Determinants of condom use during last sexual intercourse among male college youth of Kaski, Nepal: A cross-sectional survey.

BACKGROUND: The National Family Planning program of Nepal has introduced the condom as an important family planning method. Despite the continuous effort from the public and private sectors at various levels, its use among youth remains low. Therefore, this study aimed to assess the factors associated with condom use during the last sexual intercourse among male college youth.
METHODS: We conducted a cross-sectional study and analyzed the responses of 361 male college youth (aged 19 to 24 years who reported being sexually active preceding six months of the survey), among the 903 participants who reported being involved in vaginal and anal sexual intercourse. The chi-square test was primarily used to find the associated factors and then, stepwise logistic regression was performed by selecting the covariates after the multicollinearity test followed by adjustment of confounders.
RESULTS: We found that more than one-fourth (27.4%) of the sexually active male youth had used the condoms during their last sexual intercourse. Postgraduate male youth were four times more likely to use the condoms during the last sexual intercourse than undergraduate male youth (AOR = 4.09, 95% CI; 2.08-8.06). Similarly, married youth were less likely to use the condoms during the last sexual intercourse with 95% lower odds than their counterparts (AOR = 0.05, 95% CI; 0.01-0.38). Male youth with adequate knowledge about the condoms were 8 times more likely to use them compared to those with inadequate knowledge (AOR = 8.42, 95% CI; 4.34-16.33). Likewise, male youth with favorable attitude towards the condoms were 2.5 times more likely to use them compared to their counterparts (AOR = 2.58, 95% CI; 1.23-5.42). Similarly, male youth having two or more sex partners were 4.5 times more likely to use the condoms than the youth having only a sex partner (AOR = 4.57, 95% CI; 2.38-8.76).
CONCLUSION: The study concluded that slightly more than one-fourth (27.4%) of male college youth in Kaski district used the condoms during their last sexual intercourse. Level of education, marital status, knowledge about condoms, attitude toward condoms, and number of sex partners are the determinants of condom use among male college youth so recommended for early behavioral interventions, especially in knowledge and attitude. Further studies focusing on including the rural youth and larger geography may help to reach a firmer conclusion.

Introduction

Adolescents are defined as the people belonging to the age between 10 to 19 years while young and youth fall under 10–24 and 15–24 age groups respectively [1]. Globally, 1.2 billion youth account for one out of every six people worldwide [2]. Nearly, every fifth (19.38%) Nepalese is a youth, and so, youth’s sexual and reproductive health is an important scope for Nepal, which is also prioritized, especially the youth and urbanization, in the official documents of the government [3].

The youth face various health problems that can affect their quality of life. First and foremost is HIV/AIDS, which is increasingly affecting young people [4]. There is variation in the sexual activities of youth between the countries of the world [5]. However, a common pattern is for youth reaching puberty and engaging in sexual activity earlier [6]. Evidence shows that youth with sexual initiation in their early life are more likely to have multiple sex partners and are at risk of sexually transmitted infections [7]. The previous study conducted in Kaski, Nepal showed that nearly two-thirds (60.4%) of the sexually active male youth had multiple sex partners [8]. Also, a study conducted in Achham district of Nepal showed that the prevalence of condom use among sexually active youth during the last two sexual intercourses was 31% and 35% [9]. Similarly, less than half of the total youth students in Kathmandu valley of Nepal had only used the condoms while engaging in sexual intercourse with commercial sex workers [10]. Low prevalence of the condom use among sexually active youth puts them at risk of sexually transmitted infections, unsafe abortion, unwanted pregnancies, and pregnancy-related complications [11]. According to the Nepal Demographic Health Survey 2016, youth aged 15 to 24 years were more likely to report STI and its symptoms than older men. Relatedly, just more than two-thirds (68.9%) of the same age group had used the condoms during last sexual intercourse with multiple sex partners and 56.2% had used them during the last paid sexual intercourse [12]. In line with, the recent data from the National Centre for AIDS and STI control show that the prevalence of HIV infections among the age group of 20–24 years in Nepal was 11.5% [13]. Thus, the literature suggests that the sexual activity of youth in Nepal is risky.

The National Family Planning program of Nepal introduced the condom as an important family planning method. Moreover, it is also being promoted through social marketing in Nepal by various organizations. Existing policies and programs and their focus are on condom use for sexually active youth and its easy access throughout the country [12]. However, the socio-cultural context of Nepal imposes barriers to using it among unmarried youth as sexual activities are not easily acceptable among them in Nepal [14]. A previous study among male college youth of Kaski district revealed that a substantial proportion of them was engaged in risky sexual behavior where more than half (51.61%) of them had not used the condoms at every act of sexual intercourse with commercial sex worker [8]. Moreover, studies have also documented that living with parents and higher education levels are important predictors of consistent condom use [15]. Similarly, knowledge and attitude toward condom use can greatly impact condom use [16]. Thereupon, this study, along with prevalence, also aimed to examine these factors among male college youth in Kaski, Nepal.

Materials and methods

Study setting and design

A cross-sectional survey was conducted among male college students aged 19–24 years from 25 bachelor’s and master’s level colleges in Kaski district of Nepal. To calculate the sample size, the prevalence of condom use during the last sexual intercourse among sexually active youth was taken from a study conducted in Kathmandu which was 39% [17]. With permitted error (5%), Z-value (1.96), finite population correction (FPC for total students of 6369), non-response rate (23%) that was taken from a similar study conducted in Nepal [9], and a design effect of two, we obtained 849. However, we reached out to 903 sexually active youth from whom only 361 were involved in vaginal or anal sexual intercourse and were enrolled in the study.

The list of the bachelor and master level colleges of Kaski district, Nepal was obtained from the Rural municipality/municipality profile of Kaski, 2018. Then, the number of male youth of each class of the colleges was assessed through the information provided by related colleges. The total number of classrooms of undergraduate level as bachelor first, second, third and fourth year were 87, 86, 84 and 58 respectively and the postgraduate level was 21. Based on the average classroom size, 46 classes (Bachelor first year = 12, second year = 12, third year = 11, fourth year = 8, and Masters first year = 3, proportionately based on the population) were randomly selected for each grade to get the sample size. Thus, male college youth of the selected classes were the study sample.

Participants

The participants were sexually active male college youth aged 19–24 years, who reported their vaginal or anal sexual intercourse within six months preceding the survey. However, we excluded the incomplete responses and those not meeting the criteria from the analysis.

Data collection

Data were collected through a self-administered questionnaire in the selected bachelor and master level colleges of Kaski, Nepal in 2019. Two male enumerators were recruited and trained with a two days’ workshop for data collection procedures and ethical considerations.

Before data collection, a brief script was prepared to maintain the consistency of the information provided to each class. An orientation session of 10–15 minutes was conducted in each selected class by male enumerators. During orientation, students were made clear about the purpose of the study and also, praised for their participation. They were made assured of the anonymity and the benefits and risks. After clearing the students’ curiosity, verbal consent was obtained. The students were requested to open and fill out the sealed questionnaire and then submit it to the enumerator in the same envelope.

Questionnaire

An Illustrative questionnaire for an interview-survey with young people was used to assess the participants’ knowledge about the condoms and their use and attitude toward them [18]. Similarly, to assess the behavioral factors, Nepal Adolescent and Youth Survey 2011/12 questionnaire was used [19].

Measures

Condom use during last sexual intercourse

The outcome of the study was condom use during the last sexual intercourse. For the study purpose, last sexual intercourse refers to the latest vaginal or anal sexual intercourse that was carried out within six months preceding the survey. It was assessed with the question, ’Did you or your partner use any contraceptive devices during your latest sexual intercourse? The respondents answered this question with two options, yes and no. Those who answered yes were asked the question, ’Which contraceptive device did you or your partner use during your latest sexual intercourse? The options for this question were contraceptive pills, contraceptive injections, emergency contraceptive pills, and the condoms. Those who did not use any contraceptive devices were asked about alternative measures. The options were: withdrawal and safe period. For the analysis purpose, only those who answered condom during their latest sexual intercourse were considered condom users during the latest sexual intercourse.

Indicators of socio-demographic variables

Age, marital status, place of permanent residence, and living arrangement of the respondents were used as sociodemographic variables.

Condom knowledge

Condom knowledge was assessed with five items (Score, 0–5; a median, 3) which was adopted from the illustrative questionnaire for young people, which was further dummied as inadequate; median value below 3 and adequate; ≥ 3. The items were related to the condom that protects against sexually transmitted infections including HIV and AIDS, pregnancy, and its use. The internal consistency (Cronbach’s alpha) of the scale was 0.56. The mean covariance between the items was 0.08 and the item mean-variance was 1.95. For construct validity, principal component analysis was conducted which revealed one factor with eigenvalues greater than 1 and the total variance explained was 47.31. The content validity of the scale was established using a panel of three judges competent in the field of reproductive health, who were requested to assess the relevance of the content used in the questionnaire.

Attitude toward condom

Participants’ attitude toward condom was examined with eight items (Score, 0–8; a median, 5), which was further dummied as unfavorable attitude; median value less than 5 and favorable attitude; median ≥5. The internal consistency (Cronbach’s alpha) of the scale was 0.73. The mean covariance between the items was 0.18 and the item-mean variance was 1.50. The construct and content validity of the attitude scale was also conducted using the same steps of the knowledge scale. Principal component analysis for assessing construct validity revealed two factors with eigenvalues greater than 1 and the total variance explained was 49.32 and 23.96% respectively.

Sexual behavior

Three sexual behaviors of the participants were measured: age at sexual debut, number of sex partners, and relationship with the sex partner. Age at sexual debut and the number of sex partners were assessed as continuous variables. However, they were later categorized for analysis purposes.

Statistical methods

Data were entered into the Epi Data 3.1 version and exported to SPSS for analysis. Descriptive statistics were applied to describe the characteristics of the study population and the prevalence of condom use during the last sexual intercourse. Chi-square (χ2) statistics were used to identify the association between explanatory variables and condom use during the last sexual intercourse. Stepwise logistic regression was performed by selecting the covariates after the multicollinearity test followed by adjustment of confounders. The variables were considered significant at a p-value less than 0.05. Model 1 included the socio-demographic variables; model 2 comprised the factors of model 1 and knowledge variable; model 3 included the factors of model 2 and attitude variable; and model 4 comprised the factors of model 3 and behavioral variables. Altogether there were 74 ambiguous responses of the sexually active male youth in which 12 responses were of sexually active male youth within six months preceding the survey. Likewise, among 21 incomplete responses, 6 largely incomplete responses were of sexually active male youth within six months preceding the survey. Thus, ambiguous responses that were logically inconsistent were excluded after verification through the consultation of reproductive health experts and incomplete data were also eliminated from the analysis.

Ethical considerations

The ethical process was approved by the Institutional Review Committee of Pokhara University. Also, a letter of permission was obtained from the Ministry of Social Development, Gandaki Province. Respondents were assured and maintained confidentiality and anonymity. Oral consent was obtained from the participants and no personal identifiers were recorded. They were provided information about the voluntary nature of participation in the survey and the provision of withdrawal from the survey at any time.

Results

Altogether 27 students were not present on the day of survey administration whereas 41 students decided not to participate before the start of the survey or chose to stop participation before completing the entire survey. Another 74 ambiguous responses and 21 incomplete responses were eliminated from the analysis. The valid responses for the analyses were 903 sexually active male college youth. However, only 361 were found to be involved in vaginal or anal sexual intercourse within six months before the study and henceforth analyzed.

Table 1 shows that nearly two-thirds (64.81%) of the respondents belong to the age group of 19–21 years. The mean age of the respondents was 20.97±1.56 years. Similarly, more than two–thirds (67.31%) of the respondents were undergraduate students. Nearly two out of three (61.77%) of the total respondents from the study were not the permanent residents of Kaski. Similarly, the majority (89.75%) of the respondents were unmarried. Nearly half (40.2%) of the respondents lived alone.

Table 1

Socio-demographic variables (n = 361).

Variables	Frequency	Percentage (%)
Age of the respondents (Range = 19–24, Mean ±Standard Deviation 20.97±1.56)
19–21 years	234	64.81
22–24 years	127	35.18
Level of education
Undergraduate	243	67.31
Postgraduate	118	32.68
Permanent residence
Kaski	138	38.22
Outside Kaski	223	61.77
Marital status
Married	37	10.24
Unmarried	324	89.75
Currently living with
With family	173	47.90
With relatives	34	2.50
With friends	9	9.40
Alone	145	40.20

For the ’agree’ option 1 score was given while ‘disagree’ and ‘don’t know’ scored 0 and summed up for knowledge (Table 2) and attitude (Table 3). A score below the median of the condom knowledge was classified as inadequate, and the median and above as an adequate. Similar scoring procedure was applied for the condom attitude as unfavorable and favorable.

Table 2

Condom knowledge of college youth (n = 361).

Statements	In group n (%)	% used condom	p-value
1.Condoms are an effective method of preventing pregnancy
Agree	217(60.1)	48.9	<0.001
Don’t know	2 (0.6)	0.8
Disagree	142 (39.3)	50.4
2.Condoms can be used more than once
Agree	21 (5.8)	7.3	0.015
Don’t know	8 (2.2)	2.7
Disagree	332 (92.0)	90.1
3.Condoms are an effective way of protecting against HIV/AIDS
Agree	257 (71.2)	62.2	<0.001
Don’t know	9 (2.5)	3.4
Disagree	95 (26.3)	34.4
4.Condoms can slip off the man and disappear inside the woman’s body
Agree	20 (5.5)	4.6	0.048
Don’t know	24 (6.6)	8.4
Disagree	317 (87.8)	87.0
5.Condoms are an effective way of protecting against sexually transmitted diseases
Agree	243 (67.3)	58.8	<0.001
Don’t know	4 (1.1)	1.5
Disagree	114 (31.6)	39.7

Table 3

Attitude towards condom (n = 361).

Statements	In group n (%)	% used condom	p-value
1.A girl can suggest to her boyfriend to use a condom
Agree	205(56.8)	45.0	<0.001
Don’t know	7(1.9)	2.7
Disagree	149(41.3)	52.3
2.A boy can suggest to his girlfriend to use a condom
Agree	198 (54.8)	42.4	<0.001
Don’t know	8(2.2)	3.1
Disagree	155(42.9)	54.6
3.Condoms are suitable for casual relationships
Agree	175(48.5)	34.0	<0.001
Don’t know	7 (1.9)	2.7
Disagree	179 (49.6)	63.4
4.Condoms are suitable for steady, loving relationships
Agree	140 (38.8)	29.0	<0.001
Don’t know	7 (1.9)	2.7
Disagree	214 (59.3)	68.3
5.It would be too embarrassing for someone like me to buy or obtain condom
Agree	230 (63.7)	69.8	<0.001
Don’t know	4 (1.1)	1.1
Disagree	127 (35.2)	29.0
6.If a girl suggested using condom to her partner, it would mean that she didn’t trust him
Agree	190 (52.6)	65.6	<0.001
Don’t know	8(2.2)	2.7
Disagree	163 (45.2)	31.7
7.Condom reduces sexual pleasure
Agree	278 (77)	80.9	0.002
Don’t know	10(2.8)	3.4
Disagree	73 (20.2)	15.6
8.If unmarried couples want to have sexual intercourse before marriage, they should use the condom
Agree	184 (51)	37.8	<0.001
Don’t know	8 (2.2)	3.1
Disagree	169(46.8)	59.2

Table 4 demonstrates that more than half of the respondents (53.2%) had inadequate knowledge about the condom and nearly three-fifths (56%) had an unfavorable attitude toward the condom.

Table 4

Knowledge and attitude category (n = 361).

Category	Frequency	Percentage (%)
Condom knowledge (Median,3; Min-Max, 0–5)
Inadequate knowledge (<3)	192	53.2
Adequate knowledge (≥ 3)	169	46.8
Condom attitudes (Median,5; Min-Max, 0–8)
Unfavorable attitude (<5)	202	56.0
Favorable attitude (≥5)	159	44.0

Table 5 shows that nearly half (47.5%) of the respondents had their first sexual intercourse at the age below 18 years. Nearly two-thirds (60.4%) of the sexually active respondents had two or more than two partners. More than three fourth (81.7%) of the total respondents had a girlfriend as their latest sex partner.

Table 5

Behavioral factors (n = 361).

Variables	Frequency	Percentage (%)
Age at first sexual intercourse (Mean ±SD, 18.09±2.05; Min-Max,12–23)
<18 years	171	47.5
≥18 years	190	52.8
Number of sex partner
One	143	39.6
≥2	218	60.4
Latest sex partner
Wife	33	9.14
Girlfriend	295	81.7
Casual friend	13	3.6
Sex worker	20	5.5
Condom use during last sexual intercourse
Yes	99	27.4
No	262	72.6
Alternative of condom among condom non-users (n = 262)
Yes	123	46.9
No	139	53.1
Alternative measures used by condom non-users (n = 123)
Safe period	33	26.8
Withdrawal	38	30.9
Contraceptive pills	12	9.8
Contraceptive injection	16	13.0
Emergency contraceptive pills	24	19.5

Condom use during the last sexual intercourse was the main outcome of the study. As shown in Table 5 nearly three-fourths (72.6%) of the sexually active male youth who had reported sexual intercourse within six months preceding the survey, did not use a condom during their last sexual intercourse. Nearly half (46.94%) of the condom non-users had used alternative measures. Similarly, nearly one-third (30.89%) of the condom non-users had used withdrawal followed by a safe period (26.83%), emergency contraceptive pills (19.51%), contraceptive injection (13%), contraceptive pills (9.76%), and abortion (4.88%).

Bivariate analysis

We found that age of the respondents (χ2 = 29.08, p-value <0.001), level of education (χ2 = 23.70, p-value <0.001), permanent residence (χ2 = 10.20 p-value = 0.001),marital status (χ2 = 12.65, p-value <0.001), living arrangement (χ2 = 15.28, p-value <0.001), knowledge about condom (χ2 = 62.15,p-value <0.001),attitude towards condom (χ2 = 80.77, p-value <0.001) and number of sex partners (χ2 = 74.50, p-value <0.001) significantly associated with condom use during the last sexual intercourse. There were no significant differences between age at first sexual intercourse, relationship with sex partner and condom use during the last sexual intercourse (Table 6).

Table 6

Association of different variables with condom use during the last sexual intercourse among the youth (n = 361).

Variables	Condom used		Pearson chi-square (χ2)	p-value	UOR (At 95% CI)
	Yes	No
Age of the respondents
19–21 years	148(63.2)	86(36.8)	29.08	<0.001*	0.19(0.10–0.36)
22–24 years	114(89.8)	13 (10.2)			Ref
Level of education
Undergraduate	157(64.6)	86 (35.4)	23.70	<0.001*	4.42(2.34–2.34)
Postgraduate	105(89)	13(11)			Ref
Permanent residence
Kaski	51(36.95)	87(63.04)	10.20	0.001*	2.13(1.33–3.42)
Outside Kaski	48(21.52)	175(78.47)			Ref
Marital status
Married	1(2.70)	36(97.29)	12.65	<0.001*#	0.06(0.009–0.47)
Unmarried	98(30.24)	226(69.75)			Ref
Living arrangement
With family	64(37)	109(63.01)	15.28	<0.001*	2.56(1.58–4.14)
Alone and with others a	35(18.61)	153(81.38)			Ref
Knowledge about condom
Inadequate knowledge	106(55.2)	86 (44.8)	62.15	<0.001*	Ref
Adequate knowledge	156(92.3)	13(7.7)			9.73(5.16–18.34)
Attitude towards condom
Unfavorable attitude	11(6.14)	168(93.85)	80.77	<0.001*	0.070(0.036–0.13)
Favorable attitude	88(48.35)	94(51.64)			Ref
Age at first sexual intercourse
<18 years	45(26.31)	126(73.68)	0.207	0.649	0.89(0.56–1.43)
≥18 years	54(28.42)	136(71.57)			Ref
Number of sex partners
1	68(47.55)	75(52.44)	74.50	<0.001*	Ref
≥2	194(89)	24(11)			8.91(5.21–15.24)
Relationship with the sex partner
Girlfriend and wife	233(71.9)	91(28.1)	0.69	0.26	1.41(0.62–3.21)
Others b	29(78.4)	8(21.6)			Ref

aWith friends and relatives,

bCasual friend and sex worker,

# p-value from Fisher Exact;

Statistically significant at

*p<0.05

Multivariate analysis

In the model (Table 7), adjusted odds ratio (AOR) at 95% Confidence Interval was calculated from logistic regression analysis in order to examine the association between selected variables and condom use during the last sexual intercourse. The variables were considered significant at a p-value less than 0.05. Altogether four models were developed where in the first model variables of socio-demographic characteristics were incorporated. Knowledge, attitude, and behavioral factors were added in the second, third, and fourth models, respectively. After assessing multicollinearity in the variables, it was found that the age of the respondent and level of education were highly correlated (r = 0.9). Thus, the variable ‘respondent’s age’ was not entered in the logistic model. Among the eight variables that were incorporated in the model, five variables remained statistically significant in the final model after controlling for other variables.

Table 7

Adjusted odds ratio to examine the strength of association between condom use during last sexual intercourse and related variable (n = 361).

Variable	Model I	Model II	Model III	Model IV
Level of education
Undergraduate	Ref	Ref	Ref	Ref
Postgraduate	4.09(2.08–8.06)**	3.87(1.87–7.99)**	3.61(1.74–7.50)**	3.58(1.45–8.81)**
Marital status
Married	0.05(0.01–0.38)**	0.06(0.01–0.47)**	0.06(0.01–0.50)**	0.07(0.01–0.57)**
Unmarried	Ref	Ref	Ref	Ref
Permanent residence
Kaski	1.33(0.65–2.72)	1.31(0.60–2.89)	1.40(0.62–3.11)	1.26(0.52–3.06)
Outside Kaski	Ref	Ref	Ref	Ref
Living arrangement
With family	3.11(1.53–6.29)**	2.32(1.07–5.03)**	1.99(0.90–4.41)	2.03(0.84–4.89)
With others a	Ref	Ref	Ref	Ref
Knowledge about condom
Inadequate		Ref	Ref	Ref
Adequate		8.42(4.34–16.33)**	5.31(2.53–11.11)**	4.14(1.81–9.46)**
Attitude toward condom
Unfavorable			Ref	Ref
Favorable			2.58(1.23–5.42)**	2.28(1.01–5.17)**
Age at sexual debut
<18 years				0.56(0.28–1.11)
≥18 years				Ref
Number of sex partners in life time
1				Ref
≥2				4.57(2.38–8.76)**
Relationship with a latest sex partner
Girlfriend and wife				0.41(0.13–1.25)
Others b				Ref

aWith friends and relatives,

bCasual friend and sex worker;

Statistically significant at

**p<0.05from multivariate analysis

Model 1: Background variables, Model 2: Background and knowledge variables, Model 3: Background, knowledge and attitude variables, Model 4: Background, knowledge, attitude, and behavioral variables

As shown in Table 7, postgraduate male youth were 4 times more likely to use a condom during last sexual intercourse compared to undergraduate male youth (AOR = 4.09, 95% CI; 2.08–8.06). Similarly, married male youth were less likely to use a condom during last sexual intercourse with 95% of lower odds than unmarried male youth (AOR = 0.05, 95% CI; 0.01–0.38).

The variables that were significant in the first model retained significance in the second model even after adjusting the knowledge variable. Model 2 showed that male youth having adequate knowledge about the condoms were 8 times more likely to use them during last sexual intercourse than male youth having inadequate knowledge about them (AOR = 8.42, 95% CI; 4.34–16.33). Model three explained that youth having the favorable attitude toward the condoms were 2.5 times more likely to use them during their last sexual intercourse compared to those having unfavorable attitudes (AOR = 2.58, 95% CI; 1.23–5.42) (Table 7).

In the fourth model the variables: level of education, marital status, condom knowledge and attitude remained significant even after adjustment of the behavioral variable. Among the three variables of behavioral factor, the number of sex partners in lifetime remained statistically significant in model 4. The analysis indicates that male youth having two or more sex partners were 4.5 times more likely to use a condom during last sexual intercourse than male youth having one sex partner (AOR = 4.57, 95% CI; 2.38–8.76) (Table 7).

Discussion

The study examined the determinants of condom use during the last sexual intercourse among sexually active male youth of Kaski, Nepal. The findings showed that more than half (55.98%) male youth of Kaski, Nepal were sexually active whereas less than one-fourth (23%) of the total youth had experienced sexual intercourse within six months preceding the survey. Sexuality, although a sensitive issue and so the inconsistencies regarding self-reporting are rampant, this finding indicates that the majority of male youth in Kaski, Nepal are sexually active. The prevalence of sexual intercourse among youth in this study is higher than that of rural India where 30% of youth had sexual intercourse in the same age group of 19–24 years [20]. This difference may be due to rural-urban variation. However, the study’s prevalence is lower than that of a similar study conducted among the youth of the USA, Tanzania, and Thailand, where prevalence was 57%, 70.06%, and 62.4% respectively [21-23]. This might be due to the differences in perception towards sexual intercourse and relationships. Also, one has to consider that methodological diversity may explain these differences.

This study revealed that less than one-third (27.4%) of male youth had used the condom during the last sexual intercourse which is consistent with the study conducted in Achham district of Nepal where condom use during the last sexual intercourse was 31% [9]. Despite the Nepal government’s effort to make the condoms easily available and accessible, their use is low among male college youth. In countries such as Southern Brazil, China, Canada, United States, Ethiopia the prevalence of condom use in the last sexual intercourse among university students was 61.4%, 44.2%, 47.2%, 63.8%, and 55.8% respectively [24-28]. This difference might be due to the knowledge level about the condoms and youth’s attitude to use them within and outside the country.

Consistent with the previous research [15], this study provides evidence that Postgraduate students were 4 times more likely to use a condom during the last sexual intercourse compared to undergraduate students (AOR = 4.09, 95% CI; 2.08–8.06). Similarly, more than half of the respondents had inadequate knowledge (53.2%) about condoms and their use. Male youth having adequate knowledge about condoms were 8 times more likely to use a condom during the last sexual intercourse than male youth having inadequate knowledge about condoms (AOR = 8.42, 95% CI; 4.34–16.33). The main reason for the gap in knowledge regarding condoms and their use among male college youth might be due to the socio-cultural environment in Nepal that imposes a barrier, especially among the unmarried youth to share knowledge regarding SRH [14]. In contrast to this finding, a study conducted in Ethiopia revealed that 75.1% of the male youth had adequate knowledge of condom use. The main reason for the high level of condom knowledge in Ethiopia may be due to the presence of the HIV/AIDS clubs in the schools [16] whereas this kind of provision is lacking in the Nepalese context.

The present study found that more than half (56.7%) of the total respondents had unfavorable attitudes toward the condom. In contrast to this finding, a study conducted in Ethiopia revealed that 83.6% had a favorable attitude toward condoms [16]. This difference is probably due to a fairly traditional Nepalese society that is changing slowly in terms of developing a more open attitudes toward sexual and reproductive health and its important aspects [14]. Multivariate analysis showed that the male youth having a favorable attitude toward the condoms were 2.5 times more likely to use them during the last sexual intercourse with compared to the male youth having an unfavorable attitude (AOR = 2.58, 95% CI; 1.23–5.42) which is consistent with the findings of Thailand, Croatia, United States and China [29-32]. Thus, attitude toward the condoms among youth is likely to develop the patterns of condom use behavior [33]. Also, it reflects the choice to use or ignore condoms among them [34].

In this study, more than three-fifths (60.4%) of the total youth had two or more sex partners, which is in line with the previous finding of a similar study conducted in the same age group of Kaski, Nepal [8]. However, this finding is quite more than the study conducted in the Achaam district of Nepal, where 28.2% of youth had two or more than two partners [9]. This inconsistency might be due to urban-rural variation. Also, permanent-temporary residence variation might have fueled this gap as a previous study had shown that the youth in temporary residence were found to be involved in risky sexual behavior [10]. The minimum age at the sexual debut of male college youth in the study was 12 years so the curriculum addressing safe sex education at the school level should be provided before the initiation of the sexual activities.

The result of the study on the prevalence of condom use among married male youth was just one percent which is somewhat consistent with the finding of the Nepal Demographic Health Survey, in which it was 4% [12]. Also, married youth in this study were less likely to use the condoms during the last sexual intercourse with 95% of lower odds than unmarried youth (AOR = 0.05, 95% CI; 0.01–0.38). This seems particularly in line with previous studies indicating that cohabitation or being married was associated with low condom use [35]. Thus, this study provides additional evidence of differences in condom use according to the marital status which indicates the need to develop strategies responsive to address the diverse contexts of condom use as per marital status. It is important to note, however, that our study findings revealed less condom use among married youth but did not investigate the reasons for not using it. Therefore, the reasons for the non-use of condoms in marital relations need to be explored and addressed in Nepal.

This study has limitations to be noted. Because of the sensitive nature of the issue, the information from this study may be either under or over-reported although efforts were made to minimize the chance of reporting bias. Additionally, external validity may be limited to male college youth in Nepal. This study conducted in Kaski, Nepal is in the first row of its kind among unmarried youth that reflects the youth knowledge level of the condom, their attitude toward it, and its usage. Our findings extend previous research by identifying the factors associated with the condoms and alternative measures used by the youth. This study is of Kaski, Nepal but it reflects the scenario of sexual behavior of youth in Nepal because national-level studies focus mostly on married youth only. The findings of this study alert health program planners and policymakers including the non-governmental organizations to the popular belief of traditional Nepalese cultural norms where sexual relations happen only inside the married statuses and contraceptives are only important to married youth. Thus, more studies should be conducted to design the interventions for increasing the use of condoms among youth by using identified predictors of this study.

Conclusion

The study concluded that slightly more than one-fourth (27.4%) of male college youth in Kaski district, Nepal had used a condom during their last sexual intercourse. Level of education, marital status, condom knowledge and attitude, and number of sex partners were the important determinants of condom use during last sexual intercourse among male college youth and recommended for early behavioral interventions. Further studies covering larger geography including rural areas may help to reach a firmer conclusion.

Data set.

(SAV)

Click here for additional data file.

Questionnaire.

(DOCX)

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Bivariate analysis of all reported sexual active male youth.

(DOCX)

Click here for additional data file.

Validation of the questionnaire.

(DOCX)

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Weighted & unweighted number.

(DOCX)

Click here for additional data file.

18 Nov 2020

PONE-D-20-30105

Determinants of condom use during last sexual intercourse among male college youths of Kaski, Nepal: A cross-sectional survey

PLOS ONE

Dear Dr. Adhikari,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

There are a number of limitations in the present paper in terms of methodology that are described below. In addition we have found that a related study [https://www.jhas.org.np/jhas/index.php/jhas/article/view/134/114] has been published based on the same survey. You should be aware of PLOS ONE policy regarding related papers: If a submitted study replicates or is very similar to previous work, authors must provide a sound scientific rationale for the submitted work and clearly reference and discuss the existing literature. Submissions that replicate or are derivative of existing work will likely be rejected if authors do not provide adequate justification (http://www.plosone.org/static/publication#results). The mentioned paper was not included among the reference or put in context as required, and if the required justification and incorporation in the study is not given that is grounds for rejection. There are also concerns regarding the English language that needs to be copy edited before final acceptance.

Both reviewers pose a number of questions and make useful suggestions for the improvement of the paper. In particular there are concerns regarding the lack of a methods section, a lack of specified objectives, and limitations of the current analysis.

Regarding the lack of specified objectives and the setup, there is only a talk regarding “So this study examined the factors associated with condom use at last sexual intercourse among the male college youths”. What specific factors were in mind when carrying out the analysis? What is known regarding these factors in similar or other populations? There is talk regarding the DHS 2016 and levels of STI of youth. The DHS also recollected information on condom use at last sex and at last- paid sex. That information needs to be incorporated and discussed.

Regarding the methodological parts of the survey, the description is not enough as assessed by reviewer 1, including lack of data on the universe, the sampling procedure, protocol on reaching the units, patterns of missingness. The sample seems to have strata and a cluster design but apparently there are no weights present in the data. It does not seem that there are equal probabilities of selection given the research design, or adjustment for non-response. All this has to be justified / remedied.

Regarding the statistical analysis there is a tension between the two sets of factors that are being analyzed, some sociodemographic and others regarding attitudes towards condom use, which seem to be the most clearly related to condom use. The way they are addressed and combined is less than satisfactory:

4. As mentioned by both reviewers, the treatment of knowledge and attitude towards the use of condoms is not adequately explained. We don’t know whether there is any connection with this way of measuring and any of the previous literature. We don’t know why the variable has been defined in such an arbitrary way, first treating all items alike and then choosing a threshold. We don’t know the respective prevalence of the different items in the population, as mentioned by reviewer 2, or in the sample of sexually active individuals. You can check how scale validation can be carried out (and an example of a similar, but different scale, here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608159/, see also 10.1037/0278-6133.13.3.224 on the UCLA condom attitude scale).

5. As mentioned by reviewer 2, it would be good to extend the analysis of the knowledge and attitude items to the total population for comparison. I’d suggest presenting at least a tabulation of row percentages by item for the total population, the sexually active population, and among the latter, users and non-users. Item validity and reliability analysis can lead to an improved scale.

6. Using both the attitude and knowledge and the sociodemographic variables in the same model to compute the AOR is not adequate. I’d suggest splitting current table 4 in 2, one with the tabulations and unadjusted AOR, and another one with model results. In the second one a model with only sociodemographic determinants should be reported, possibly a model only with the knowledge-attitude components, and if desired a model with all of them. For interpretation of sociodemographic patterns the first model should be used. The reason is that the model including attitude asks questions like “what is the probability of using condom according to living arrangement conditional on attitude and knowledge and the rest of SE factors”. That is not the question of interest. It is logical that use is connected to attitude towards condom use. We want to know what are the students that will be more likely to both use and have a more positive attitude towards it.

7. Regarding the presentation of results and discussion, as both reviewers point out this section needs to be improved connecting the results to prior studies and noting the limitations of the current study (sample size among them). PLOS ONE endorses the use of the strobe statement that you should check in revising the introduction, the results section and the discussion, https://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/STROBE_checklist_v4_cross-sectional.pdf

There are in addition other minor points made by the reviewers that require attention.

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Academic Editor

PLOS ONE

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2. Please include additional information regarding the validation of the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. Furthermore, if the questionnaire is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Comments:

I have few comments for this manuscript given in each section, as follows:

Introduction

1. In the first sentence of the third paragraph, “youths aged 15 to 24 years were more likely to report STI and its symptoms than older men”. Do “youths” in this sentence specifically refer to male youths? This is due to the comparison group is older men. Please clarify.

2. The second sentence in the same paragraph, “the prevalence of HIV/AIDS …. was 11.5%” is vague. Please clarify whether the figure of 11.5% represents the prevalence of HIV or the prevalence of AIDS. In addition, 11.5% was considerably high prevalence for young people aged 20-24 years. Please check again the source and/or interpretation of the data.

3. In many settings, adolescents (10-19 years) are also vulnerable to HIV infection. The prevalence of protected sex among this group tends to be low due to insufficient HIV knowledge and facing more barriers in accessing contraceptive methods (e.g. condom). Please provides strong reasons why this study focused on male college youths (19-24 years) instead of males at secondary educational level (10-19 years).

Methods

1. The information on data analysis is missing. Please add information on how data were analysed in the methods section.

2. What are the validity and reliability of the condom knowledge and attitude towards condom? Please elaborate more.

Results

1. Even though this paper only analysed the data from 361 students due to eligibility criteria of vaginal or anal sex, it is better to inform the readers about the characteristics of all recruited students (903). Authors can add a cross-tabulation table between characteristics and sexual activity (anal and/or vaginal sex) along with the results of Chi-square test as a supplementary file or an appendix. This potentially informs the readers what students’ characteristics prone to have vaginal and/or anal sex. Authors can put interpretation for this table in the results section and no need to explain in detail since it is not the aim of this study.

2. Before summing up the total score of knowledge and attitude and grouping into binary variables, it is important to have a table listing indicators used to measure knowledge and attitude and present the proportions of students who answered correctly for each item. This can inform authors and readers what components of knowledge and attitude are still lacking among respondents and potentially inform for policy recommendations.

3. Even though there was multicollinearity among independent variables, the bivariate analyses should be presented for all independent variables. Therefore, please add the bivariate associations for age and condom use; level of education and condom use. In addition, please elaborate more on multicollinearity testing informed in the results section. Were variables of age and level of education omitted due to a high correlation between both?

4. What does the symbol “#” mean in p-value of the Chi-square test for marital status and condom use?

5. Please be consistent in presenting the information for a continuous variable, such as age at first sex that can follow the information presented for condom knowledge (mean ±SD: ; Min-Max).

6. Please be consistent in grouping a variable of age at first sex in the descriptive table (Table 3) and in the table of bivariate and multivariate analyses (Table 4). The same variable was grouped in different ways. This does not make sense.

7. For presenting the cross-tabulation (Table 4), please use row percentage, not column percentage. Please revise the table accordingly.

8. There are a lot of mistakes in Table 4. I could not find where is the OR for the association between the sexual partner at last sex and condom use. However, authors interpreted the results of this association.

Discussion

1. The discussion section is lacking information on how associations between independent variables and condom use occurred in the context of Nepal. For example, those with unfavourable attitude towards condom were less likely to use a condom at the last sex, but no adequate explanations for this. Please explain why this study found this association within a sample of Nepalese youths. What does “unfavourable attitude” mean? Please elaborate more on other associations too.

2. “In this study, 60.4% had two or more sex partners, which is in line with the findings of Kathmandu, Nepal, where 54.9% had so”. This sentence is not clear. Please revise and add a reference if authors want to compare to previous study findings.

3. Please elaborate more in one paragraph about the implication of the study findings. What can authors suggest to increase the use of condoms among male youths by considering socio-cultural norms as barriers to condom use among unmarried youths?

4. In addition to study limitations, please add the strengths of this study.

Addictional comments:

The manuscript should be proofread by a native speaker before further submission.

Reviewer #2: Review opinion.

Although sex life is a difficult theme to research, no matter how anonymous it is, good results have been obtained through a detail research design. Research about the use of condom in youth and the impact on young people’s life has been meaningful. However, the following corrections are required.

1. Research Design

The process of subject selection for the study needs to be further explained; e.g.: the study population, the number of students per class, how did you choose the classes (randomly or not), and the student’s major.

2. Knowledge and attitude toward the use of condoms

Please explain why you used the mean score. In particular, knowledge is measured in a 5-point scale, but there is no explanation on the basis for dividing the results into appropriate or inappropriate.

Also, the variable attitude presents the same issue.

3. Table 4. Needs to be organized and corrected for typos.

4. Discussion

- Considering that this study was conducted on university and graduate students aged 19-24, the results of the study need to be compared with prior studies that also consider the age of the subjects.

- The discussion of the results seems very weak when compared with prior studies.

- Logic is very weak when discussing number of partners and condom use. Consider reviewing related prior studies.

- There is no supporting information explaining the use of condom for married people.

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Reviewer #1: No

Reviewer #2: Yes: Eun Woo Nam

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23 Jan 2021

Reviewer 1 and 2: We have incorporated all of your suggestions in the revision except the weighted calculations. We calculated the weighted estimator of the sample and found 1.04 when the formula Wi=K/Si (Tyagi, S., Sharma, B., Singh, P. and Dobhal, R., 2013. Water quality assessment in terms of water quality index. american Journal of water resources, 1(3), pp.34-38.) was applied. Hence the estimator is minimal, it does not make a large effect, we did not feel necessary to carry out further calculations as implicitly mentioned by Korn and Graubard(Korn, E.L. and Graubard, B.I., 1995. Examples of differing weighted and unweighted estimates from a sample survey. The American Statistician, 49(3), pp.291-295.).

We would like to thank both reviewers since your comments helped to refine the manuscript to a great extent. Although we believe the manuscript has reached to an acceptable level, we still appraise truly if further comments and feedback deemed necessary.

Submitted filename: New comments and justifications.docx

Click here for additional data file.

18 Feb 2021

PONE-D-20-30105R1

Determinants of condom use during last sexual intercourse among male college youths of Kaski, Nepal: A cross-sectional survey

PLOS ONE

Dear Dr. Adhikari,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript has improved but it still requires important editing. Particularly in the description of methods and analysis, as suggested by the reviewer, and language. There is still a need to copy edit, and to tone down some of the claims. Particularly the introduction NEEDS an improvement. I am pointing out incorrections, but the whole thing needs to be improved. If there was an English language editing, the editor did a very bad job. There are still many incorrections and the article cannot be published unless the language improves drastically You can do a grammar check with any word processor or grammarly.com. There are plenty of problems.  Also, for future revisions, make sure that the line numbers are included in the manuscript with track changes and that the detailed answers to the suggestions are submitted together with the revised manuscript.

A first required change is the use of “male college youths” in some parts of the text instead of “male college youth”, which is also used. Youth can be plural, and use of “youths” should be avoided. Please replace all uses of “youths” for “youth”.

“Among the various health issues related to sexual and reproductive health, the major concern of youths is that they expose to the Sexually Transmitted Infections”. Please rephrase. The sentence does not make grammatical sense. Who is “they”?. Also, use “a major concern”, it is unclear that it is “the” major concern, and that does not stem from the reference given.

“There is the variation of sexual activities of youths between the countries of the world”: It should be “there is variation in sexual activity of youth among ..

“But the common problem faced by most of the countries is that young people are reaching puberty earlier and are often engaged in sexual activities”. Countries do not face problems, and it is debatable whether reaching puberty earlier and engaging in sexual activities is a problem. You have to use neutral language. The same for the following sentence “. You could write something as “A common pattern is for youth reaching puberty and engaging in sexual activity earlier. Evidence shows earlier sexual initiation to be associated with having multiple sex partners  and higher risk of sexually transmited infections”.

You should introduce at this stage evidence from the prior study in JHAS such as proportion ever sexually active and multiple partnership in Kaski compared to DHS or the other studies in Achham and Kathmandu.

“These existing literature of Nepal indicates that the sexual behavior of youths of Nepal are risky.” Revise. It does not make grammatical sense.

You also need to refer to the other article in the statement of the research objectives. You just say “Despite the efforts from various level, the prevalence of condom use among youths is low [12]. So this study examined the condom use at last sexual intercourse among the male college youths.”. You are not looking at this in the vacuum. You are looking at youth in a particular city where you have studied sexual behaviour. This is important as commented before: “If a submitted study replicates or is very similar to previous work, authors must provide a sound scientific rationale for the submitted work and clearly reference and discuss the existing literature. Submissions that replicate or are derivative of existing work will likely be rejected if authors do not provide adequate justification (http://www.plosone.org/static/publication#results). The mentioned paper was not included among the reference or put in context as required, and if the required justification and incorporation in the study is not given that is grounds for rejection”. This justification needs to be incorporated in the text as an antecedent of the current study. Also you are saying in the response that this study uses “new data”. You have to clarify that: Was there one interview which is common to both studies or two different interviews? This is confusing.

“It is evident that several factors influences condom use among youths as their sociodemographic characteristics: residence, education, living arrangement”. Nothing is evident. That is not, in particular, evident. Also, verb and noun should agree in number. The English language of the article really needs improvement.

Sample weights are still not used. The description of sampling has been provided: “The total number of classes of undergraduate level as: Bachelor first ,second, third and fourth and year was 87,86.84 and 58 respectively and of post graduate was 21.As per the population proportion to size the total number of classes to be taken from undergraduate to post graduate level was 46 .Thus the 46 classes were selected by generating random number and all male college youths of the selected classes were the study population.”. First, language should still be improved. Second, it emerges that there are unequal probabilities of selection. Students in smaller classes have a higher probability of selection since there is a random sample of classes, not of students. The argument given for not using weights is a reference to an article on water management that is not relevant methodologically, and the reproduced equation does not make sense in this setting. You are not calculating a weighted average. You are estimating a GLM model with unequal probabilities of selection. This requires use of normalized weights with an average level of one.

The section on the results of the multivariate analysis reads very poorly. It should be a little more than reproducing the elements of the table. Think of the reader.

Discussion: Needs improvement in the language and the substance. For instance, what does it mean “The study revealed the aspects of youth's sexual behavior that may point to advance the well-being of youth's reproductive and sexual health”. Besides the clumsy redaction that does not seem to be the purpose of the article. You have looked at the determinants of condom use at last intercourse, and there are no policy variables included.

Please submit your revised manuscript by Apr 04 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

José Antonio Ortega, Ph.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Revisions for the given comments were satisfactory. However, I have some comments that need to be addressed by the authors, as follows:

1. Pokhara and Kaski are interchangeably used in the manuscript, such as in the last sentence in the introduction and some parts of the results. Do both names refer to the same district?

2. In the sub-section of questionnaire, please provide the citations from where questionnaires were adopted.

3. In the methods section, please make clear whether any records with missing data that were removed from 361 males who engaged in sexual intercourse in last 6 months.

4. For bivariate analysis (Table 6), please mention the reference category or group for all variables. No reference group was mentioned for the age of the respondent and educational level.

5. For the same table, please check again the association between the number of sex partners and condom use. From the table, those who had 2 partners or more were more likely to use a condom at last sex (OR=8.91; 95%CI=5.21-15.24). Surprisingly, based on the differences in the proportion of condom use by the number of sex partners, the proportion of condom use was lower among those with ≥ 2 partners (11.01%) compared to those with 1 partner only (52.44%). Please check again the results whether there was a mistake in coding the categories. Please check also for other variables: level of education, relationship with sex partners, and provide interpretation for Table 6.

6. Authors reported a high correlation between the age of the respondents and level of education (r=0.9) and decided to not include both variables in the multivariate model. However, two highly correlated variables indicate that both cannot be included in the multivariate model in a time, but we can select one of them. Therefore, authors can include either age of the respondents or educational level in the model. I suspect that educational level can be strongly associated with condom use.

7. For multivariate analysis (Table 7), I am wondering why the number of sex partners was not statistically significant associated with condom use. The 95%CI (3.01 – 11.07) informs that the value of one (1) is not within the intervals. Please re-check the results.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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26 Jul 2021

We are very much thankful to the editor and the reviewers for your generous comments on the manuscript entitled " Determinants of condom use during last sexual intercourse among male college youths of Kaski, Nepal: A cross-sectional survey". We hope the scientific comments you aroused have helped rectify the manuscript and accordingly, we have revised it by addressing all the concerns raised by editor and reviewers. The responses along with the comments are described in this rebuttal letter. We also apologize for a bit delayed response.

Editor comments and changes /justification

1. Comment # 1: A first required change is the use of “male college youths” in some parts of the text instead of “male college youth”, which is also used. Youth can be plural, and use of “youths” should be avoided. Please replace all uses of “youths” for “youth”.

Our response: We thank the editor for this lexical error and all "youths” are now replaced by “youth” in the manuscript.

2. Comment # 2: Among the various health issues related to sexual and reproductive health, the major concern of youth is that they expose to the Sexually Transmitted Infections”. Please rephrase. The sentence does not make grammatical sense. Who is “they”?.Also, use “a major concern”, it is unclear that it is “the” major concern, and that does not stem from the reference given.

Our Response: Thank you for this lexical and grammatical issue. We have, now, rephrased it as: “The youth face various health problems that can affect their quality of life. First and foremost is HIV/AIDS, which is increasingly affecting young people.” We hope the sentence is sensible now.

3. Comment # 3: But the common problem faced by most of the countries is that young people are reaching puberty earlier and are often engaged in sexual activities”. Countries do not face problems, and it is debatable whether reaching puberty earlier and engaging in sexual activities is a problem. You have to use neutral language. The same for the following sentence “. You could write something as “A common pattern is for youth reaching puberty and engaging in sexual activity earlier.

Our response: Thank you again for notifying us. The sentence "But the common problem faced by most of the countries is that young people are reaching puberty earlier and are often engaged in sexual activities" is now written as "A common pattern is for youth reaching puberty and engaging in sexual activity earlier".

4. Comment # 4: Evidence shows earlier sexual initiation to be associated with having multiple sex partners and higher risk of sexually transmited infections”. You should introduce at this stage evidence from the prior study in JHAS such as proportion ever sexually active and multiple partnership in Kaski compared to DHS or the other studies in Achham and Kathmandu.

Our response: We are thankful to the generous comment. Prior study of JHAS ,Achham ,Kathmandu and DHS data are now added and arranged with this sentence. We found it as improving the rigor of the manuscript.

5. Comment # 5: These existing literature of Nepal indicates that the sexual behavior of youths of Nepal are risky.” Revise. It does not make grammatical sense.

Our response: The sentence is now revised as " Thus, the literature suggests that the sexual activity of youth in Nepal is risky."

6. Comment # 6: You also need to refer to the other article in the statement of the research objectives. You just say “Despite the efforts from various level, the prevalence of condom use among youths is low [12]. So this study examined the condom use at last sexual intercourse among the male college youths.” You are not looking at this in the vacuum. You are looking at youth in a particular city where you have studied sexual behaviour. This is important as commented before.

Our response: We are thankful for the comments. More literatures for the justification have been added in the revised manuscript

7. Comment # 7: If a submitted study replicates or is very similar to previous work, authors must provide a sound scientific rationale for the submitted work and clearly reference and discuss the existing literature. Submissions that replicate or are derivative of existing work will likely be rejected if authors do not provide adequate justification (http://www.plosone.org/static/publication#results). The mentioned paper was not included among the reference or put in context as required, and if the required justification and incorporation in the study is not given that is grounds for rejection”. This justification needs to be incorporated in the text as an antecedent of the current study. Also you are saying in the response that this study uses “new data”. You have to clarify that: Was there one interview which is common to both studies or two different interviews? This is confusing.

Our response: In line with the editor’s comment, we have now introduced our prior study of JHAS in the sentence "Evidence shows earlier sexual initiation to be associated with having multiple sex partners and higher risk of sexually transmitted infections” ,and the mentioned paper is also included in the reference in the 8th number. In addition, the mentioned paper study is also discussed in the context of multiple sex partners at the discussion section.

• It is also explained as the rationale in the last paragraph of introduction that "Previous study conducted among male college youth of Kaski district revealed that the substantial proportion of male college youth was engaged in risky sexual behavior where more than half (51.61%) of the male youth had not used condom at an every act of sexual intercourse with commercial sex worker. So this study is important to examine the prevalence and determinants of condom use at last sexual intercourse among male college youth of Kaski district"

• Regarding the interview, two different interviews were conducted. Prior study (published in JHAS) among the participants who were sexually active during the last one year period, after preliminary findings of which further intrigued us to think about the condom use during the last vaginal/anal intercourse (within 6 months) would be even more interesting and important from the scientific point of view, and so accessed among those and included as per the criteria, which helped us to get to 361. This study is, so, the further culmination of previous study which, probably, was able to answer, another but an important research question.

8. Comment # 8: It is evident that several factors influence the condom use among youth as their sociodemographic characteristics: residence, education, living arrangement”. Nothing is evident. That is not, in particular, evident. Also, verb and noun should agree in number. The English language of the article really needs improvement.

Our response: It is revised as "Studies have documented that living with parents and higher education level are the important predictors of consistent condom use"

9. Comment # 9: Sample weights are still not used. The description of sampling has been provided: “The total number of classes of undergraduate level as: Bachelor first ,second, third and fourth and year was 87,86.84 and 58 respectively and of post graduate was 21.As per the population proportion to size the total number of classes to be taken from undergraduate to post graduate level was 46 .Thus the 46 classes were selected by generating random number and all male college youths of the selected classes were the study population.”. First, language should still be improved. Second, it emerges that there are unequal probabilities of selection. Students in smaller classes have a higher probability of selection since there is a random sample of classes, not of students. The argument given for not using weights is a reference to an article on water management that is not relevant methodologically, and the reproduced equation does not make sense in this setting. You are not calculating a weighted average. You are estimating a GLM model with unequal probabilities of selection. This requires use of normalized weights with an average level of one.

Further commented/clarification on 16th July, 2021 (upon our request): Regarding the question of Dr. Adhikari, please reply to him that I'd be glad to see their resubmission. Turning to their question regarding point 9:

Upon re-reading of the sampling procedure, it seems that there might be (prior) equal probabilities of selection since all male students in each sampled class were targeted so the probability of selection is given by the proportion of classes surveyed to all classes. There would be unequal probabilities if a fixed number of students were sampled, but this is not apparently the case. However, ex-post there are still different probabilities of sampling in each of the education levels. Eg: What if all the 46 randomly selected classes belonged to the 87 first-year classes? The prior probability of choosing students from each level is the same as in the population, but, after the sample is taken, the proportion of students from each level in the sample could be as drastic as only first-year students. Note you could use weights to adjust for this (unless one education level is totally missing!) defined as the proportion of level i (eg: first year students) in the population divided by the proportion of first year students in your sample. In this way you give more weight to students from levels that are underrepresented and the weights are normalized (have an average of one). This is equivalent to using strata. You can use these weights (defined at the student-year level, first to fourth and postgraduate) in your analysis. Alternatively, you can show that your sample is balanced, (eg, if all weights calculated in this way are very close to one) and not use weights.

Still, the paragraph was hard to read. Eg: "and all male college youths of the selected classes were the study population". This confuses sample and population. All the male college youths in the selected classes constitute your sample. The population includes all male college youths, in all classes irrespective of sampling status.

Second, the sentence "As per the population proportion to size the total number of classes to be taken from undergraduate to post graduate level was 46" is also confusing". Do you mean something like "based on average classroom size, 46 classes would have to be targeted to reach desired sample size". If this is so, then put the paragraph that follows on targeted sample size before and not after describing the sample selection. Note that given unequal classroom sizes what varies depending on the classroom sample is sample size, which is not fixed.

In short: there is a need for a thorough language check. Regarding weights, you can either show that your sample is balanced and the proportions in the sample of students by year are similar to the proportions in the population, or else use weights as suggested (ratio of the previously mentioned proportions).

Our response: We are very much thankful to your comments and the language feedback. Firstly, regarding the thorough language check, we took it seriously, and all three authors, checked and peer reviewed the language after corrected in online Grammerly. that was checked after revising the manuscript as commented and feedback. The illogical, insensible and unintelligible sentences that have been commented have been revised in consultation with the professional language expert.

Secondly, and may be, even more importantly, in response to the weightage calculation/balanced sample, we are grateful to the reviewers and editors, for providing the academic suggestions. As per your suggestions and to be more assured, we consulted the biostatistician and his verdict was consistent with your later one. Henceforth, we calculated the weighted proportion of the actual male youth and compared it with the unweighted number that was sampled for study, and it revealed that the sample is balanced. We also carried out the chi-square test if there exists any association between the number of students of weighted and unweighted and the finding was insignificant (chi-square statistic, 0.60; p-value, 0.96) and concluding that there was no association between the two data sets (supporting file 5).

Thirdly, the doubt that has been aroused by the reviewer that the disproportionate sampling would have occur and all the classrooms would have been selected only from bachelor level, we were conscious about that, and we had then selected the classrooms from each of bachelor’s 1st, 2nd, 3rd, 4th, and master’s 1st years in accordance with the proportion to the number of students in the classrooms. So, the representation from all the levels was assured (supporting file 5).

10. Comment # 10: The section on the results of the multivariate analysis reads very poorly. It should be a little more than reproducing the elements of the table. Think of the reader.

Our response: Thinking the reader, as per your suggestions, the manuscript in now revised and added the explanation of each model so that author can connect the interpretation with table easily.

11. Comment # 11: Discussion: Needs improvement in the language and the substance. For instance, what does it mean “The study revealed the aspects of youth's sexual behavior that may point to advance the well-being of youth's reproductive and sexual health”.Besides the clumsy redaction that does not seem to be the purpose of the article. You have looked at the determinants of condom use at last intercourse, and there are no policy variables included.

Our response: “The study revealed the aspects of youth's sexual behavior that may point to advance the well-being of youth's reproductive and sexual health” is replaced by The study examined the determinants of condom use during last sexual intercourse among sexually active male youth of Kaski, Nepal. We have also thoroughly checked the manuscript, that has already clarified in response of comment 9.

As the study had focused on determinants of condom use during last sexual intercourse and had not included policy variables so policy related aspects are no more discussed now in the revised manuscript and is omitted.

12. Upon re-reading of the sampling procedure, it seems that there might be (prior) equal probabilities of selection since all male students in each sampled class were targeted so the probability of selection is given by the proportion of classes surveyed to all classes. There would be unequal probabilities if a fixed number of students were sampled, but this is not apparently the case. However, ex-post there are still different probabilities of sampling in each of the education levels. Eg: What if all the 46 randomly selected classes belonged to the 87 first-year classes? The prior probability of choosing students from each level is the same as in the population, but, after the sample is taken, the proportion of students from each level in the sample could be as drastic as only first-year students. Note you could use weights to adjust for this (unless one education level is totally missing!) defined as the proportion of level i (eg: first year students) in the population divided by the proportion of first year students in your sample. In this way you give more weight to students from levels that are underrepresented and the weights are normalized (have an average of one). This is equivalent to using strata. You can use these weights (defined at the student-year level, first to fourth and postgraduate) in your analysis. Alternatively, you can show that your sample is balanced, (eg, if all weights calculated in this way are very close to one) and not use weights.

Our response: This comment was given on 16th Jul, 2021 and included in comment 9, above, and responded accordingly.

Comments of Reviewer 1 and changes/justification

1. Pokhara and Kaski are interchangeably used in the manuscript, such as in the last sentence in the introduction and some parts of the results. Do both names refer to the same district?

Our response: We are thankful to your comments. Consistency has been maintained through out the manuscript by using the word Kaski.

2. In the sub-section of questionnaire, please provide the citations from where questionnaires were adopted.

Our response: Dear reviewer, citations are now provided while explaining the questionnaires.

3. In the methods section, please make clear whether any records with missing data that were removed from 361 males who engaged in sexual intercourse in last 6 months.

Our response: Dear reviewer, it is now explained in the statistical method section of manuscript and written as Altogether there were 74 ambiguous responses of the sexually active male youth in which 12 responses were of sexually active male youth within six months preceding the survey. Likewise, among 21 incomplete responses, 6 largely incomplete responses were of sexually active male youth within six months preceding the survey. Thus, ambiguous responses that were logically inconsistent were excluded after verification through the consultation of reproductive health experts and incomplete data were also eliminated from the analysis.

4. For bivariate analysis (Table 6), please mention the reference category or group for all variables. No reference group was mentioned for the age of the respondent and educational level.

Our response: The reference group is now mentioned for the age of the respondent and educational level.

5. For the same table, please check again the association between the number of sex partners and condom use. From the table, those who had 2 partners or more were more likely to use a condom at last sex (OR=8.91; 95%CI=5.21-15.24). Surprisingly, based on the differences in the proportion of condom use by the number of sex partners, the proportion of condom use was lower among those with ≥ 2 partners (11.01%) compared to those with 1 partner only (52.44%). Please check again the results whether there was a mistake in coding the categories. Please check also for other variables: level of education, relationship with sex partners, and provide interpretation for Table 6.

Our response: The result of all variables of Table 6 was checked and it was found that there was mistake on data for the association between the number of sex partners and condom use. The proportion of condom users among ≥ 2 partners is 194 (89 %) and with 1 partner only is 68(47.5%).For other variable also it was checked and no mistake was found.

6. Authors reported a high correlation between the age of the respondents and level of education (r=0.9) and decided to not include both variables in the multivariate model. However, two highly correlated variables indicate that both cannot be included in the multivariate model in a time, but we can select one of them. Therefore, authors can include either age of the respondents or educational level in the model. I suspect that educational level can be strongly associated with condom use.

Our response: Educational level is now added in the model.

7. For multivariate analysis (Table 7), I am wondering why the number of sex partners was not statistically significant associated with condom use. The 95%CI (3.01 – 11.07) informs that the value of one (1) is not within the intervals. Please re-check the results.

Our response: The result was checked and it was found that sex partners was statistically significant with condom use in table 7 so the manuscript is revised as per it.

Submitted filename: Response to reviewers_Jul26-2021.docx

Click here for additional data file.

6 Dec 2021

Determinants of condom use during last sexual intercourse among male college youths of Kaski, Nepal: A cross-sectional survey

PONE-D-20-30105R2

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Additional Editor Comments (optional):

The editor wants to commend the authors for a manuscript very much improved that now reads profesionally and has overcome the main limitations of analysis and interpretation making it amenable for publication. It is not felt necessary to send the manuscript back to the reviewers considering the appropriate reaction to reviewer 1 comments and that it was the editor who had the strongest reservations on earlier drafts.

Reviewers' comments:

17 Dec 2021

PONE-D-20-30105R2

Determinants of condom use during last sexual intercourse among male college youth of Kaski, Nepal: A cross-sectional survey

Dear Dr. Adhikari:

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