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F1000Research

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10.12688/f1000research.158273.1

Research Article

Articles

The Effects of Information-Motivation-Behavioral Skills Model in Predicting Safer Sexual Dual Protection Behaviors Among Female University Students: A Cross-sectional Study

[version 1; peer review: 1 approved with reservations]

Feyisa

Banti Negero

Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0009-0007-9949-1477 a 1 Debelew

Gurmesa Tura

Zewdie Birhanu

Conceptualization Data Curation Formal Analysis Investigation Methodology Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 3 1Population and Family Health, Jimma University College of Public Health and Medical Sciences, Jimma, Oromia, 378, Ethiopia 2Population and Family Health, Jimma University College of Public Health and Medical Sciences, Jimma, Oromia, 378, Ethiopia 3Department of Health Behavior and Society, Jimma University College of Public Health and Medical Sciences, Jimma, Oromia, 378, Ethiopia

a nagaro_b@yahoo.com

No competing interests were disclosed.

3 4 2025

2025

387

18 3 2025

2025

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background

The burden of sexually transmitted infections (STIs) and unintended pregnancy remains a significant public health concern, with young women being disproportionately affected. While both risks can be prevented simultaneously by the same safe sexual practice, such as abstinence or dual protection use, little is known about the patterns and predictors of a range of safer sexual dual protection behaviors among youth based on theoretical models in Ethiopia. This study aimed to examine the effects of information-motivation-behavioral skills (IMB) model in predicting various safer sexual dual protection behaviors, including primary sexual abstinence and dual-protection use among female university students in Ethiopia.

Methods

A cross-sectional study was conducted among female university students at MattuUniversity. Data were collected using a self-administered questionnaire and analyzed using SPSS version 23. Bivariate and multivariate analyses were conducted using structural equation modeling (SEM) with AMOS 23.

Results

Of the 1,020 participants, 624 (61.2%) practiced primary sexual abstinence, whereas 396 (38.8%) have ever had sexual intercourse, of whom only 76 (20.5%) used dual protection at their last sexual encounter. Results of the structural equation model analysis indicated that primary sexual abstinence was strongly correlated with motivation (β = 0.34, P < 0.001) and behavioralskills (β = 0.24, P < 0.001) and information (β = 0.11, P < 0.001). Among sexually active participants, dual protection use was strongly correlated with motivation (β = 0.23, P < 0.05) and behavioral skills (β = 0.24, P < 0.001), while it was moderately correlated with information (β = 0.04, P < 0.05). Approximately 28% of the variance in primary sexual abstinence and 27.4% of the variance in dual protection use was explained by the model constructs.

Conclusions

The findings indicate that the IMB model is useful for identifying powerful predictors of sexual abstinence and dual protection use among female university students, which has potential implications for designing interventions to improve knowledge, motivation, behavioral skills and practice of abstinence and/or dual protection use among youth at risk of both STI/HIV and unwanted pregnancy in settings with high HIV burdens.

IMB model HIV risk reduction safer sexual dual protection behaviors primary sexual abstinence dual protection use female university students

Institute of Health, Jimma University

Financial support for the research, which amounts to Eth Birr = 60,000. 00 was provided by the Jimma University Institute of Health as a PhD student’s research grant to cover some of the expenses for data collection and analysis. The funders have no competing interests or conflicts of interest concerning the manuscript preparation and its submission for publication in this journal.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Introduction

Globally, HIV/AIDS and unwanted pregnancies remain major public health problems, with young women being disproportionately affected. In 2020, an estimated 1.5 million people were newly infected with HIV globally. ^{1,
2} In sub-Saharan Africa, women and girls account for 63% of new HIV infections, with 83% occurring among adolescent girls and young women aged 15–24 years. ^{2,
3} In Ethiopia, although trends in the rates of HIV among adults declined from 1.5% in 2011 to 0.93% in 2019, women continued to be disproportionately affected compared with men (1.22% versus 0.64%), and the highest prevalence occurred among unmarried women (9%). ^{4–
7} In addition, the rates of unwanted pregnancies among young women in Ethiopia remains high, with about 37% of unwanted pregnancies occurring in young women aged 20-24 years in 2011. ⁶ Recent data also indicated that the proportion of young girls who begun childbearing before age 20 was 28 % in 2016. ⁸ The fact that young women in sub-Saharan Africa are substantially affected by the HIV epidemic and unintended pregnsncy is because they face several vulnerabilities that increase their sexual risk of STIs/HIV and unwanted pregnancy. These vulnerabilities are rooted in gender roles/social norms, and their limited access to sexual health information, education and resources, all of which prevent them from making essential decisions about their sexual health, with most lacking the knowledge and skills needed to protect themselves from HIV infections and unwanted pregnancy. ^{1–
3}

To combat the spread of HIV infections, HIV/AIDS prevention programs have emphasized safer sexual behaviors such as abstinence, mutual monogamy, and condom use to reduce the risk of HIV infection among youth. ³ Similarly, HIV/AIDS prevention programs in Ethiopia also focus their messages and efforts on three aspects of sexual behaviour: such as condom use, limiting sexual partners, and delaying sexual debut (abstinence) among unmarried youth. ⁶ Despite the efforts, recent studies on sexual behaviors of students in Ethiopia indicated a rising trend in premarital sexual activity among university students, while the use of condoms in this group remained low. ^{9,
10} In addition, because young women are at increased risk and vulnerable to STI/HIV infections and unwanted pregnancy from the same unsafe sexual practice and both can be prevented simultanousely by the same safer sexual practices as dual protection, the recent WHO/UNAIDS recommendation on HIV prevention for young women emphasizes the need for dual protection:defined as safer sexual behaviors that provide simultaneous protection against both risks ofHIV/STI and unwanted pregnancy through either abstinence, consistent condom use, or dual-method use as comprehensive strategies to reduce the dual risks associated with sexual activity among youth in settings with high HIV burden. ^{2,
3}

To achieve maximum protective effects, while abstinence is the most effective (100%) way to avoid risks of both STI/HIV and unwanted pregnancy among youths, which is recommended for unmarried youths in many communities with supportive norms and cultures in Africa, condoms are the only barrier methods available to reduce the risk of STI/HIV infections and prevent pregnancy, when used consistently among sexually active young women. However, despite the improvements in the rate of contraceptive methods use among unmarried sexually active young women in Ethiopia to 55% in 2016, only 4% used condoms, ^{5,
8} indicating that they are not dually protected and thus remain at an increased risk of HIV infection. Nevertheless, despite the ranges of dual protection options, little is known about correlates and effects of knowledge, motivation and behavioral skills in predicting safer sexual dual protection behaviors, such as abstinence and dual protection use based on theoretical models for guiding the design of targeted interventions to promote a range of safer sexual dual protection behaviors for youths.

Theoretical perspectives

Various behavioral theories have been used to understand HIV risk behaviors and promote safer sexual behaviors across populations at-risk worldwide. Of these, the information-motivation-behavioral skills model ^{8,
11–
14} is one that has been widely used and received considerable empirical support in terms of its comprehensiveness, specification of relationships, and ease of translation into empirically-based targeted interventions for particular populations. ^{15,
16} The IMB model asserts that HIV prevention information, motivation, and behavioral skills are fundamental determinants of HIVpreventive behaviors. ^{12–
14} The IMB model specifies that information and motivation work largely through behavioral skills to influence HIV-preventive behaviors. The model also assumes that information and motivation may have a direct effect on behavior when complicated behavioral skills are not necessary for practice, such as abstinence, as opposed to using condoms by young women. ^{12–
14}

The IMB model’s constructs are also regarded as highly generalizable determinants of sexual health behaviors across diverse populations and behaviors of interst. ^{15–
17} Within the model, however, it is asserted that specific information, motivation, and behavioral skills contents should be most relevant to a specific preventive behavior (abstinence or condom use). According to the IMB model, specification of information, motivation, and behavioral skills content most relevant to a specific behavior (abstinence or condom use) and identification of the IMB model’s constructs that most strongly influence the practice of such behavior are crucial for designing empirically targeted interventions for a particular population. ^{8,
12–
14,
17,
18} However, despite the recommendation for its application to a range of sexual health behaviors across populations, there is limited research using the IMB model for understanding and predicting safer sexual dual-protection behaviors, such as abstinence and dual protection use, among youth at risk of STI/HIV and unwanted pregnancy. Therefore, this study aimed to examine the effects of IMB model in predicting safer sexual dual protection behaviors such as abstinence and dual protection use among female university students in Ethiopia and to use the findings for designing targeted interventions to promote safer sexual dual protection behaviors for this population.

In applying the IMB model to predict primary sexual abstinence, we hypothesized that individual’s levels of safer sexual dual protection information, motivation, and behavioral skills relevant to abstinence behavior will determine sexual abstinence among unmarried youth. Specifically, having specific information about risks of HIV/pregnancy and the benefits of abstinence, motivation to practice abstinence (attitudes toward abstinence and social norms about abstinence), and behavioral skills required for abstinence (perceived ability to refuse sex and self-efficacy for abstinence) will directly determine primary sexual abstinence. Information and motivation may also affect behavioral skills, indirectly affecting primary sexual abstinence.

Similarly, in applying the IMB model to predict dual protection use, we also hypothesize that individual’s levels safer sexual dual-protection information, motivation, and behavioral skills relevant to dual protection behaviors will predict dual-protection use among sexually active students. Specifically, having specific information (knowledge about risk of HIV/pregnancy and benefits of dual protection use (either consistent condom use alone or dual methods use), motivation to practice dual protection behaviors (attitudes toward dual protection use and social norms about dual protection use), and behavioral skills for using dual protection (ability to negotiate with partners and self-efficacy for using condoms) will determine dual protection use among young women. In addition, information and motivation also work through behavioral skill to affect dual protection use indirectly, which means that behavioral skills can partially mediate the effects of information and motivation on dual protection use. Finally, there is covariance between information and motivation in accordance with the model

Methods Study setting and period

This study was conducted at Mattu University in Ethiopia. Mattu University is a newly established third-generation public university in the country. It has two campuses: Mattu main campus, located at 551 km southwest of Addis Ababa, and Bedele campus, located at 431 km southwest of Addis Ababa. This study was conducted between 1 April and 20 December2023.

Study design

A cross-sectional survey was used to assess student’s baseline levelsof information, motivation, behavioral skills, and risky and safer sexual behaviors, and identify deficits in information, motivation, and behavioral skills associated with risky sexual practices in this population.

Participants

The source populations were all female university students attending regular programs in the two campuses of Mattu University. The study population consisted of randomly selected female students from the source populations during the study period.

Inclusion and exclusion criterion

The inclusion criterion was that being unmarried female students, attending in non-health programs in 2 ^nd and 3 ^rd year levels, and willing to participate and provide informed consent. Whereas, married female students, attending health programs in 1 ^st and 4 ^th year levels, and those who were critically ill were excluded. The reasons for excluding health programs was to make the participants comparable at baseline, assuming that students in health programs might have greater knowledge about HIV risk and prevention than students in non-health programs. The reasons for excluding 1 ^st and 4 ^th year students was because the time of entry for freshmen is not fixed in the country and students in 4 ^th year and above are likely to be out of campus for apparentship programs, so that it may be difficult to get them for the study.

Sample size and its determination

To obtain a sufficient number of participants for numerical analysis, the sample size for the study was calculated for different objectives, and the largest size was taken as the final sample size.

The sample size for the intervention study was determined using the formula for two proportion comparisons based on the 2016 EDHS data for the proportion of young women reporting condom use at their last sex (p = 0.24), and the anticipated increase in the percentage of dual protection use at 6 months post-intervention to 44% (P2 = 0.44), considering an allowed margin of error of 5% (d =0.05), with a 95% CI and a power of 90% (1- β) to detect a 20% difference in proportions between the two groups (Δ = 0.20), yielding a total sample size of N = 1,050. n = 2 ( z α / 2 + z 1 − β ) 2 ( μ 1 − μ 2 ) 2 δ = 2 ( 1.96 + 1.28 ) 2 ( ∆ δ ) 2 = 2 ( 10.51 ) δ 2 = 21 ( 0.20 ) 2 = 21 0.04 = 525 × 2 = 1050

Thus, since 1,050 was the largest sample size calculated, it was taken as the final sample size to be used for all objectives, including this study. However, out of the total planned numbers (N= 1,050) participants, a total of 1,020 participants have accutually responded to the questionnaires in this survey, making a response rate of 97.1%. Of the 1020 participants, about half (n ₁=502) participants were in Mattu campus (latter assigned to the intervention group) and the other half (n ₂=518) participants were in Bedele campus (served as the control group).

Sampling technique

A multistage sampling technique was used to recruit participants from two campuses of Mattu University. First, three non-health colleges from each campus were selected using stratified sampling. Then; two departments from each college were selected using random sampling. Finally, two classrooms in 2 ^nd and 3 ^rd year levels were selected from each department, in which all female students who fulfilled the inclusion criteria were invited to participate in the study.

Variables

A/ Dependent variables: The dependent variables are safer sexual behaviors such as: 1.

Primary sexual abstinence

Dual protection use (either consistent condom use aloneor using dual methods (condoms plus other contraceptive method) at last sex in past 12 months

B/Independent variables: The independent variables are the constructs of the IMB model

Information (knowledge) of HIV risk reduction/safer sexual dual protection behaviors with abstinence and dual protection use (consistent condom use/dual method use).

Motivation (attitude) to practice abstinence and dual protection use (consistent condom use/dual method use)

Behavioral skills (self-efficacy) for practicing abstinence, and dual protection use (consistent condom use/dual method use)

C/Control variables: The control variables are the underlying social demographic factors (eg., gender, age, ethnicity, religion and others)

Measurement

To assess the levels of HIVrisk reduction/dual protection information, motivation, behavioral skills, and behaviors, a validated measure of the IMB model of HIV prevention behaviors was adopted from previous research. ^{8,
12,
15–
17,
19}

A/Measures of Information

Levels of HIV risk reduction and dual protection information were measured with 12 items, using T/F responses. i) Knowledge about HIV risk and prevention was assessed with 8 items, such as (1) “HIV can be transmitted through sexual intercourse”; 2) “Abstinence is the most effective way of avoiding risk of STI/HIV”; or 3) “Consistent condom use is an effective method of preventing STI/HIV". ii) Knowledge about safer sexual dual protection behaviors was assessed with 4 items, such as (1) “Abstinence is the best way to avoid the risk of HIV/STI and pregnancy for unmarried youth”; (2) “Consistent condom use prevents HIV/STI and pregnancy, providing dual protection against both”; and (3) “Dual methods use is options for dual protection against both HIV/STI and pregnancy simultaneously".

B/Measures of motivation

Motivation to practice safer sexual dual protection behaviours were measured separately for abstinence and for dual protection use, using behavior-specific items for each.

i/Motivation to practice abstinence was assessed based on: a) Attitude towards abstinence with 2-items: (eg., 1) “the belief that abstinence can prevent pregnancy and HIV”, and 2) “the belief that abstinence can foster attainment of career goals”, b) Social norms regarding premarital sex was assessed with 2 items: (eg., 1) "Most people who are important to me" think that I should abstain from sex”) and 2) “Having sex before marriage is against my religion”.

ii/Motivation to practice dual protection use was assessed on the basis of a) attitudes toward condom use with 4 items: (e.g., 1) “condoms do not interfere with sexual enjoyment,” 2) “consistent condom use is effective for preventing HIV/STI and pregnancy”, and 3) “condoms should always be used, even if a woman is using hormonal contraception. b) Social norms about condom use with two items: (1) “The belief that condom use may show my partner that I do not love/trust him” and 2) “If I ask my partner to use condoms, he would suspect me that I have another partner and that he would become angry at me”.

C/Measures of behavioral skills

Behavioral skills for safer sexual dual protection behaviours were measured separately for abstinence and dual protection use, using behavior-specific items: i/ Behavioral skills for abstinence were assessed with 2 items: a) Perceived ability to refuse sex (eg., “How confident are you that you are able to refuse sex?”), b) Self-efficacy for abstinence (eg., “How effectively could you maintain abstinence, even if you are pressured by friends?”. ii/Behavioral skills for dual protection use were assessed with 4 items: a) perceived ability to negotiate with partner (e.g., 1) “How confident are you in your ability to negotiate with partners to use condoms consistently?”, and 2) “How confident are you in using condoms consistently even if you are using hormonal contraception?”). b) Self-efficacy in using condoms (e.g., 1) “If your steady partner doesn’t want to use a condom, how certain are you that you could convince him to use condoms?”; 2) “If you are already using another method of contraception for pregnancy, how certain are you that you could always use condoms for reducing the risk of HIV?

D/Measures of safer sexual dual protection behaviors

Safer sexual dual protection practices were measured with self-reported sexual practices and protection method used, which includes: a)

Primary sexual abstinence was assessed by asking all participants to rate on “ever had sexual intercourse?”, with response options (Yes/No).

Secondary sexual abstinence was assessed among sexually experienced participantsto rate on “current sexual activity in the past 12 months” with response options (Yes/No)

Condom use at last sex was assessed among currently sexually active to rate on “condom use at last sex in the past 12 months”, with response options (Yes/No).

Consistent condom use was assessed among condom users to rate on their frequency of condom use during intercourse in the past 12 months, with response option on scale ranged from Never (1) to “sometimes” (2) to “always” (3).

Dual protection use was assessed by asking“Did you use dual protection method (either consistent use of condoms alone or two methods approach (condoms plus other contraceptive method) at last sex in the past 12 months”?, with a response option (yes/no).

f )

Dual -method use was assessed by asking “Did you use condoms plus other contraceptive methods in the past 12 months” with responses (yes or no).

Operational definition: a)

Unsafe sex practices: refer to sexual behaviors that increase the risk of STIs/HIV, and unintended pregnancies. These practices may include: Early sexual debut, Not using condoms or having multiple sexual partners:

Dual protection is defined as simultaneous protection from pregnancy and STI/HIV infection through either the consistent use of a condom alone, or the use of two methods (condom plus other contraceptive methods), or abstinence.

Consistent condom use is defined as always using a condom in every sex

Dual-method useis defined as the simultaneous use of a condom for STI/HIV prevention and hormonal methods for pregnancy prevention in the last sex.

Knowledge of safer sexual dual protection behaviors was measured with 4 items, using T/F response. If the student answered the mean score and above, she was considered having high knowledge and low knowledge otherwise.

f )

Attitudes toward abstinence were assessed with 2 items, using 5 pionts Likert scale. If the student answered the mean score and above, she was considered having positive attitude and negative attitude otherwise

Social norms about abstinence were assessed with two items, using 5 pionts Likert scale. If the female student answered the mean score and above, she was considered having supportive norms and unsupportive norms otherwise.

Attitudes toward dual protection use were assessed with 4 items, using 5 pionts Likert scale. If the student answered the mean score and above, she was considered having positive attitude and negative attitude otherwise

Social norms about dual protection use were assessed with 2 items, using 5 pionts Likert scale. If the student answered the mean score and above, she was considered having supportive norms and unsupportive norms otherwise.

Perceived ability/self-efficacy for abstinence were assessed with two items, using 5 pionts Likert scale. If the student answered the mean score and above, she was considered having high self-efficacy and low perceived self-efficacy otherwise.

Perceived ability and self-efficacy for using dual protection were assessed with 4 items, using 5 pionts Likert scale. If the student answered the mean score and above, she was considered having high self-efficacy and low perceived self-efficacy otherwise.

Data collection instruments

For the purpose of this data collection, an anonymous self-administered questionnaire was developed from a validated questionnaire of behavioral survey including UNAIDS behavioral surveillance survey (BSS) questionnaire (FHI 2000) and previous studies for testing the IMB model of HIV preventive behaviors (Misovich, Fisher, & Fisher,1994). In these questionnaires, the questions are closed-ended responses. The questionnaire is organized into three sections following a logical sequence. The first part involves the socio-demographic variables such as age, religion, ethnicity, residence, academic level of students. The second part includes questions on levels of IMB model’s safer sexual HIV-risk reduction/dual protection information, motivation and behavioral skills determinants of sexual behaviors. The third part includes questions on students’ sexual behavior including self-reported sexual initiation/pre-marital sex, recent sexual activity, and numbers of sexual partners, consistent condom use in the last 12 months and dual protection use at last sex in the last 12 months.

Data collection method and procedure

Given the confidential nature of the information and level of education, it is appropriate to use self-administered questionnaires in order to make respondents to be more comfortable and will probably give more candid answers. The data collection has occured at baseline and at 6-months post-intervention. The questionnaires were administered by a research team that had a BSc, but not staff of the same university, and trained to help students complete the questionnaire. The role of the supervisors was to explain the purpose of the study, to tell them that completing the questionnaire is voluntary and that responses would be anonymous, and to obtain informed consent prior to participation; to give any clarification on questions whenever it is necessary; and to collect back the completed questionnaires form the participants at the end.

Data quality assurance

To ensure reliability of the quantitative study, standardized questionnaires for measuring sexual behaviors and contraceptive use were adopted from previously validated scales of measurement. Measures were administered at a single point in time within the university to minimize contamination from discussion of measures among students. In order to minimize socially desirable answers, in addition to the use of a self-administered questionnaire, the participants were informed about the objective of the study and the importance of their answers by giving emphasis to the value of honest answers for improving health of youth.

Data analysis

The collected data were cleaned, edited, and analyzed using SPSS version 23. Descriptive statistics were used to summarize participants’ sociodemographic characteristics and levels of information, motivation, behavioral skills, and behavior. To examine correlates and effects of the IMB model in predicting primary sexual abstinence and dual protection use, bivariate and multivariate analyses were performed using SEM with AMOS 23. ^{20,
21} To test the model fit to the observed data, we used various fit indices provided by AMOS, including the chi-square test value (p>0.05), the comparative fit index value (CFI>0.90), and the root mean square error of approximation value (RMSEA<.05), all indicating a better fit. Estimatation of the parameters for the measurement model ( confirmatory factor analysis) and the structural model ( path analysis) was accomplished with maximum likelihood estimate in AMOS. Confirmatory factor analysis was used to examine the relationships between the observed variables and latent constructs in the model (i.e., to test the reliability of the measurement model). Path analysis was used to examine the relationships between the information-motivation-behavioral skills (i.e. the structural model) and identify predictors of primary sexual abstinence and dual protection use.

Ethical consideration and informed consent to participate

Ethical approval was obtained from the Institutional Review Board (IRB) of Jimma University with reference No: JUHI/IRB 329/23, date 20/03/2023, which states that “the research protocol meets the ethical and scientific standards outlined in national and international guidelines” in accordance with the Declaration of Helsinki. A formal letter of support was obtained from Mattu University to their respective colleges requesting to cooperate with researchers during the study. Informed consent was obtained from all the participants based on “ written consent form” prepared for this purpose and to be signed by all the participants before participating. As all university-level students are older than 18 years, they are believed to be capable of providing informed consent. In addition, the law in Ethiopia does not require such a group of young people to be accompanied by parents or guardians to provide consent to their behaviors, stating that “Assent will be sought from a study participant under the age of 18 years old” (NRERG 7th ed: Art 6.15). Before start, the study’s objective was explained to the participants and voluntary participation was allowed by explaining their full rights to participate or not, and to withdraw their consent at any stage if they wish without giving any reason or no penalty. Furthermore, the participants were also assured that the questionnaire was anonymous and that their responses were fully confidential. Finally, after making sure that they have read the consent form and understood the objectives of the study and their full rights to decide to participate, all the participants were asked to sign on the consent form and then they have signed the written consent form before participating and returned it to the supervisors, which is then filed and documented safely with the principal author.

Results Descriptive statistics

i/Sociodemographic characteristics and sexual behaviors of the participants

As shown in Table 1, of the 1,020 participants, 820 (80.4%) were aged 20–24 years, with a mean age of 20.77 years (SD = 1.146). Regarding ethnicity, 526 (51.6%) students were Oromos, followed by Amhara (356; 34.9%). By religion, 442 (43.3%) were Orthodox, 364 (35.7%) were Protestants, 180 (17.6%) were Muslims, and 34 (3.3%) were Waaqeffata. With regard to sexual behaviors, 624 (61.2%) reported never having sexual intercourse, whereas 396 (38.8%) had ever had sexual intercourse. Of these, only 20.5% used dual protection in the past 12 months, with 22 (5.9%) using condoms alone and 54 (14.6%) using a two-method approach (see Table 1).

Table 1. Percentage distribution of the study participants by demographic characteristics and sexual behaviors (n=1020).

Demographic characteristics	Category	Number	%
Age group	15-19	170	16.7
	20-24	820	80.4
	25-29	30	2.9
Ethnic groups	Oromoo	526	51.6
	Amhara	356	34.9
	Sidama	111	10.9
	Others *	27	2.6
Religious group	Waaqeffannaa	34	3.3
	Protistant	364	35.7
	Ortodox	442	43.3
	Musilims	180	17.6
Place of residence	Urban	466	45.7
Place of residence	Rural	554	54.3
Sexual behaviors and dual protection use
Ever had sexual intercourse (n=1,020)	Yes	396	38.8
Ever had sexual intercourse (n=1,020)	No	624	61.2
Sexual activity in the past 12 months (n=396)	Yes	370	93.4
Sexual activity in the past 12 months (n=396)	No	26	6.6
Condom use at last sex in the past 12 months (n=370)	Yes	175	47.3
Condom use at last sex in the past 12 months (n=370)	No	195	52.7
Dual protection use for preventing both STI/HIV and pregnancy in the past 12 months	Yes	76	20.5
	No	294	79.5
Types of dual protection methods used (consistent condom use alone or dual methods use)	Consistent condom use	22	5.9
	Two methods use	54	14.6

Represents those other ethnic groups including Gorage, Walayitta, Tigre and Hadiya.

ii/Levels of information, motivation and behavioral skills of HIV risk-reduction/dual protection behaviors among the study participants

As presented in Table 2, regarding levels of information on HIV risk reduction and dual protection, about two-thirds, 679 (66.6%) of participants have high knowledge about HIV risk and prevention, whereas only half, 522 (51.2%) have high knowledge of safer sexual dual protection behaviors. Concerning motivation to practice abstinence, fewer than half, 474 (46.5%) of participants have a positive attitude toward abstinence and 442 (43.3%) have supportive norms about abstinence. With regard to motivation to practice dual protection among sexually active participants (n=396), only 173 (43.7%) have a positive attitude toward dual protection and 157 (39.6%) have supportive social norms for dual protection. Regarding behavioral skills for sexual abstinence, less than half, 493 (48.3%) of participants have high self-efficacy for practing abstinence. Whereas conserning behavioral skills for dual protection use among sexually active participants (n=396), less than half, 195 (49.2 %) of them have high self-efficacy for dual protection (See Table 2).

Table 2. Summary statistics of levels of HIV risk-reduction/dual protection information, motivation, behavioral skills among female university students and reliability scales (n=1020).

IMB variables category		n	%	Mean	SD	α
Information
Knowledge about HIV risk and prevention	High	679	66.6	6.18	1.395	.56.
Knowledge about HIV risk and prevention	Low	341	33.4	6.18	1.395	.56.
Knowledge of safer sexual dual protection behaviors	High	522	51.2	2.79	1.023	.66
Knowledge of safer sexual dual protection behaviors	Low	498	48.8	2.79	1.023	.66
Motivation
Attitudes toward abstinence	Positive	474	46.5	3.3	1.84	.97
Attitudes toward abstinence	Negative	546	53.5	3.3	1.84	.97
Social norms about abstinence	Supportive	442	43.3	3.44	1.48	.89.
Social norms about abstinence	Unsupportive	578	56.7	3.44	1.48	.89.
Attitudes toward dual protection use	Positive	173	43.7	3.63	1.583	.91.
Attitudes toward dual protection use	Negative	223	56.3	3.63	1.583	.91.
Social norms about dual protection use	Supportive	157	39.6	3.62	1.576	.89.
Social norms about dual protection use	Unsupportive	239	60.4	3.62	1.576	.89.
Behavioral skills
Self-efficacy for abstinence	High	493	48.3	3.57	1.58	.91
Self-efficacy for abstinence	Low	527	51.7	3.57	1.58	.91
Self-efficacy for using dual protection	High	195	49.2	3.12	1.616	.89
Self-efficacy for using dual protection	Low	201	50.8	3.12	1.616	.89

Bivariate correlations analysis

i/Correlation analysis among indicators of IMB model and primary sexual abstinence

As shown in Table 3, the results of Spearman’s correlations analysis showed that the informational indicators of knowledge about HIV risk and prevention and knowledge of safer sexual dual protection behaviors were strongly correlated (r =.593, p<.001). In addition, the informational indicators of knowledge about safer sexual dual protection behaviors was strongly correlated with the motivational indicators of attitudes toward abstinence (r =.073, p<.05) and social norms about abstinence (r =.076, p<.05), but not correlated with behavioral skills indicators of self-efficacy for abstinence (r =.004, p>.05). Further, the motivational indicators of attitude toward abstinence was strongly correlated with social norms a bout abstinence (r =.711, p<.001) and with behavioral skills indicators of self-efficacy for abstinence(r=.454, p<.001). Finally, in the bivariate analysis, the results indicated that primary sexual abstinence was strongly correlated with knowledge about HIV risk and prevention(r =.110, p<.01); knowledge of safer sexual dual protection behaviors (r =.111, p<.01), attitude towards abstinence (r = 0.474, p<.01), social norms about abstinence (r = 0.360, p<.01), and self-efficacy for abstinence (r = 0.390, p < 0.01) (see Table 3).

Table 3. Correlations among indicators of information, motivation and behavioral skills and primary sexual abstinence among female university students (n=1020).

	Spearman’s Correlations (r)
	Indicators of IMB model construct	1	2	3	4	5	6
1	Knowledge about HIV risk reduction	1
2	Knowledge about safer sexual dual protection behaviors	.593 ^**	1
3	At Attitude toward sexual abstinence	.051	.073 ^*	1
4	Social norms about abstinence	.051	.076 ^*	.711 ^**	1
5	Self-efficacy to maintain abstinence	-.016	.004	.454 ^**	.365 ^**	1		^*
6	Primary sexual abstinence	.110 ^**	.111 ^**	.474 ^**	.360 ^**	.390 ^**	1

The correlation is significant at the 0.01 level (2-tailed).

Correlations are significant at the 0.05 level (2-tailed

ii/Correlations analysis among indicators of the IMB model and dual protection use

As shown in Table 4, among sexually active participants, the results of Spearman’s correlations analysis also showed that the informational indicators of knowledge about HIV risk and prevention and knowledge of safer sexual dual protection behaviors were strongly correlated (r =.722, p<.001). In addition, the informational indicators of knowledge about HIV risk and prevention was strongly correlated with the motivational indicators of attitudes toward dual protection use (r =.597, p<.001) and social norms about dual protection use (r =.547, p<.001) and also with behavioral skill indicators of self-efficacy for using dual protection (r = .508, p < .001). Similarlly, knowledge of safer sexual dual protection behaviors was strongly correlated with the motivational indicators of attitudes towards dual protection use (r =.542, p<.001) and social norms about dual protection use (r =.476, p<.001) as well as with behavioral skill indicators of self-efficacy for using condoms /dual protection (r = .471, p < .001). In addition, the motivational indicators of attitudes toward dual protection use was strongly correlated with social norms about dual protection use (r =.910, p < .001) and also with the behavioral skill indicatprs of self-efficacy for dual protection (r =.637, p < .001). Finally, in the bivariate analysis, the results showed that dual protection use was significantly correlated with knowledge about HIV risk reduction (r =.332, p < 0.001) and knowledge of safer sexual dual protection behaviors (r =.337, p < 0.001), attitudes toward dual protection use (r = .477, p < 0.05), social norms about dual protection use (r = .372, p < 0.001), and percirved self-efficacy for using dual protection (r =.501, p < 0.001) (see Table 4).

Table 4. Correlational analysis among constructs of the IMB model and dual protection use among sexually active female university students (n=396).

Spearman's Correlations(r)
Indicators of IMB model construct		1	2	3	4	5	6
1	Knowledge about HIV risk reduction	1	.	.	.
2	Knowledge about SSDP behaviors	.722 ^**	1	.			*
3	Attitude towards dual protection use	.597 ^**	.542 ^**	1	.	.
4	Social norms about dual protection use	.547 ^**	.476 ^**	.910 ^**	1	. ^*
5	Self-efficacy for dual protection use	.508 ^**	.471 ^**	.637 ^**	.565 ^**	1
6	Practice of Dual protection use	.332 ^**	.337 ^**	.477 ^**	.372 ^**	.501 ^**	1

Key:

Correlation is significant at the 0.01 level (2-tailed)

Multivariate analysis

i/SEM analysis of the IMB model predictors of primary sexual abstinence

The test of the model's fit to assess the extent to which the data conformed to the model revealed that the chi-square statistic (X2 =11.399, p =.220), a comparative fit index (CFI =.99), and a root mean square error of approximation (RMSEA =.019), all indicating the model fit to the data was acceptable.

Confirmatory factor analysis (CFA)

As presented in Table 5, the maximum likelihood estimates of the measurement model for primary sexual abstinence indicate that the entire factors loadings estimated for constructs of IMB model were strong and statistically reliable. Specifically, the factor loadings of 0.89 for knowledge of HIV risk and prevention and 0.82 for knowledge about safer sexual dual protection behaviors on the information construct suggest their strong and significant reliability. In addition, the factor loadings of .93 for attitudes toward abstinence and.91 for socialnorms about abstinence on the motivation construct also suggest strong reliability. Finally, the factor loadings of.88 for perceived ability to refuse sex and.93 for self-efficacy in practicing abstinence on the behavioral skill showed statistically reliable (see Table 5).

Table 5. Maximum likelihood estimates of the measurement model parameters for the IMB model of primary sexual abstinence among female university students (n=1020).

Variables			Estimate	S.E.	t.value	P. value	Standardized factor loading (B)
Information	-->	Knowledge of HIV risk and prevention	1.268	.176	7.20	***	.98
	-->	Knowledge of SSDP behaviors	1.000				.81
Motivation	-->	Attitude toward sexual abstinence	1.020	.033	31.15	***	.93
	-->	Social norms about sexual abstinence	1.000				.91
Behavioral skills	-->	Percieved ability to refuse sex	.912	.038	23.69	***	.86
	-->	Self-efficacy for abstinence	1.000				.93

Indicators with loadings of 1.00 set the metric of the construct.

***

p < 0.001; SSDP = Safer sexual dual protection.

Path analysis

As shown in Table 6 and Figure 1, results of path analysis coefficient in predicting primary sexual abstinence indicated that information (β = 0.11, p < 0.001), motivation (β = 0.34, p < 0.001) and behavioral skills (β = 0.24, p < 0.001) were significantly associated with primary sexual abstinence. Overall, the model's constructs accounted for approximately 28% of the variation in primary sexual abstinence. Concerning the mediation effect analysis, the impacts of information (β = 0.11, p < 0.001) and motivation (β = 0.522, p < 0.001) on behavioral skills were positive and statistically significant. Both information and motivation constructs accounted for 27% of the variation in behavioral skills for abstinence (See Table 6 and Figure 1).

Table 6. Maximum likelihood estimates of the structural model parameters for the IMB model of primary sexual abstinence among female university students (n=1,020).

Parameters			Estimate	S.E.	t.vale	P. value	Standardized path coefficient	R2
Information	-->	Behavioralskills	.147	.036	4.115	***	11	.27
Motivation	-->	Behavioralskills	.521	.033	15.995	***	.52	.27
Information	-->	Primary sexual abstinence	.147	.036	4.115	***	.11	.28
Motivation	-->	Primary sexual abstinence	.368	.037	9.941	***	.34
Behavioral skills	-->	Primary sexual abstinence	.254	.037	6.782	***	.24
Information	<-->	Motivation	.013	.006	2.149	.032	.07

R2 represents the proportion of explained variance in the dependent variable that is accounted for by the independent variable.

***

p < 0.001.

Figure 1. Significant regression paths in the IMB model predicting primary sexual abstinence among female university students (n=1020).

Source: Adopted from the IMB model of HIV prevention behavior. ^{6–
8}

Note: Oval represents latent constructs, and rectangles represent observable variables.

Single-headed arrows represent regression paths, and double-headed arrows represent correlation

Regression coefficients and covariance estimates are standardized.

ii/SEM analysis of the IMB model predictors of dual protection use

The test of model fit to assess the extent to which the data conformed to the model specification revealed that the chi-square statistic (X2 =11.399, P =.220), a comparative fit index (CFI =.99), and a root mean square error of approximation (RMSEA =.048), all indicating the model fit to the data was acceptable.

Confirmatory factor analysis (CFA)

As presented in Table 7, the maximum likelihood estimates of the measurement model showed that all factor loadings estimated for IMB model were strong and statistically reliable. Specifically, the factor loadings of 0.89 for knowledge about HIV risk and prevention and 0.82 for knowledge about safer sexual dual protection behaviors on the information construct suggest strong and significant reliability. In addition, the factor loadings of 1.1 for attitudes toward dual protection use and 0.89 for social norms about dual protection use on the motivation construct also suggest their strong and significant reliability of relationship. Finally, the factor loadings of 1.1 for perceived ability to negotiate safer sex and 0.86 for self-efficacy in using dual protection on the behavioral skill demonstrated their strong and reliabile relations (p < 0.001) (see Table 7).

Table 7. Maximum likelihood estimates of the measurement model parametersfor the IMB model of dual protection use among sexually active female university students (n=396).

Variables			Estimate	S.E.	t	P	Standardized factor loading (B)
Information	-->	Knowledge of HIV risk & prevention	1.094	.070	15.681	***	.89
Information	-->	Knowledge of SSDP behaviors	1.000				.82
Motivation	-->	Attitude toward dual protection use	1.155	.038	30.643	***	1.1
Motivation	-->	Social norms about dual protection use	1.000				.89
Behavioral skills	-->	Percieved ability to negotiate safer sex	1.000				1.1
Behavioral skills	-->	Self-efficacy for using dual protection	.943	.039	24.154	***	.68

Indicators with factor loadings of 1.000 set the metric of the construct.

***

p< 0001.

SSDP = Safer sexual dual protection.

Path analysis

As shown in Table 8 and Figure 2, the results of path analysis coefficient in predicting dual protection use indicated that information (β = 0.27, p < .001) and motivation (β = 0.40, p < .001) were positively and significantly associated with SSDP behavioral skills and that behavioral skills, in turn, were reliably associated with dual protection use (β = 0.27, p < 0.001). In addition, the direct effect of motivation on dual protection use was strong and statistically significant (β = 0.29, p < 0.001), whereas, the direct effect of information on dual protection use was moderate (β = 0.04, p < 0.05). Overall, the IMB model constructs accounted for approximately 27.4% of the variation in dual-protection use, and also both the information and motivation constructs explained approximately 37% of the variation in behavioral skills (see Table 8 and Figure 2).

Table 8. Maximum likelihood estimates of the structural parameters for the IMB model of dual protection use among sexually active female university students (n=396).

Parameters			Estimate	S.E.	t.	P	Standardized path coefficient	R2
Information	-->	Behavioral skills	.356	.074	4.820	***	.27	. 37
Motivation	-->	Behavioral skills	.495	.062	7.945	***	.40	. 37
Information	-->	Dual protection use (DPU)	.039	.060	1.351	.025	.04	.27
Motivation	-->	Dual protection use (DPU)	.270	.222	2.443	***	.29
Behavioral skills	-->	Dual protection use (DPU)	.199	.044	4.414	***	.27
Information	<-->	Motivation	.116	.013	9.001	***	.656

R2 represents the explained variance in the dependent variable that is accounted for by the independent variable.

***

= p < 0.001.

Figure 2. Significant regression paths in the IMB model predicting dual protection use among sexually active female university students (n=396).

Source: Adopted from the IMB model of HIV prevention behavior. ^{6–
8}

Note: Oval represents latent constructs, and rectangles represent observable variables.

Single-headed arrows represent regression paths, & double-headed arrows represent correlations.

Regression coefficients and covariance estimates are standardized.

Discussion

The current study utilized the IMB model to examine the effects of information, motivation and behavioral skills on safer sexual dual protection behaviors with primary sexual abstinence and dual protection use among female university students in Ethiopia. The results indicated that significant proportion of female university students have engaged in premarital sexual activity, with low use of condom/dual protection that can increase their risks and vulnerability to STI/HIV infections and unwanted pregnancy. The findings of this study is similar with the results of studies among Wolaita Sodo University students (56.7%) in Ethiopia and the United States (66%). ^{9,
22} However, our finding is lower than those of studies at Jimma University (73%) and Mattu secondary school students in Ethiopia (77.3%) reported primary sexual abstinence. ^{10,
23} The difference may be due to the difference in the study area and time period.

In addition, although over two-third of the participants have higher knowledge about HIV risk and prevention, majority of them still have a significant knowledge gaps regarding safer sexual dual protection behaviors, have a negative attitude towards abstinence and dual protection use, and lower self-efficacy for practicing abstinence and for using dual protection in this study despite the fact that knowledge of HIV risk and safer sexual behaviors is crucial to enable people to avoid HIV infection, especially for youth, who are often at greater risk because they may have shorter relationships and thus more partners or may engage in other risky behaviours. In addition, attitudes and skills for practicing safer sex can affect one’s practice of sexual behaviors. ^{24,
25} However, the findings of this study is consistent with the results of studies conducted among WolaitaSodo University students and Mattu secondary school students in Ethiopia, where many students had unfavorable attitude towards safer sex and inadequate skills for practicing abstinence. ^{9,
23}

In this study, the results of bivariate correlation analysis among indicators of IMB model and primary sexual abstinence showed knowledge of safer sexual dual protection behaviors, attitude toward abstinence , and perceived self-efficacy for abstinence were strongly correlated with the practice of primary sexual abstinence among participants. This finding is consistent with the results of previous studies on the determinants of sexual abstinence amongmeddawalabu university students, in Ethiopia ^{26–
28} and among high school students in the United States ²² which indicated that having a positive attitude, social support and higher self-efficacy were correlated with sexual abstinence.

Similarly, the results of bivariate correlational analysis between indicators of IMB model and dual protection use among sexually active participants indicated that knowledge of HIV risk reduction/safer sexual dual protection behaviors, attitude towards dual protection use, social norms about dual protection and perceived self-efficacy in using dual protection were strongly correlated with reporting dual protection use among sexually active young women in this study.

In examination of the theorized effects of IMB model in predicting primary sexual abstinence, all information, motivation, and behavioral skills were directly and significantly predictive of primary sexual abstinence in this study, supporting the IMB model’sassumptions and consistent with the results of the model tests in previous resreach. ^{16,
17,
29} Overall, the full model's constructs accounted for about one-third of the variance in primary sexual abstinence in this study. This finding is consistent with the findings of previous studies with the model, in which the model’s constructs accounted for about one-third to one-half of the variance in condom use. ^{16,
17,
29–
33} In addition, analysis of the mediation effects in the model showed that the impacts of information and motivation on behavioral skills were positive and statistically significant. Both information and motivation constructs accounted for about one-third of the variance in behavioral skills needed for abstinence in this study. These findings are also in line with the model’s assumption that information and motivation may have a direct effect on behavior when complicated skills are not needed for practice, such asabstinence. ^{16,
17,
29–
33}

In the SEM analysis of the IMB model in predicting dual protection use among sexually active participants, the results showed that information and motivation were positively and significantly associated with dual protection behavioral skills, and that dual protection behavioral skill, in turn, were reliably associated with dual protection use. This finding is consistent with those of previous studies testing the IMB model’s assumption that information and motivation are significantly associated with behavioral skills and that behavioral skills, in turn, are associated with HIV preventive behavior (condom use). ^{13,
17,
18,
20} The model constructs accounted for about 27.4% of the variation in dual protection use in this study. Thisisconsistent with those of previous studiesin which the model’s constructs accounted for one-third to one-half of the variance in condo use. ^{16–
19,
29,
34}

Overall, the findings of this study confirmed the generalizability and utility of the IMB model for understanding a range of safer sexual behaviors, including abstinence and dual protection use with diverse populations as it is recommended in literatures. ^{16,
17,
29} The results also support the IMB model as a paradigm for explaining and predicting sexual health behavior of youth.

Limitations

This study has several limitations. First, the study focused only on female students for the purpose of examining predictors of dual protection use to prevent both STI/HIV and unwanted pregnancy, excluding male students for priority concern. Second, the data based on self-reported sexual behaviors may lead to bias arising from socially desirable responses, because sex is a sensitive topic in Ethiopian culture. However, the use of self adminstared data collection methods and anounmous questioniiares was to reduce such bias. Third, the data from the cross-sectional survey can reveal only the associations between variables at a single point in time; thus, it is recommended that future research should focus on longitudinal studies to test the model.

Conclusions

The current research represents the first attempt to utilize the IMB model for understanding psychological determinants of safer sexual dual protection behaviors among youth in Ethiopia. The findings indicate that a sizable percentage of female university students are engaged in premarital sexual practices with low use of dual protection, while the majority of participants have considerable gaps in knowledge about safer sexual dual protection behaviors, unfavorable attitudes toward abstinence and dual protection use, and lower perceived self-efficacy for practicing abstinence and for using dual protection, all suggesting that sexual health education programs needs to focus on behavior-specific gaps to reduce sexual risks of youths.

Overall, the current study confirm the generality and utility of the IMB model for understanding a range of safer sexual dual protection behavior such as abstinence and dual protection use among youth with different sexual practices in separate model test as recommended in literature. By focusing on the application of the IMB model to predict different types of safer sexual dual protection behavior, such as primary sexual abstinence and dual protection use, with behavior-specific test of the model, this study provides novel insights into the interplay between information, motivation, and behavioral skills in promoting specific safer sexual dual protection behaviors, including abstinence and/or dual protection use, among youths. These insights will not only advance our theoretical understanding of sexual behavior of youth in high HIV burden settings, but also inform the development of comprhensive interventions that address the diverse needs of young people with different sexual experiences. Finally, future IMB model test should focus on a search for possible sex differences in the determinants of safer sexual dual protection behaviors.

Ethical consideration and informed consent to participate

Ethical approval was obtained from the Institutional Review Board (IRB) of Jimma University with reference No: JUHI/IRB 329/23, date 20/03/2023, which states that “the research protocol meets the ethical and scientific standards outlined in national and international guidelines” in accordance with the Declaration of Helsinki. A formal letter of support was obtained from Mattu University to their respective colleges requesting to cooperate with researchers during the study. Informed consent was obtained from all the participants based on “ written consent form” prepared for this purpose and to be signed by all the participants before participating. As all university-level students are older than 18 years, they are believed to be capable of providing informed consent. In addition, the law in Ethiopia does not require such a group of young people to be accompanied by parents or guardians to provide consent to their behaviors, stating that “Assent will be sought from a study participant under the age of 18 years old” (NRERG 7th ed: Art 6.15). Before start, the study’s objective was explained to the participants and voluntary participation was allowed by explaining their full rights to participate or not, and to withdraw their consent at any stage if they wish without giving any reason or no penalty. Furthermore, the participants were also assured that the questionnaire was anonymous and that their responses were fully confidential. Then, after making sure that they have read the consent form and understood the objectives of the study and their full rights to decide to participate, all the participants were asked to sign on the consent form and they have signed the written consent form before participating and returned it to the supervisors, which is then filed and documented safely with the principal author.

Author contributions

All authors listed on the title page have made a substantial, direct, and intellectual contribution to the work in the conceptualization, design, data collection, analysis, or interpretation of data and revising the article and preparation of the manuscript and approved it for publication. All authors read and approved the final manuscript

Data availability statement

Open Science Framework (OSF) repository.|The effects of information-motivation-behavioral skills model in predicting safer sexual dual protection behaviors among female university students: A cross-sectional study, along with the persistent identifies: https://doi.org/10.17605/OSF.IO/SE8M7. ³⁵

The project contains the following underlying data: 1.

SPSS Datasets : consisting of survey responses on participants’ levels of information, motivation, behavioral skills and risky and safer sexual behaviors among female university students.

Supporting files : consisting of Questionaires in English and its transilated version to Afaan Oromo and Amharic language, Consent form for participants and a copy of Ethical approval letter.

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Reporting guidelines

To comply with consensus-based minimum reporting guidelines for observational studies, the current research reporting checklist has followed the STROBE guidelines.

Acknowledgments

We would like to acknowledge Jimma University for financial support and Mattu University for providing this educational opportunity. We wish to acknowledge the data collectors for their support and collaboration throughout the study. Finally, our deepest gratitude goes to the study participants.

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Reviewer response for version 1

Luc

Casey Morgan

1 Referee https://orcid.org/0000-0003-3669-9821 1University of Illinois, Urbana, USA

Competing interests: No competing interests were disclosed.

8 5 2025

2025

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

approve-with-reservations

Great and robust paper on an important topic. Focusing more on structural recommendations is needed to ensure this is ready for journal indexing

Conclusion in abstract - Please offer a more focused conclusion from the findings of the IMB. Is there a specific construct like motivation versus information, for example, that may be worth commenting on?

abstract - you comment on the correlations - but I would spend more time in the results presenting the path analyses.

Introduction - can you comment on the use of the IMB model on your dual use outcome a little more? as well as if it has been used in your study population of young women in college? You said there is "limited" research. Does that mean there is no research? Or are there a few articles? I would include these few articles if so.

Methods - typically I don't see methods with a large section on sample size determination. Up to you if you feel it is necessary to include.

Methods - For how you defined the IMB models, have these definitions been used in other studies?

Discussion - you spend a lot of time discussing the constructs of the SEM as being consistent with previous studies. That is great - but please comment on structural recommendations stemming from this findings. What kind of interventions or policy changes can be made to ensure that certain significant SEM constructs are considered in interventions? Maybe information and motivation are significantly ascoiated with behavioral skills... so what would an effective program/intervention look like that incorporates this? Some research must be published on this.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

HIV epi, IMB model,

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Feyisa

Banti Negero

Population and Family Health, Jimma University College of Public Health and Medical Sciences, Jimma, Oromia, Ethiopia

Competing interests: No conflict of interest

1 7 2025

Author's Response To Reviewers’ Comments

Dear F1000research Editors and Reviewers：

Thank you for your letter and the reviewers' comments concerning our manuscript entitled " The effects of information-motivation-behavioral skills model in predicting safer sexual dual protection behaviors among female university students: A cross-sectional study " These comments are valuable and helpful for revising and improving our manuscript. We have addressed the comments carefully and have made the necessary revisions/corrections, which we hope meet with approval. The main corrections in the manuscript and the responses to the reviewers' comments are as follows：

S.N Reviewers’ comments

1 Abstract: - you comment on the correlations - but I would spend more time in the results presenting the path analyses.

Author’s response :

We appreciate the reviewer’s comments and important suggestions

We fully accepted the comments and used it for revising and re-writing our results as follows:

The results of path analysis in predicting primary sexual abstinence indicated that primary sexual abstinence was directly and significantly predicted by motivation (β = 0.34, p < 0.001), behavioral skills (β = 0.24, p < 0.001) and information (β = 0.11, p < 0.001). In mediation analysis, the impacts of motivation (β = 0.522, p < 0.001) and information (β = 0.11, p < 0.001) on behavioral skills were positive and statistically significant, thus both had indirect effect on primary sexual abstinence through behavioral skills.

Among sexually active participants, the results of path analysis in predicting dual protection use indicated that dual protection use was directly and strongly predicted by motivation (β = 0.29, p < 0.001) and behavioral skills (β = 0.27, p < 0.001), but it was weakly predicted by information (β = 0.04, p < 0.05). In mediation analysis, the impacts of motivation (β = 0.40, p < .001) and information (β = 0.27, p < .001) on behavioral skills were strong and statistically significant, thus both had indirect effect on dual protection use through behavioral skills.

Reviewers’ comments:

Author’s response :

Yes, we have addressed the comments and made the necessary revision as follows:

The findings indicate that the IMB model is useful for identifying important predictors of abstinence and dual protection use among female university students, which has potential implications for designing interventions to improve abstinence and/or dual protection use among youth at risk of STI/HIV and unwanted pregnancy in settings with high HIV burdens.

Though Motivation construct has a stronger effect than information construct, given that both are significantly associated with behavioral skills, and thus have indirect effect on behavior through behavioral skills, it is worth to incorporate all components of the IMB model, including information, motivation and behavioral skills in intervention to promote dual protection behavior for youth.

Reviewers’ comments:

2. Introduction

a/- can you comment on the use of the IMB model on your dual use outcome a little more?

as well as if it has been used in your study population of young women in college?

Author’s Response:

We appreciate the reviewer’s comments and important insights

Yes, we can elaborate more about the use of IMB model in dual protection behaviors.

In the context of this study, dual protection refers to practice of safer sexual behaviors that provide simultaneous protection against both HIV/STI and unwanted pregnancy through abstinence, consistent condom use, or dual method use as complementary strategies to maximize prevention efforts for youth.

The information-motivation-behavioral skills model[8-12] has been widely used in the areas of HIV/AIDS prevention efforts and received considerable empirical support in terms of its comprehensiveness, specification of relationships, and ease of translation into empirically-based targeted interventions for particular populations [13, 14]. The IMB model asserts that HIV prevention information, motivation, and behavioral skills are fundamental determinants of HIV preventive behaviors [10-12]. The IMB model’s constructs are also regarded as highly generalizable determinants of sexual health behaviors across diverse populations and behaviors of interest [13-15]. However, despite the recommendation for its application to a range of sexual health behaviors across populations, there is limited research using the IMB model for understanding and predicting safer sexual dual-protection behaviors, such as abstinence and dual protection use, among youth at risk of STI/HIV and unwanted pregnancy.

Reviewers’ comments:

b/ You said there is "limited" research. Does that mean there is no research?

Or are there a few articles? I would include these few articles if so.

Author’s Response:

No, it doesn’t mean that there is no research, but there are few studies. Yet, d espite the ranges of dual protection options, s tudies on dual-protection to date, almost exclusively has focused on dual-method use (using condom for STI/HIV prevention and hormonal contraceptive for pregnancy prevention) measured at a single point in time (e.g., at last sexual intercourse). However, focusing exclusively on dual-method use has important limitations in that it ignores the importance of abstinence and consistent condom use for effective risk reduction approach.

Reviewers’ comments:

3 Methods section:

a/ - typically I don't see methods with a large section on sample size determination. Up to you if you feel it is necessary to include.

Author’s Response:

We appreciate the comments and important suggestions

To obtain a sufficient number of participants for numerical analysis, the sample size for the study was calculated for different objectives, and the largest size was taken as the final sample size.

n= 2 z α/2 + z 1-β 2 μ1-μ2 2 δ = 2 1.96+1.28 2 ∆ δ 2 = 2 10.51 δ 2 = 21 0.20 2 = 21 0.04 =525×2=1050

Thus, since 1,050 was the largest sample size calculated, it was taken as the final sample size to be used for all objectives, including this study. However, of the total planned numbers (N= 1,050) , a total of 1,020 participants have actually responded to the questionnaires in this survey, making a response rate of 97.1%.

Reviewers’ comments:

b/ Methods - For how you defined the IMB models, have these definitions been used in other studies?

Author’s Response:

Yes,

The IMB model asserts that HIV prevention information, motivation, and behavioral skills are fundamental determinants of HIV preventive behaviors [10-12]. The information-motivation-behavioral skills model[8-12] has been widely used in the areas of HIV/AIDS prevention efforts and received considerable empirical support in terms of its comprehensiveness, specification of relationships, and ease of translation into empirically-based targeted interventions for particular populations [13, 14].

Reviewers’ comments:

4 Discussion section

a/- you spend a lot of time discussing the constructs of the SEM as being consistent with previous studies. That is great - but please comment on structural recommendations stemming from this findings.

Author’s Response:

We appreciate the comments and important insights

b/ What kind of interventions or policy changes can be made to ensure that certain significant SEM constructs are considered in interventions?

Maybe information and motivation are significantly associated with behavioral skills... so what would an effective program/intervention look like that incorporates this?

Some research must be published on this.

Author’s Response:

Thanks a lot for your useful suggestions

The IMB model is useful for identifying important predictors of abstinence and dual protection use among female university students, which has potential implications for designing interventions to improve abstinence and/or dual protection use among youth at risk of STI/HIV and unwanted pregnancy in settings with high HIV burdens.

Developing targeted interventions that address specific misconceptions and cultural barriers related to dual protection, is crucial to ensuring they are culturally sensitive and relevant.