respondents have a good level of knowledge and the remaining 47.2% of respondents have a lack of knowledge level. Ref. [9] said knowledge or cognitive is a very important domain in shaping one's actions (overt behavior). Knowledge is the result of knowing after a person has made sensing of a certain object. It will be difficult for a person to make decisions or act on the problems at hand if the knowledge he has is very minimal [6]. In the end, this is what underlies the formation of behavior on the knowledge or insights that the individual has. The knowledge factor is included in the predisposition or factor that facilitates and underlies the occurrence of behavior [10].
Knowledge itself is influenced by several factors including age, education, mass media / sources of information, social and culture, environment, and experience [9]. Furthermore, Ref. [11] explained any factors that play a role or influence a person's knowledge such as (1) Vol. 01, No. 01, August 2022, p. 20 Although the results of this study showed that more than half of the respondents had good knowledge (52.8%), there were still respondents who were less knowledgeable (47.2%) related to the Adolescent Reproductive Health Triad. Researchers assume the level of knowledge about reproductive health in a person is due to the above factors. However, of the factors behind the level of knowledge of adolescents, mass media factors or sources of information that now tend to dominate adolescents.
In order to increase knowledge, especially related to adolescent reproductive health , adolescents can take advantage of digital technology through their gadgets , by accessing adolescent reproductive health information on the BKKBN or GenRe (Generation Planning) page. Schools can provide education about adolescent reproductive health to students through counseling, counseling, and student organizations related to adolescent health. In addition, schools can facilitate students in terms of adolescent reproductive health development by initiating the Adolescent Information and Counseling Center (PIK-R) program in order to increase adolescent reproductive health knowledge through peer educators fostered by puskesmas or the local Health Office.

B. Attitude Description of the KRR Triad
The results showed that as many as 48.6% of respondents had an attitude score above the average score. To find out the attitude tendency that the respondent has, a cut off is needed, namely by using the mean attitude value. If the attitude score ≥ average, it can be categorized as a positive attitude, while if the attitude score < average, it can be categorized as a negative attitude [11]. The average attitude of respondents is 17.21 with a minimum score of 9 and a maximum value of 22, so it can be known that as many as 48.6% of respondents tend to have a positive attitude and the remaining 51.4% of respondents tend to have a negative attitude. The positive attitude referred to in this study is an attitude that is not supportive towards the Triad KRR, while a negative attitude is an attitude that supports the Triad KRR (3 threats to adolescent reproductive health).
The results of the univariate analysis showed that almost half of respondents agreed with the statement: 'when interacting with people with HIV/AIDS, it is necessary to keep their distance to prevent transmission'. This shows that adolescents or it could be that society in general still assumes that interacting with people with HIV/ AIDS can cause transmission. So far there have been no studies that prove this, and HIV/ AIDS transmission can only occur through sexual contact, blood (wounds) and transmission from mother to child (through pregnancy, childbirth, breastfeeding) [4]. This mistake needs to be straightened out through health education and continue to interact with sufferers so as not to be shunned by their social environment. Interacting with people with HIV/ AIDS will not cause Page | 27 transmission except for having sexual contact or other bodily fluids such as sexual fluids (semen) and blood that intersect with wounds in the body.
The results of the study conducted showed that less than half of the respondents (48.6% ) had a positive attitude and 51.4% had a negative attitude towards the Adolescent Reproductive Health Triad.
Researchers assume this attitude is influenced by socio-cultural factors (beliefs) in their environment, sources of information (education or mass media) and personal experiences related to reproductive health. Ref. [12] said that the issue of sexuality cannot be separated from the socio-cultural-political context and power relations that shape perceptions of sexuality itself.
Today, talks around reproductive and sexual health are still considered taboo by most of the public which is actually quite essential to the development of reproductive health. This habit then becomes a belief or presumption of sexuality as a dirty and taboo thing. The attitude of beating sex in adolescents will only reduce their likelihood of not talking openly but not to prevent sexual behavior [13].
Teenagers have a high sense of curiosity about their sexuality and then look for it themselves by asking people they trust such as parents, girlfriends, and friends. According to the Indonesian Demographic and Health Survey in 2017, it showed that as many as 62% of adolescent girls and 51% of adolescent boys chose their peers to be a place to discuss their reproductive health. Diananda (2018) said, the need for peers or friendship in the adolescent social environment is important, because with adolescent friends can be more open in exchanging information to people he trusts and in this case have similarities in age, experiences and emotions. Most teenagers choose to accept their peers' views for themselves because they are considered important. It is even more important than the views of their own parents so that teenagers put their peers or group first so that they can be accepted into their peer community.

C. Behavior Overview of the KRR Triad
The results showed that as many as 56.9% of respondents with a behavior score above the average score. To find out the direction of behavior in respondents, a cut off is needed. The results of this study are in line with the results of Ref. [14] on students of SMKN 4 Padang, where as many as 52% of respondents behaved well and 48% of respondents who behaved badly. Ref. [15] said, behavior is influenced by internal and external factors. Internal factors, namely the characteristics of the person in question, are innate, for example, the level of intelligence, emotional level, gender and so on. Meanwhile, external factors, namely the environment, both physical, social, cultural, economic, political and so on.
Fitriani continued, external factors are factors that dominate a person's behavior.
Another behavioral theory is the stimulus-organism-response or SOR proposed by Skinner. In simple terms, this SOR theory indicates the emergence or formation of behavior due to the presence of stimuli or stimuli, then continued in the organism to respond to the stimulus. The results of the univariate analysis showed a balanced proportion between respondents who were dating and those who were not dating on the grounds that they did not conform to religious or community norms. This shows that not all teenagers are dating, but the data also shows that there are teenagers who date without paying attention to the norms adopted by their social environment, such as kissing girlfriends (11.1%) Page | 28 and touching/fingering certain body parts, such as thighs, neck, genitals of friends/opposite sexes/girlfriends when the opportunity arises (9.7%).
As parents, they can understand the development of their teenage children by paying attention to changes in behavior in adolescents. If the behavior change that occurs tends to lead to risky behavior, parents can invite their teen to talk about it in a friendly and open-minded manner without judgment to understand certain behavior changes in their teenage child and can provide advice such as the impact of risky behaviors triad KRR. In addition, schools have the same role in preventing risky behaviors in adolescent students by facilitating adolescent self-development in the form of positive and useful activities, as well as providing reproductive health education and organizing religious activities in schools. Guidance counseling (BK) teachers in schools can assist adolescents in solving their problems.
Synergy between parents and schools is the main key in preventing adolescents from risky behaviors of the Adolescent Prostitution Triad.

D. The Relationship of Knowledge to the Behavior of the KRR Triad
The results of statistical tests with spearman ranks showed that there was no relationship between This shows that adolescents who have good knowledge, do not necessarily have good sexual behavior, as well as adolescents who have less knowledge, may have good sexual behavior. This result is different from the research conducted by Ref. [16], where the results of the study showed that there was a relationship between knowledge and sexual behavior in students of SMK PHI Bekasi with the acquisition of a p-value statistical test of 0.011 (p<0.05).
Knowledge is the result of human sensing, or the result of knowing a person about objects through the senses they have [9]. But the acceptance of non-comprehensive knowledge can lead to poor sexual behavior [17]. Knowledge is not the only domain that shapes behavior, but there are other factors such as attitudes, beliefs, beliefs and values. Knowledge is part of predisposition, where in the formation of behavior there is a contribution from other factors, namely enabling and reinforcing [10].
The absence of a relationship between knowledge and the behavior of the KRR Triad in this study can be caused by other factors outside the variables studied, for example from the characteristics of respondents in the form of varied sex and age can be a factor behind insignificant results or the absence of relationships between the variables studied. The results of the study by Ref. [18] showed that there was a relationship between gender and sexual behavior of junior high school students in Semarang City (p-value = 0.045). Sexual behavior in men tends to be more intense than in women. Norms in society also contribute to the stereotype of gender that women should maintain their virginity and not with virginity in men.
Although the results of this study show that there is no relationship between knowledge and the behavior of the KRR Triad, it is necessary to be aware that there are 47.2% of respondents who still have below-average knowledge, which may affect attitudes and behaviors in the future. Although a good level  Vol. 01, No. 01, August 2022, p. 20-31 Page | 29 of knowledge is not necessarily risky behavior, even some respondents admitted to having watched porn videos/movies (30.6%), had kissed a girlfriend (11.1%), had or liked to smoke (9.7%), had touched/fingered certain body parts such as thighs, neck, genitals of friends or girlfriends (5.6%), and had consumed liquor (2.8%).
In preventing risky behaviors in adolescents, There are several ways to avoid free sex behavior in adolescents, one of which is by increasing faith and piety to God Almighty, helping adolescents channel their interests, talents, and potential in positive activities, and equipping adolescents with useful information such as the dangers and impacts of promiscuity such as sexually transmitted diseases [6].
In addition, from the results of this study, the author argues that the attention and role of the family, environment, and school to adolescent growth and development is very necessary. Preventing adolescents from risky behaviors The KRR Triad is not enough just to provide education, but also to accompany and provide an example to adolescents that every action has consequences and impacts that must be ready to be accounted for.
Involving adolescents in positive activities in order to increase insight and development of interests, talents, and potentials can encourage adolescents to behave healthily and prevent adolescents from risky behaviors of the KRR Triad. Researchers also recommend optimizing the functioning of health centerin schools in terms of preventive and promotive. Schools can partner with local puskesmas in fostering adolescent reproductive health, either in the form of counseling or initiating peer educator programs or the Adolescent Information and Counseling Center.

E. The Relationship of Attitudes to the Behavior of the KRR Triad
The results of a statistical test with spearman rank showed that there was a relationship between attitudes and behavior (p = 0.043) of the Adolescent Reproductive Health Triad in students of SMK DPI Tasikmalaya City in 2021. This is in line with the research of Ref. [16], where the results of the statistical test obtained a p-value of 0.043 (p<0.05) which showed that there was a relationship between attitudes and sexual behavior in students of SMK PHI Bekasi. Attitudes are still limited to a person's opinion or assessment of matters related to health, health-sickness, and factors related to health risks [19].
Meanwhile, according to Ref.
[90], attitude is not yet an action or activity, but is a behavioral 'predisposition'. If a person has a positive attitude towards something then he will accept or carry out something, and vice versa if a person has a negative attitude then he will reject or not carry out something.
Preventing risky behaviors in adolescents cannot only be done by limiting adolescents from association with their peers, so the role of parents, health workers, and teachers (schools) is needed in building positive adolescent attitudes towards the Adolescent Reproductive Health Triad . Parents, health workers, and teachers (schools) are reinforcing factors for adolescents to behave in a healthy life.
All three are positioned as influential figures so that they are used as role models and references for adolescents, and are supported by adolescents' access to health services other than educational institutions (enabling) that facilitate the realization of health behaviors [9].
Positive attitudes of adolescents towards the KRR Triad can be formed through education to meet the needs of information, counseling and adolescent reproductive health services. This can be done by  Vol. 01, No. 01, August 2022, p. 20-31 Page | 30 synergizing between Puskesmas and schools to organize programs related to adolescent reproductive health. In addition to reproductive health, education is also needed to encourage adolescents to adopt a healthy lifestyle and become peer educators. On the other hand, the role of parents is also important in shaping positive attitudes of adolescents by providing a sense of security and confidence to adolescents by carrying out 8 family functions [20] including; religious, socio-cultural, loving-kindness, protection, reproduction, socialization and education, economics, and environmental development in meeting the needs of adolescents, being a good listener and example, and helping adolescents face and solve the problems faced. Teachers and parents should be open when discussing reproductive health with adolescents in order to foster trust in adolescents and not be closed to their own reproductive health problems.

Conclusion
The average student knowledge score about the Adolescent Reproductive Health Triad at SMK DPI Tasikmalaya City in 2021 was 4.54 with the lowest score of 2 and the highest score of 6. More than half of respondents (52.8% ) had knowledge scores above the average score. The average student attitude score on the Adolescent Reproductive Health Triad at SMK DPI Tasikmalaya City in 2021 was 17.21 with the lowest score of 9 and the highest score of 22. There were 48.6% of respondents with an attitude score above the average score. The average student behavior score on the Adolescent Reproductive Health Triad at SMK DPI Tasikmalaya City in 2021 was 5.51 with the lowest score of 1 and the highest score of 7. More than half of respondents (56.9%) had behavioral scores above the average score. There is no relationship between knowledge and behavior of the Adolescent Reproductive Health Triad in students of SMK DPI Tasikmalaya City in 2021 (p-value = 0.135). There is a relationship between attitudes and behaviors of the Adolescent Reproductive Health Triad in students of SMK DPI Tasikmalaya City in 2021 (p-value = 0.043).