Assessing the drivers of sexual behavior among youth and its social determinants in Nepal

Grishu Shrestha; Reecha Piya; Sampurna Kakchapati; Parash Mani Sapkota; Deepak Joshi; Sushil Chandra Baral

doi:10.1371/journal.pone.0315495

. 2025 Jan 3;20(1):e0315495. doi: 10.1371/journal.pone.0315495

Assessing the drivers of sexual behavior among youth and its social determinants in Nepal

Grishu Shrestha ¹, Reecha Piya ¹, Sampurna Kakchapati ^1,^*, Parash Mani Sapkota ¹, Deepak Joshi ¹, Sushil Chandra Baral ¹

Editor: Shalik Ram Dhital²

PMCID: PMC11698523 PMID: 39752621

Abstract

Introduction

Sexual behavior among youth is a public health concern, particularly in contexts where cultural norms, socio-economic factors, and access to comprehensive sexual education play pivotal roles. This paper aims to examine the determinants of sexual behavior among Nepali youths.

Methods

This study analyzed data from 7,122 individuals aged 15–24 years from the Nepal Demographic and Health Survey (NDHS) 2022, focusing on a nationally representative sample. This study assessed the prevalence of sexual behaviors, including premarital sex, recent sexual activity, and multiple sexual partners. Determinants examined included socio-demographic characteristics, media use, smoking, and alcohol consumption. Bivariate and multivariate logistic regression analysis were conducted to determine the associations between social determinants and sexual behaviors.

Results

The prevalence of premarital sex among the youth was 10.4%, with 15% of male youths reporting recent sexual activity and 2.8% having sexual intercourse with multiple partners. Variables significantly associated with premarital sex included older age groups (AOR = 2.81; 95% CI: 1.98–3.99), male (AOR = 7.87; 95% CI: 5.00–12.39), sales occupations (AOR = 2; 95% CI:1.12–3.57), smoking (AOR = 2.71; 95% CI:1.74–4.23), smokeless tobacco products (AOR = 1.94; 95% CI:1.12–3.34), and alcohol consumption (AOR = 2.97; 95% CI:2–4.41). Variables significantly associated with recent sexual activity included older age groups (AOR = 2.1; 95% CI:1.46, 3.03), being unmarried (AOR = 9.34; 95% CI:5.19–16.82), smoking (AOR = 2.01; 95% CI:1.33–3.05), use of smokeless products (AOR = 1.7; 95% CI:1.98–3.67), and alcohol consumption (AOR = 1.91; 95% CI:1.30–2.82). Youths using smokeless products had higher odds (AOR = 3.33; 95% CI:1.75–6.35) of having multiple sexual partners compared to those youths not using smokeless products.

Conclusion

Social determinants, along with smoking and alcohol consumption, were associated with sexual behaviors among youth. This study highlights the need for multicomponent health promotion (new public health) interventions which consider multi-level strategies, including culturally tailored sexual health programs, drug use behaviors, healthy lifestyle choices, comprehensive sexual health education for evidence-based interventions.

Introduction

Certain sexual activities may increase the likelihood of sexually transmitted infections (STIs) and unintended pregnancies [1, 2] including having multiple sexual partners, participating in sexual activity under the influence of substances, and not using condoms [2, 3]. These behaviors can lead to reproductive health issues, such as STIs, human immunodeficiency virus (HIV) infections, unintended pregnancies, and abortions, while also contributing to psychological distress [1–3].

According to the United Nations, youth is defined as individuals aged between 15 and 24 years, representing a transitional phase from childhood dependence to adulthood independence [4]. Adolescents often engage in sexual activities at an early age, which become one of the major public health concerns among youth due to potential adverse outcomes [2, 5]. Various factors responsible to youths’ engagement in sexual behavior, including biological factors such as age, sex; social factors such as peer pressure, substance abuse; and psychological factors such as low self-esteem and emotional distress [1–3, 6]. Limited knowledge about the consequences of sexual behavior, developmental stage, and limited access to health care services increase their vulnerability [2, 7]. The Nepal Demographic and Health Survey (NDHS) 2022 revealed that 46% of young women and 39% of young men aged 15–24 years have ever engaged in sexual intercourse. Among never married youths, 25% of men and 2% of women reported having had sex. Three percent of men had two or more sexual partners in the past twelve months, with 15% reporting sexual intercourse with individuals who were neither their wife nor in committed relationships [8].

Nepal has undergone significant demographic transformations, with a raising population of youths aged 15–24 years [4, 9]. As these youths transition into adulthood, they confronted challenges and opportunities related to their sexual well-being [10–12]. This demographic shift has raised a more open attitude towards sexual behaviors, leading to discussions about sexual health and, increasing their vulnerability to STIs/HIV [12]. A study conducted in Kathmandu, Nepal, found that 58% of adolescents had just a moderate knowledge of sexual and reproductive health. This status, however, provides opportunities for effective intervention [13, 14].

Factors such as gender norms and power dynamics greatly influences the sexual behavior of youths. These dynamics can result in situations where individuals, especially young women, have limited agency in making decisions about sex and contraception [14, 15]. Education and economic status are known as critical determinants of sexual behavior [3, 7, 16]. Access to quality education equips young individuals with the knowledge and skills necessary to make informed decisions about their sexual health [11, 15, 17]. Equally, economic vulnerability can impede access to healthcare services, influencing family planning and contraception decisions [7, 18].

Despite improvement in sexual education in Nepal, gaps persist in providing comprehensive information about safe sex practices, use of contraception, and sexual health in line with health promotion best practices [15, 19]. This lack of education contributes to misconceptions and risky behaviors among young people [19, 20]. In many parts of Nepal, especially remote or marginalized communities, access to quality healthcare services, including sexual and reproductive health services, remains limited. This lack of access may result in unprotected sex due to insufficient information, resources, and support [11, 19, 21]. Stigma surrounding discussions of sex can hinder open conversations, contributing in misinformation and risky behavior [21, 22]. With the increasing availability and accessibility of technology, including smartphones and social media, young people in Nepal are exposed to a wide range of information, some of which may be inaccurate or misleading. This digital landscape can significantly influence perceptions and behaviors regarding sex and relationships [23, 24]. Previous studies have documented that various factors influence sexual behavior among youth [1–3, 7], however, this study is significant as it examines the variations in sexual behaviors across different demographic groups, as well as the impact of risky behaviors such as smoking and alcohol use and media exposure [3, 5, 7, 10].

This study aims to explore the determinants of sexual behavior among Nepali youths, examining variations across demographic groups and the influence of risky behaviors such as smoking and alcohol use. The findings will have significant implications for policy and programmatic interventions aimed at promoting sexual health and reducing STI vulnerabilities.

Materials and methods

Data source

This study analyzed secondary data from the NDHS 2022, a nationally representative and internationally comparable descriptive cross-sectional household survey.

Study settings

Nepal is a landlocked country located in South Asia, occupying an area of 147, 516 km². It consists of seven administrative provinces, which include 77 districts, six metropolitan cities, 11 sub-metropolitan cities, 276 urban municipalities, and 460 rural municipalities distributed across three ecological belts: mountain, hill, and terai.

Sample size

The sample size and sampling technique of NDHS 2022 are described elsewhere [25]. The NDHS-2022 dataset included approximately 4,913 males and 14,845 females. For this study, data were extracted from NPMR82SV SPPS 20 version file, focusing on youth aged 15–24 years, resulting in a subset sample of 7,122 individuals (1,842 male youths and 5,280 female youths) were considered.

Study variables

Dependent variables

The outcomes for this study were premarital sex, recent sexual activity, and multiple sexual partners. Premarital sex refers to never-married youths who have engaged in sexual intercourse. Recent sexual activity is considered as having sexual intercourse in the last 12 months with a partner who was not a wife or cohabitant. Multiple sexual partners is defined as having sexual intercourse with more than one partner in the past 12 months. Data on premarital sex encompasses a sample of 4426 male and female youths including those who were unmarried, while recent sexual activity and multiple partners include the data of 1,842 male youths.

Independent variables

Independent variables included individual youth characteristics, household characteristics, and community characteristics. Individual youth characteristics include age (15–19 years and 20–24 years), sex (male and female) marital status (married and unmarried), education (no education, basic, secondary, higher), occupation (not working, agriculture, professional or technical or manager or clerical, sales and service, skilled or unskilled labor, others), used of media (yes, no), use of internet (yes, no), current smoking status (yes, no), use of smokeless products (yes, no) and alcohol consumption (yes, no). Household characteristics include religion (Buddhist, Christian, Hindu, Muslim, Others), ethnicity (Dalits, Janajati, Muslim, Other Terai caste, Upper Caste Groups), number of family members (1–2 members, 3–5 members, 6 members and above), and wealth quintile (poor, middle, and rich). The wealth index was modified from five wealth quintiles to three wealth quintiles for easy explanation, communication and data limitations. Community characteristics include area of residence (urban and rural), ecological region (mountain, hill and terai), province (Koshi, Madhesh, Bagmati, Gandaki, Lumbini, Karnali, and Sudurpaschhim)

Statistical analysis

Data were extracted in SPSS version 20 and the SPSS datasets were imported to R statistical program for further analyses. The analyses included descriptive statistics, bivariate analysis, and logistic regression analysis. All data were weighted to account for the complex sample design, such as stratified sampling and unequal selection probabilities. The study utilized weighted techniques based on NDHS data to account for the complex survey design and ensure the representativeness of the analyses. The NDHS dataset provides sampling weights for each respondent, which was used to adjust for selection of probabilities at different stages of sampling, including stratification and clustering. These sampling weights are crucial for generating nationally representative estimates and accounting for oversampling in specific regions or population groups.

Pearson’s Chi-squared test assessed children’s characteristics, mother’s characteristics, and household characteristics among children who were developmentally on track. Statistical analysis was conducted using R version 4.2.0 and RStudio 1314, employing the survey package for weighted analysis. Initially, each explanatory determinant were included in the model individually to examine its univariate relationship with the outcomes. Variable with significant univariate relationships (p < 0.05) were considered for inclusion in multivariate logistic regression models to identify key determinants.

The rationale behind, initially including variables one at a time helped avoid multicollinearity and assess each determinant’s unique contribution to the outcome. This step-by-step approach identified potential confounders and interactions influencing the final multivariate models. Multivariate logistic regression models were then constructed to identify the most important determinants for each outcome, based on their theoretical relevance and statistical significance in univariate analysis. Adjusted odds ratios (AORs) and their 95% confidence intervals (95% CI) were calculated to depict the independent relationships between independent and dependent variables.

Ethics statement

The primary data of the NDHS 2022 was approved by Nepal Health Research Council (NHRC) and made publicly available while ensuring participants anonymity. Secondary data was accessed through the DHS program.

Results

Table 1 shows the socio‑demographic characteristics of youths. The age distribution was evenly represented, with 51% in the 15–19 age group. Gender-wise, females were higher represented, comprising 74% of the population. Urban areas were slightly overrepresented, with 69% of youths residing in urban settings. Geographically, the majority of youths were from the terai region (57%). In terms of provinces, Madhesh, Bagmati, and Lumbini province had higher representation of youths. The religious composition was primarily Hindu with 82% of people falling in this group. Ethnicity, more than one third (34%) of youths belonged to the Janajati group. Educational attainment varied, with majority (60%) having completed secondary education. The occupational distribution illustrated a diverse range of employment statuses, with 40.7% reporting unemployment; the most common occupation reported was unskilled manual (6.8%). Family sizes were varied, with 38.1%) having six or more members. The wealth quintile showed a higher distribution among the rich (41.8%). In terms of health-related behaviors, the majority of youths did not engage in smoking (93%), use of smokeless products (94%), or consume alcohol (88%). Regarding sexual behavior, approximately 10.4% reported engaging in premarital sex, 15% reported recent sexual activity, and 2.8% reported having multiple sex partners.

Table 1. Socio demographic characteristics of youths (N = 7,122).

Characteristic	Overall	Percentage
Characteristic	N = 7122	(%)
Age
15–19 years	3,627	51
20–24 years	3,495	49
Sex
Male	1,842	26
Female	5,280	74
Residence
Rural	2,205	31
Urban	4,917	69
Ecological Region
Mountain	355	5
Hill	2,740	38
Terai	4,028	57
Province
Koshi	1,166	16
Madhesh	1,648	23
Bagmati	1,423	20
Gandaki	586	8.2
Lumbini	1,192	17
Karnali	478	6.7
Sudurpashchim	630	8.8
Religion
Buddhist	473	6.6
Christian	215	3
Hindu	5,862	82
Muslim	399	5.6
Others	174	2.4
Ethnicity
Dalits	1,149	16
Janajati	2,439	34
Muslim	394	5.5
Other Terai caste	1,200	17
Upper Caste Groups	1,941	27
Education
No education	410	5.8
Basic	2,287	32
Secondary	4,271	60
Higher	154	2.2
Occupation
Agriculture	373	5.2
Clerical	116	1.6
Not working	2,901	40.7
Professional/technical/managerial	310	4.3
Sales	451	6.3
Skilled manual	469	6.5
Unskilled manual	484	6.8
Unknown	2018	28.3
Family members
1–2 members	525	7.3
3–5 members	2,458	34.5
6 or more members	2,715	38.1
Unknown	1423	19.9
Wealth Quintile
Poor	2,730	38.3
Middle	1,414	19.8
Rich	2,978	41.8
Use of Media
No	1,336	19
Yes	5,786	81
Use of internet
No	1,305	18
Yes	5,817	82
Current Smoking
No	6,612	93
Yes	510	7.2
Use of Smokeless products
No	6,691	94
Yes	431	6
Alcohol Consumption
No	6,270	88
Yes	712	10
Unknown	140	1.9
Premarital Sex (N = 4426)
Yes	462	10.4
No	3964	89.6
Multiple Sex Partners (N = 1,842)
Yes	51	2.8
No	1791	97.2
Recent Sexual Activity (N = 1,842)
Yes	278	15
No	1564	85

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Table 2 provides the results of the bivariate and multivariate analysis of factors associated with premarital sex among youths. The multivariate analysis identified several significant associations, including age, sex, ethnicity, occupation, number of family members, current smoking status, use of smokeless products, and alcohol consumption. Youths from the age group of 20–24 years had higher odds (AOR = 2.81; 95% CI: 1.98–3.99) of engaging in premarital sex compared to those youths from the 15–19 years age group. Male youths were 7.87 times more likely to have premarital sex than female youths (AOR = 7.87; 95% CI: 5.00–12.39). Those from other terai caste (Teli, Kalwar, Kurmi and others) had lower odds to have premarital sex (AOR = 0.3; 95% CI:0.16–0.56) compared to youth from Dalit ethnicity. Youths employed in sales were twice as likely to engage in premarital sex compared to those youths in agriculture (AOR = 2; 95% CI:1.12–3.57). Moreover, youths who belonged to the family with more family members were less likely to have premarital sex; those from families with 3–5 family members had lower odds (AOR = 0.52; 95% CI:0.31–0.85), and those with six or more members also had lower odds (AOR = 0.5; 95% CI:0.3–0.84) compared to youths from families with one to two family members. Youth who were current smokers had higher odds (AOR = 2.71; 95% CI:1.74–4.23) of having premarital sex compared to who did not smoke. Youth who were using smokeless products were 1.94 times more likely to have premarital sex (AOR = 1.94; 95% CI:1.12–3.34) than those youth who were not using such products. Youth who consumed alcohol were 2.97 times more likely to engage premarital sex (AOR = 2.97; 95% CI:2–4.41) than those who did not consume alcohol.

Table 2. Factors associated with premarital sex among youths (N = 4426).

Characteristic	Yes	Total	Unadjusted			Adjusted
Characteristic	(%)	(n = 462)	OR	95% CI	p- value	OR	95% CI	p- value
Age
15–19 years	5.6	168	1			1
20–24 years	20.9	294	4.49	3.56,	<0.001	2.8	1.98,	<0.001
20–24 years	20.9	294	4.49	5.66	<0.001	1	3.99	<0.001
Sex
Female	3.0	88	1			1
Male	25.0	374	10.78	8.19,	<0.001	7.8	5.00,	<0.001
Male	25.0	374	10.78	14.1	<0.001	7	12.3	<0.001
Residence
Rural	10.3	130	1
Urban	10.5	332	1.02	0.82,	0.89
Urban	10.5	332	1.02	1.26	0.89
Ecological Region
Mountain	10.6	20	1
Hill	11.6	214	1.11	0.69,	0.66
Hill	11.6	214	1.11	1.77	0.66
Terai	9.5	228	0.89	0.56,	0.63
Terai	9.5	228	0.89	1.42	0.63
Province
Koshi	9.4	68	1
Madhesh	7.1	60	0.74	0.49,	0.14
Madhesh	7.1	60	0.74	1.11	0.14
Bagmati	12.9	141	1.43	0.98,	0.06
Bagmati	12.9	141	1.43	2.07	0.06
Gandaki	12.7	50	1.4	0.93,	0.11
Gandaki	12.7	50	1.4	2.12	0.11
Lumbini	10.0	74	1.07	0.73,	0.72
Lumbini	10.0	74	1.07	1.57	0.72
Karnali	12.7	32	1.4	0.95,	0.09
Karnali	12.7	32	1.4	2.06	0.09
Sudurpashchim	9.6	37	1.02	0.69,	0.91
Sudurpashchim	9.6	37	1.02	1.52	0.91
Religion
Buddhist	15.2	50	1			1
Christian	12.5	16	0.8	0.39,	0.54	1.43	0.50,	0.51
Christian	12.5	16	0.8	1.64	0.54	1.43	4.12	0.51
Hindu	10.1	366	0.62	0.41,	0.03	1.02	0.55,	0.95
Hindu	10.1	366	0.62	0.95	0.03	1.02	1.89	0.95
Muslim	8.7	20	0.53	0.27,	0.08	0.93	0.34,	0.9
Muslim	8.7	20	0.53	1.07	0.08	0.93	2.58	0.9
Others	9.0	10	0.55	0.25,	0.15	0.46	0.13,	0.23
Others	9.0	10	0.55	1.24	0.15	0.46	1.61	0.23
Ethnicity
Dalits	11.5	68	1			1
Janajati	13.2	210	1.18	0.84,	0.35	0.9	0.55,	0.87
Janajati	13.2	210	1.18	1.66	0.35	5	1.67	0.87
Muslim	8.9	20	0.75	0.40,	0.38
Muslim	8.9	20	0.75	1.43	0.38
Other Terai caste	5.9	38	0.48	0.30,	<0.001	0.3	0.16,	<0.001
Other Terai caste	5.9	38	0.48	0.77	<0.001	0.3	0.56	<0.001
Upper Caste Groups	9.2	126	0.78	0.55,	0.19	0.9	0.51,	0.73
Upper Caste Groups	9.2	126	0.78	1.13	0.19	0.9	1.61	0.73
Education
No education	5.3	6	1			1
Basic	10.2	119	2.01	0.70,	0.19	1.01	0.23, 4.45	0.99
Basic	10.2	119	2.01	5.78	0.19	1.01	0.23, 4.45	0.99
Secondary	10.4	317	2.07	0.73,	0.17	1.32	0.29, 5.92	0.72
Secondary	10.4	317	2.07	5.88	0.17	1.32	0.29, 5.92	0.72
Higher	17.4	20	3.75	1.14,	0.03	1.44	0.26, 7.86	0.67
Higher	17.4	20	3.75	12.29	0.03	1.44	0.26, 7.86	0.67
Occupation (n = 434)
Agriculture	19.4	59	1			1
Clerical	7.2	6	0.32	0.11,	0.04	0.69	0.19,	0.56
Clerical	7.2	6	0.32	0.96	0.04	0.69	2.42	0.56
Not working	5.5	108	0.24	0.17,	<0.001	0.72	0.45,	0.19
Not working	5.5	108	0.24	0.35	<0.001	0.72	1.17	0.19
Professional/technical/managerial	15.6	36	0.77	0.46,	0.33	1.38	0.70,	0.36
Professional/technical/managerial	15.6	36	0.77	1.30	0.33	1.38	2.72	0.36
Sales	20.4	63	1.76	1.14,	0.01	2	1.12,	0.02
Sales	20.4	63	1.76	2.71	0.01	2	3.57	0.02
Skilled manual	29.7	84	1.07	0.68,	0.77	1.54	0.82,	0.18
Skilled manual	29.7	84	1.07	1.69	0.77	1.54	2.88	0.18
Unskilled manual	23.9	78	1.31	0.88,	0.19	1.16	0.66,	0.61
Unskilled manual	23.9	78	1.31	1.96	0.19	1.16	2.03	0.61
Family members (n = 387)
1–2 members	19.7	64	1			1
3–5 members	11.2	186	0.51	0.35,	<0.001	0.52	0.31, 0.85	0.01
3–5 members	11.2	186	0.51	0.76	<0.001	0.52	0.31, 0.85	0.01
6 or more members	9.1	137	0.41	0.27,	<0.001	0.5	0.30, 0.84	0.009
6 or more members	9.1	137	0.41	0.61	<0.001	0.5	0.30, 0.84	0.009
Wealth Quintile
Middle	9.8	82	1
Poor	10.1	148	1.04	0.77,	0.81
Poor	10.1	148	1.04	1.39	0.81
Rich	11.0	232	1.14	0.84,	0.4
Rich	11.0	232	1.14	1.54	0.4
Use of Media
No	12.3	86	1
Yes	10.1	376	0.8	0.59,	0.16
Yes	10.1	376	0.8	1.09	0.16
Use of Internet
No	4.8	33	1			1
Yes	11.5	429	2.58	1.77,	<0.00	0.93	0.51,	0.82
Yes	11.5	429	2.58	3.76	1	0.93	1.71	0.82
Current Smoking
No	7.2	294	1			1
Yes	48.9	168	12.3	9.18,	<0.00	2.71	1.74,	<0.001
Yes	48.9	168	12.3	16.49	1	2.71	4.23	<0.001
Use of Smokeless products
No	8.5	353	1			1
Yes	43.6	109	8.38	6.03,	<0.00	1.94	1.12,	0.017
Yes	43.6	109	8.38	11.64	1	1.94	3.34	0.017
Alcohol Consumption
No	6.5	253	1			1
Yes	39.6	196	9.4	7.25,	<0.001	2.97	2.00,	<0.001
Yes	39.6	196	9.4	12.18	<0.001	2.97	4.41	<0.001

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Table 3 shows the results of the bivariate and multivariate analysis of factors associated with recent sexual activity among male youths. The multivariate analysis identified significant associations with age, ethnicity, marital status, current smoking status, use of smokeless products, and alcohol consumption. Youths from the age group of 20–24 years were 2.11 times more likely to engage in recent sexual activity than to those youths from the age group of 15–19 years (AOR = 2.11; 95% CI:1.46–3.03). Those belonging to other terai caste were 30% less likely to engage in recent sexual activity (AOR = 0.3; 95% CI:0.15–0.56) compared to youths from Dalit ethnicity. The male youths who were unmarried were 9.34 times more likely to have engaged in recent sexual activity (AOR = 9.34; 95% CI:5.19–16.82) than the male youths who were married. Youth who were current smokers were 2 times more likely to have recent sexual activity (AOR = 2; 95% CI: 1.33, 3.05) than those youth who were non-smokers. Youths using smokeless products were more likely to have recent sexual activity (AOR = 1.7; 95% CI: 1.33, 3.05) compared to those youth who did not used smokeless products. Youth, those who consumed alcohol were almost twice more likely to have recent sexual activity (AOR = 1.9; 95% CI: 1.30, 2.82) compared to those youth who did not consume alcohol.

Table 3. Factors associated with recent sex among male youth (N = 1,842).

Characteristic	Yes (%)	Total (n = 278)	Unadjusted			Adjusted
Characteristic	Yes (%)	Total (n = 278)	OR	95% CI	p-value	OR	95% CI	p-value
Age
15–19 years	10.1	99	1			1
20–24 years	20.9	179	4.5	3.56,	<0.001	2.1	1.46, 3.03	<0.001
20–24 years	20.9	179	4.5	5.66	<0.001	2.1	1.46, 3.03	<0.001
Residence
Rural	15.6	81	1
Urban	3.0	197	1	0.82,	0.89
Urban	3.0	197	1	1.26	0.89
Ecological Region
Mountain	18.4	15	1
Hill	17.4	127	1.1	0.69,	0.66
Hill	17.4	127	1.1	1.77	0.66
Terai	13.2	136	0.9	0.56,	0.63
Terai	13.2	136	0.9	1.42	0.63
Province
Koshi	12.2	38	1
Madhesh	7.8	34	0.7	0.49,	0.14
Madhesh	7.8	34	0.7	1.11	0.14
Bagmati	19.1	87	1.4	0.98,	0.06
Bagmati	19.1	87	1.4	2.07	0.06
Gandaki	19.3	24	1.4	0.93,	0.11
Gandaki	19.3	24	1.4	2.12	0.11
Lumbini	21	58	1.1	0.73,	0.72
Lumbini	21	58	1.1	1.57	0.72
Karnali	16.7	17	1.4	0.95,	0.09
Karnali	16.7	17	1.4	2.06	0.09
Sudurpashchim	14.4	20	1	0.69,	0.91
Sudurpashchim	14.4	20	1	1.52	0.91
Religion
Buddhist	18.2	27	1			1
Christian	9	5	0.8	0.39,	0.54	0.7	0.15, 3.16	0.63
Christian	9	5	0.8	1.64	0.54	0.7	0.15, 3.16	0.63
Hindu	15.3	227	0.6	0.41,	0.03	1.3	0.60, 2.63	0.55
Hindu	15.3	227	0.6	0.95	0.03	1.3	0.60, 2.63	0.55
Muslim	14.2	16	0.5	0.27,	0.08	1.3	0.43, 3.90	0.65
Muslim	14.2	16	0.5	l.07	0.08	1.3	0.43, 3.90	0.65
Others	8.3	4	0.6	0.25,	0.15	0.4	0.13, 1.39	0.16
Others	8.3	4	0.6	1.24	0.15	0.4	0.13, 1.39	0.16
Ethnicity
Dalits	16.2	44	l			1
Janajati	18.5	119	1.2	0.84,	0.35	1	0.59, 1.73	0.98
Janajati	18.5	119	1.2	1.66	0.35	1	0.59, 1.73	0.98
Muslim	14.2	16	0.8	0.40,	0.38	0.9	0.56, 2.43	0.48
Muslim	14.2	16	0.8	1.43	0.38	0.9	0.56, 2.43	0.48
Other Terai caste	6.6	23	0.5	0.30,	< 0.001	0.3	0.15, 0.56	<0.001
Other Terai caste	6.6	23	0.5	0.77	< 0.001	0.3	0.15, 0.56	<0.001
Upper Caste Groups	16.2	78	0.8	0.55,	0.19	0.8	0.47, 1.42	0.47
Upper Caste Groups	16.2	78	0.8	1.13	0.19	0.8	0.47, 1.42	0.47
Marital Status
Married	5.6	19	1			1
Unmarried	17.3	259	3.6	2.13,	<0.001	9.3	5.19, 16.82	<0.001
Unmarried	17.3	259	3.6	5.92	<0.001	9.3	5.19, 16.82	<0.001
Education
No education	11.9	6	1			1
Basic	10.6	65	1.4	0.47,	0.54	0.7	0.20, 2.61	0.61
Basic	10.6	65	1.4	4.24	0.54	0.7	0.20, 2.61	0.61
Secondary	17	193	2.1	0.72,	0.17	1.6	0.43, 5.61	0.5
Secondary	17	193	2.1	6.29	0.17	1.6	0.43, 5.61	0.5
Higher	31.9	14	4.3	1.16,	0.03	2.4	0.52, 10.79	0.26
Higher	31.9	14	4.3	16.16	0.03	2.4	0.52, 10.79	0.26
Occupation
Agriculture	11.9	45	1			1
Clerical	32	6	3.5	1.03,	0.04	2.2	0.63, 7.83	0.21
Clerical	32	6	3.5	11.74	0.04	2.2	0.63, 7.83	0.21
Not working	9.2	55	0.8	0.47,	0.22	0.6	0.39, 1.04	0.071
Not working	9.2	55	0.8	1.19	0.22	0.6	0.39, 1.04	0.071
Professional/technical/man agerial	23.6	21	2.3	1.12,	0.02	1.3	0.60, 2.66	0.53
Professional/technical/man agerial	23.6	21	2.3	4.65	0.02	1.3	0.60, 2.66	0.53
Sales	21.7	35	2	1.17,	0.01	1.3	0.71, 2.39	0.39
Sales	21.7	35	2	3.57	0.01	1.3	0.71, 2.39	0.39
Skilled manual	21.6	63	2	1.26,	<0.001	l.7	0.95, 3.11	0.073
Skilled manual	21.6	63	2	3.29	<0.001	l.7	0.95, 3.11	0.073
Unskilled manual	17.1	54	1.5	0.97,	0.07	1.4	0.80, 2.28	0.27
Unskilled manual	17.1	54	1.5	2.39	0.07	1.4	0.80, 2.28	0.27
Family Members
1–2 members	21.1	33	1
3–5 members	15	109	0.7	0.38,	0.15
3–5 members	15	109	0.7	1.16	0.15
6 or more members	14.2	86	0.6	0.35,	0.1
6 or more members	14.2	86	0.6	1.10	0.1
Wealth Quintile
Middle	12.2	43	1
Poor	14	90	1.2	0.78,	0.44
Poor	14	90	1.2	1.76	0.44
Rich	17.2	145	1.5	0.99,	0.06
Rich	17.2	145	1.5	2.27	0.06
Use of Media
No	14	46	1
Yes	15.3	233	1.1	0.70,	0.65
Yes	15.3	233	1.1	1.76	0.65
Use of Internet
No	11	17	l
Yes	15.5	261	1.5	0.84,	0.17
Yes	15.5	261	1.5	2.64	0.17
Current Smoking
No	1 l.5	160	l			I
Yes	26.4	118	2.8	2.01,	<0.001	2	1.33, 3.05	0.001
Yes	26.4	118	2.8	3.80	<0.001	2	1.33, 3.05	0.001
Use of Smokeless products
No	13.2	198	1			1
Yes	23.3	80	2	1.41,	<0.001	1.7	1.04, 2.79	0.035
Yes	23.3	80	2	2.82	<0.001	1.7	1.04, 2.79	0.035
Alcohol Consumption
No	11.I	146	I			1
Yes	25.1	132	2.7	1.98,	<0.001	1.9	1.30, 2.82	0.001
Yes	25.1	132	2.7	3.67	<0.001	1.9	1.30, 2.82	0.001

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Table 4 presents the results of the bivariate and multivariate analysis of factors associated with having multiple sexual partners among male youths. In the multivariate analysis, ethnicity, and the use of smokeless products were significantly associated with having multiple sexual partners. The youths belonging to other terai caste had lower odds (AOR = 0.022; 95% CI:0.03–0.77) of having multiple sex partner compared to those from the Dalit ethnicity. Youths using smokeless products were more likely to have multiple sex partner (AOR = 3.33; 95% CI:1.75–6.35) compared to those youths who did not use such products.

Table 4. Factors associated with multiple sexual partners among male youth (N = 1,842).

Characteristic	Yes (%)	Total (n = 51)	Unadjusted			Adjusted
Characteristic	Yes (%)	Total (n = 51)	OR	95% CI	p-value	OR	95% CI	p-value
Age
15–19 years	1.6	16	1			1
20–24 years	4.1	35	2.54	1.23,	0.01	1.57	0.79,	0.2
20–24 years	4.1	35	2.54	5.23	0.01	1.57	3.14	0.2
Residence
Rural	2.2	11	1
Urban	3.0	40	1.4	0.72,	0.32
Urban	3.0	40	1.4	2.70	0.32
Ecological Region
Mountain	3.8	3	1
Hill	2.9	21	0.77	0.29,	0.61
Hill	2.9	21	0.77	2.05	0.61
Terai	2.6	27	0.68	0.28,	0.39
Terai	2.6	27	0.68	1.66	0.39
Province
Koshi	2.4	7	1
Madhesh	1.5	7	0.64	0.19,	0.46
Madhesh	1.5	7	0.64	2.10	0.46
Bagmati	3.6	16	1.54	0.51,	0.44
Bagmati	3.6	16	1.54	4.61	0.44
Gandaki	1.8	2	0.76	0.18,	0.71
Gandaki	1.8	2	0.76	3.25	0.71
Lumbini	4.1	11	1.79	0.65,	0.26
Lumbini	4.1	11	1.79	4.93	0.26
Karnali	2.9	3	1.26	0.42,	0.68
Karnali	2.9	3	1.26	3.77	0.68
Sudurpashchim	3.0	4	1.29	0.43,	0.65
Sudurpashchim	3.0	4	1.29	3.91	0.65
Religion
Buddhist	2.3	3
Christian	0	0
Hindu	3.0	45
Muslim	2.8	3
Others	0	0
Ethnicity
Dalits	4.6	12	1			1
Janajati	3.2	20	0.68	0.29,	0.37	0.73	0.31,	0.47
Janajati	3.2	20	0.68	1.58	0.37	0.73	1.71	0.47
Muslim	2.8	3	0.58	0.12,	0.5	0.82	0.18,	0.79
Muslim	2.8	3	0.58	2.79	0.5	0.82	3.70	0.79
Other Terai caste	0.7	2	0.14	0.03,	0.01	0.16	0.03,	0.022
Other Terai caste	0.7	2	0.14	0.68	0.01	0.16	0.77	0.022
Upper Caste Groups	2.7	13	0.56	0.21,	0.25	0.86	0.31,	0.78
Upper Caste Groups	2.7	13	0.56	1.51	0.25	0.86	2.44	0.78
Marital Status
Married	4.3	15
Unmarried	2.4	36
Education
No education	0.0	0
Basic	2.8	17
Secondary	2.6	30
Higher	9.6	4
Occupation
Agriculture	1.3	5
Clerical	0.0	0
Not working	2.3	14
Professional/technical/man agerial	4.4	4
Sales	3.4	6
Skilled manual	3.8	11
Unskilled manual	3.9	12
Family Members
1–2 members	2.2	3	1
3–5 members	3.2	23	1.45	0.25,	0.68
3–5 members	3.2	23	1.45	8.39	0.68
6 or more members	2.7	16	1.23	0.21,	0.82
6 or more members	2.7	16	1.23	7.24	0.82
Children
More than one child	5.5	3	1
No children	2.7	45	0.47	0.14,	0.22
No children	2.7	45	0.47	1.58	0.22
One child	2.8	4	0.49	0.11,	0.34
One child	2.8	4	0.49	2.17	0.34
Wealth Quintile
Middle	2.5	9	1
Poor	2.3	15	0.91	0.40,	0.83
Poor	2.3	15	0.91	2.08	0.83
Rich	3.3	28	1.32	0.56,	0.52
Rich	3.3	28	1.32	3.12	0.52
Use of Media
No	3.0	10	1
Yes	2.7	41	0.89	0.34,	0.82
Yes	2.7	41	0.89	2.37	0.82
Use of Internet
No	1.0	2	1
Yes	2.9	50	3.1	0.69,	0.14
Yes	2.9	50	3.1	13.80	0.14
Current Smoking
No	1.8	25	1			1
Yes	5.9	26	3.52	1.77,	<0.001	1.65	0.74,	0.22
Yes	5.9	26	3.52	6.98	<0.001	1.65	3.70	0.22
Use of Smokeless products
No	1.6	24	1			1
Yes	8.0	27	5.44	2.76,	<0.001	3.33	1.75,	<0.001
Yes	8.0	27	5.44	10.74	<0.001	3.33	6.35	<0.001
Alcohol Consumption
No	1.6	21	1			1
Yes	5.7	30	3.7	1.87,	<0.001	1.96	0.91,	0.083
Yes	5.7	30	3.7	7.35	<0.001	1.96	4.21	0.083

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Discussion

The study findings identified a significant proportion of youths engaging in premarital sex, with a notable prevalence among male who reported recent sexual activity and multiple sexual partners. It was found that 2.8% of the female youths and 25% male youths reported engaging in premarital sex. There was a significant increase in premarital sexual activity among females from 2016, when the prevalence was 0.6%, while the prevalence among males remained relatively stagnant at 25.4% in 2016 [8]. The rise in premarital sexual activity among females can be attributed to changing societal norms, improved education and awareness, urbanization, economic independence, delayed marriages, peer influence, access to contraceptives, and women’s empowerment in recent years [12, 14, 15, 18]. Moreover, the study indicates that 15% of male youths have been involved in recent sexual activity, that was similar to findings from NHDS 2016 data (15.8%).These similarities can be attributed to cultural and social norms, a lack of comprehensive sexual education, and limited access to youth-friendly sexual and reproductive health services, all of which contribute to sustained patterns of sexual behavior among male youth over time. However, the proportion of male youths reporting multiple sexual partners was 2.8%, a decrease from 4% based on NDHS 2016 data. This decline suggest that comprehensive sex education has effectively conveyed the importance of responsible sexual behavior to male youths, emphasizing the benefits of monogamous relationships and raising awareness about STI/HIV and the risks associated with multiple partners [19, 21]. Male youths may be placing greater emphasis on the quality and stability of relationships rather than the quantity of partners. This shift potentially influenced by changing societal attitudes towards commitment and long-term partnerships [14, 20, 26]. Our findings suggest that while females are exploring premarital relationships, and male are becoming more cautious concerning engagement in multiple sexual partnerships. These distinguishing findings highlight the need for comprehensive awareness programs that addresses the evolving dynamics of sexual relationships for both sex. Despite existing laws intended to protect minors from engaging in sexual activities [27, 28], the persistently high prevalence of sexual activities necessities targeted educational programs aimed at adolescents and youths population.

In the multivariate analysis, age was associated with premarital sex and recent sexual activity. Regarding age differences (15–19 versus 20–24 years), this study confirmed that youths, who were involved in premarital sexual intercourse and recent sexual activity are comparatively more prevalent among the older age group (20–24 years). This finding aligns with similar studies [3, 5–7, 16, 17], emphasizing that older youth may face increased exposure to factors influencing sexual behavior. Social norms and peer influences also play significant roles, with older adolescents often feeling more societal pressure to engage in sexual relationships. Moreover, they are characterized by a greater emotional and physical intimacy and a preference for stable relationships or cohabitation, compared to younger adolescents who may be exploring romantic relationships for the first time [5, 10, 12].

This study has shown that male youths were more likely to be involved in premarital sex than female youths. This result is consistent with previous studies indicating that young males were more likely to have premarital sex than young females [1, 4, 16, 29]. The reason behind this might be that Nepal is a patriarchal country where males generally enjoy greater freedom compared to females [9, 10, 14]. Males can enjoy their gender privilege, while females are often expected to adhere to social norms and beliefs which oppose premarital sexual activity. Females are expected to maintain their virginity till marriage, as their virginity is greatly valued [9, 15, 30]. In addition, while considering the consequences of sexual activity, females are at higher risk of experiencing sexual health consequences like acquiring STI/HIV, teenage pregnancy, and unsafe abortion, which may make them less likely to engage in premarital sex due to the potential for unnecessary troubles and various complications [17, 30, 31]. However, underreporting of the private sexual activity by females might also be another determinant to this disparity [32].

Ethnicity was found to be associated with all sexual risk behaviors (premarital sex, recent sexual activity, and multiple partners), as the youths belonging to other terai castes were found to be less likely to be engaged in sexual risk behavior. Traditional cultural norms and values within these ethnic groups emphasize stricter social norms and expectations regarding sexual conduct. Additionally, the influence of cultural practice and community norms may play a role in discouraging premarital sex and sexual activity with multiple partners [14, 32, 33].

Youths employed in sales were more likely to be involved in premarital sex compared to those working in agriculture. Studies found that youths engaged in sales are exposed to large numbers of customers and people from different places and backgrounds [15, 20, 34] and their roles require frequent interaction with customers, people who are extroverted and possess strong communication skills are typically hired [34, 35]. The nature of their job and interactions with people may facilitate the formation of sexual partners and promote sexual activity and have active in sex life [10, 12, 34, 35]. Targeted interventions, such as awareness programs, could be provided to such youths, utilizing national and regional census data that include information about their occupation.

The findings of this study have shown that an increase in family size decreases the likelihood of engaging premarital sex. A possible explanation for this finding is that larger family size tends to result in increased supervision of individual family members, placing youths under the control of their elder household members, like parents, grand-parents, or guardians, which will hinder them from engaging in any risk taking behavior, including sexual activity [3, 26, 36]. Moreover, having many family members may allow them to spend more time with their families, and so reducing their time with peers and lowering the influence of peer pressure [26, 36]. Similar findings have been shown in studies indicating that youths living without their family or independently from their families are more likely to have sexual behavior compared to those who live with their family members [29, 36], as they enjoy greater freedom from the misunderstanding of older household members, leading to increase participation in various risky behaviors including early sexual activity.

Consistent with many studies [3, 5, 6, 16, 35], this study demonstrates a relationship between the current smoking status of youths and premarital sex as well as recent sexual activity. Additionally, the use of smokeless products was also found to be associated with premarital sex, recent sexual activity, and multiple sexual partners. Therefore, the use of any tobacco products, either cigarettes or electronic cigarettes (vapes), or chewing tobacco, can impair judgment, leading to riskier decision-making and engagement in sexual behavior [6, 7, 17]. Furthermore, social and cultural factors, such as peer influence and norms within tobacco-using communities, could contribute to higher rates of sexual activity among users of these products [14, 15, 18].

This study revealed that youth consuming alcohol increases the likelihood of involving in sexual behavior, which is similar to the findings of previous studies [3, 33, 37]. The possible explanation may be that consumption of alcohol impairs mental capabilities, inhibiting the ability to recognize risks related to sexual behavior [33, 38]. Alcohol consumption is often intertwined with social settings and peer interactions, where norms surrounding sexual behavior may be less restrained. Moreover, alcohol consumption decreases self-control, which may lead to increased sexual activity among male youths. Likewise, young people generally use alcohol as a strategy to facilitate sexual meets [33, 37, 38].

This study had few limitations. The cross-sectional nature of the data collection limits the power to establish a causal relationship. This study also did not include potentially significant variables such as parental influence, substance use, survival sex due to lack of data limitations, which could provide a comprehensive understanding of the factors influencing sexual behavior among youths. Despite these limitations, the study possesses certain strengths, including, the use of a nationally representative dataset, enhancing the generalizability of the findings to the broader youth population in Nepal.

Conclusion

This study determines vital insights into how socio-demographic variables and risk behaviors are associated with sexual behaviors among youths, presenting the need for targeted interventions. These findings highlighted the importance of behavior change communication using socioecological and health promotion models. This study recommends increasing health literacy, creating an enabling environment for safer sexual behaviors, and playing the mediating roles of different public, private, health, and non-health stakeholders.

Supporting information

S1 File

(RCM)

pone.0315495.s001.Rcm^{(41.9KB, Rcm)}

Acknowledgments

Authors would like to acknowledge the DHS program for allowing us to use the NDHS 2022 data.

Data Availability

The data are available publicly in the open-access repository. The data can be downloaded from the official website of ‘The Demographic and Health Surveys’ program.(https://dhsprogram.com/data/dataset/Nepal_Standard-DHS_2022.cfm?flag=0). The R script required to run the analysis is provided as a Supporting Information file.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0315495.r001

Decision Letter 0

Shalik Ram Dhital

20 Feb 2024

PONE-D-24-00348Exploring the Drivers of Risky Sexual Behavior and its social determinants in Nepali Youth: Insights from NDHS 2022PLOS ONE

Dear Dr. Kakchapati,

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.

Please submit your revised manuscript by Apr 05 2024 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:

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We look forward to receiving your revised manuscript.

Kind regards,

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Authors

I am writing to express my gratitude for your submission of “Exploring the Drivers of Risky Sexual Behavior and its social determinants in Nepali Youth: Insights from NDHS 2022” PONE-D-24-00348 to the PLOS ONE journal. I am pleased to inform you that your paper has undergone initial review, and we have received feedback from two reviewers who have provided valuable insights and suggestions for improvement.

Firstly, I would like to commend you on the quality of your work. We found merit in your research, acknowledging its potential significance to the field. However, there are several areas identified where revisions could enhance the clarity, rigor, and impact of your findings.

I have attached the reviewers' comments and suggestions for your consideration. Each comment has been carefully addressed to guide you in addressing specific aspects of your paper. While some revisions may require substantial changes.

I kindly request that you carefully review the feedback provided by the reviewers and consider how the best to incorporate their suggestions into your revised manuscript. Once you have completed your revisions, please resubmit your revised manuscript through our online submission system, along with a detailed response to each reviewer comment explaining how you have addressed their concerns.

We look forward to receiving your revised manuscript.

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

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: Yes

Reviewer #2: Partly

Reviewer #3: No

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: 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: Yes

Reviewer #2: No

Reviewer #3: No

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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: This article is well presented and written. I have following comments:

Title: Exploring does not suit for this quantitative study.

Abstract:

The objective verb “delves” need to be replaced with specific action verb.

In methods, authors are explaining determinants as if they were the results.

In the last sentences of Results, there is only one factor mentioned while the sentence starts with “variables that were”

What are the targeted interventions?

Introduction

Introduction needs some specific examples, not only theoretical sentences like “Moreover, the country diverse cultural tapestry encompasses a rich array of traditions, norms, and values that often play a pivotal role in shaping attitudes towards sexuality”

If authors conclude in introduction (the high risk of risky sexual behavior among Nepali youth is influenced by a complex interplay of cultural, educational, economic, gender-related, healthcare-related, and technological factors); why this study is needed. It seems like already known. That is why authors need to be careful on what research has been done and what not, to justify this study.

Discussion:

Are there any limitations for this study?

Conclusion:

What are the vital insights? Need to specify.

Also specify the targeted interventions you can suggest based on findings.

Reviewer #2: The authors have demonstrated significant effort in utilizing NDHS data to offer a nationally representative insight into the risky sexual behavior among youth. However, there are areas in the writing that require refinement. Specifically, language usage can be enhanced, and grammatical errors need attention through proofreading.

Below are some significant points for improvement:

Introduction:

1. This section lacks strength and fails to effectively convey the significance of the research. It is essential to strengthen the introduction by articulating why this research is important and building a compelling narrative. Emphasizing the research gap and illustrating how this study addresses it is crucial. Providing specific data and prevalence rates, if available, to support arguments would strengthen the introduction further.

2. Introduction 3rd para: “ In developing country like Nepal, there is increasing modernization of society and culture especially among the young generation which has brought a positive attitude towards the sexual behavior and other risky behaviors which make them more vulnerable to STIs (11).”This sentence is confusing and long. Please consider shortening it or breaking it down. It is unclear what do you mean by “positive attitude towards sexual behaviors”, and if it is positive why does it “make them more vulnerable”?

3. “Moreover, the country” – change ‘country’ to ‘country’s’?

4. ‘Education and economic status are known to be influential determinants of sexual behavior’- provide reference for this sentence

5. ‘It may also influence decisions related to family planning and contraception’- please avoid using ambiguous pronoun, be more specific what “it” means when beginning a sentence

6. Please use “the” after “despite” – despite the efforts instead of despite effort

Methods

1. Please specify the specific datasets used from the NDHS, such as the IR (Individual Recode) file and MR (Men's Recode) file.

2. Elaborate on the modifications made to variables for this study, such as the wealth index. Provide rationale for why it was modified to only three categories, and extend this explanation to other modified variables.

3. It is advisable to include specific subsections under the methods section. Additionally, consider adding a subsection on variables, clearly outlining the outcome variables with their operational definitions and independent variables. Elaborate on any modifications made to these variables.

4. Specify the variables used for weighting, considering that different datasets may require different weighting variables, particularly for men and women. Describe how this variation was accounted for in the analysis.

5. Explain the rationale for extracting data to SPSS rather than directly to an R file.

6. Revise the statement "A P < 0.05 was used to define the statistical significance" to make it sound more professional and academic.

7. Elaborate on the method used to identify the most important variables for inclusion in the multivariate logistic regression models. Explain why explanatory determinants were initially included one at a time to examine their univariate relationship with the outcome, and how multivariate logistic regression models were subsequently used to identify the most important determinants for each outcome.

8. Reframe the sentences of ethical considerations to clarify that ethical approval was not sought for this study. Explain that the authors used secondary data that had already undergone ethical approval for the original NDHS. Specify how and where the dataset was obtained, emphasizing the use of anonymized data that is publicly available. Describe the approval process from the DHS to gain access to the data.

Results

Revise the following sentence “In terms of provinces, the Madhesh province, Bagmati province, and Lumbini province are among the most highly represented provinces.” Please clarify the province was highly representative for what?

As of PLOS guidelines, the tables should be in-text, right below the text explaining the findings and all cells should be outlined.

Please shorten the descriptive results and highlight the key findings only in the text instead of repeating all the results presented in the table.

Discussion

1. First paragraph: Please summarize the key results—the main takeaway from the results section for a smooth transition to the discussion section. This introductory paragraph of the discussion should guide readers through the results that will be elaborated on in subsequent paragraphs.

2. Improving the discussion: Enhance the discussion by emphasizing how your research addresses research gaps. Highlighting the policy implications is also recommended, particularly as you're working with nationally representative datasets. Stakeholders like the Ministry of Health and Population (MOHP) would find these results valuable, so linking them to policies could be fruitful.

3. Include a limitations section in the discussion. It's essential for every research study to honestly acknowledge limitations, focusing on both the limitations of the researchers and limitations in the data.

Conclusion

This section should reiterate the main takeaway from the results, emphasizing their implications for future actions. Recommendations should be pragmatic and rooted in the findings. Since the study did not directly measure the need for comprehensive education, it's crucial to focus on data-driven decision-making. Thus, the conclusion and recommendations should be closely linked to the results. Additionally, suggesting avenues for future research based on the limitations of this study and identified data gaps could be a key recommendation.

Reviewer #3: Thank you, editor, for sending this manuscript review. This reviewer has following observation.

1. Authors included major background variables and some behavioural variables in the analysis. However, from the policy and programs point of view, important variables are missing. For example, for the outcome variables of recent sexual activity and extra marital activities, whether their partners are living with them or not, use of family planning services in the recent sexual activity, age at their marriage, number of children, some variables related to health seeking practices for sexual and reproductive health. This information are variables in the NDHS 2022 dataset which requires to further dig down rather than restricting analysis traditional variables. Regarding the pre-marital intercourse, there are some behavioural information which authors can look and answers the why questions.

Except this major analytical issue, authors can improve syntax issues in writing and improve readability of the paper.

Authors presented the yes percentage and total n of the row numbers in the same place. Please first put yes % and next column put total from which that row percentage was calculated.

**********

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Rajendra Karkee

Reviewer #2: No

Reviewer #3: No

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PLoS One. 2025 Jan 3;20(1):e0315495. doi: 10.1371/journal.pone.0315495.r002

Author response to Decision Letter 0

21 Apr 2024

REVIEWER 1 EVALUATION

This article is well presented and written. I have following comments:

1. Title: Exploring does not suit for this quantitative study.

Author Response: Exploring has been removed from the title as suggested. We had added the word Assessing instead of exploring.

2. Abstract:

The objective verb “delves” need to be replaced with specific action verb.

Author Response: The verb ‘delves’ has been replaced as suggested. Replace it with word “examine” on page 2, line 23.

In methods, authors are explaining determinants as if they were the results.

Author Response: We had revised the method section as suggested on page 2, line 26-29.

In the last sentences of Results, there is only one factor mentioned while the sentence starts with “variables that were”.

Author Response: The sentence has been revised as suggested page 2-3, line 39- 41.

What are the targeted interventions?

Author Response: The targeted interventions could be the sexual health education for the youths which has been mentioned in the conclusion section on page 3, line 46-48.

3. Introduction

Author Response: The sentence had been removed and we have revised the section at page 4, line 80-85.

Author Response: Thank you for the suggestion. We have revised the manuscript based on your suggestions. We had update the manuscript adding the rationale why this study is needed, what research has been done and what not, to justify this study. The revised text is on Page 6, 112-124.

Discussion:

Are there any limitations for this study?

Author Response: Limitations has been added after the discussion on page 38, line 434-435.

Conclusion:

What are the vital insights? Need to specify.

Author Response: We had specific vital insights in page 39, line 438-450.

Also specify the targeted interventions you can suggest based on findings.

Author Response: The targeted intervention for suggestion has been added in page 39, line 441-450.

REVIEWER 2 EVALUATION

The authors have demonstrated significant effort in utilizing NDHS data to offer a nationally representative insight into the risky sexual behaviour among youth. However, there are areas in the writing that require refinement. Specifically, language usage can be enhanced, and grammatical errors need attention through proofreading.

Below are some significant points for improvement:

Introduction:

Author Response: Thank you for the suggestion. Based on your suggestions, we had revised the manuscript, adding the significance of the research, research gaps. The revised text is on Page 6, 112-124. We also add the specific data and prevalence rate on Page 5, 85-90.

Author Response: We have break down the sentence and revised it as suggested on page 4, line 81-85.

3. “Moreover, the country” – change ‘country’ to ‘country’s’?

Author Response: The sentence has been revised to add the data in that section.

4. ‘Education and economic status are known to be influential determinants of sexual behaviour’- provide reference for this sentence

Author Response: Reference has been added.

5. ‘It may also influence decisions related to family planning and contraception’- please avoid using ambiguous pronoun, be more specific what “it” means when beginning a sentence

Author Response: The sentence has been revised.

6. Please use “the” after “despite” – despite the efforts instead of despite effort

Author Response: ‘The’ was added after despite as suggested.

Methods

1. Please specify the specific datasets used from the NDHS, such as the IR (Individual Recode) file and MR (Men's Recode) file.

Author Response: The data set used from the NDHS were NPMR82SV and NPIR82SV. The name of specific datasets is mentioned in Page 8 line 152-153.

Author Response: The wealth index variable was modified from five categories to three categories for easy interpretation of the data, ease to communicate and data validation. We had added this information in Page 9, 173-175.

Author Response: Based on we had added the subsection, study design, study settings, sample size, study variables, statistical analysis and ethics statement.

Author Response: We have added this information in Page 9, 181-187.

5. Explain the rationale for extracting data to SPSS rather than directly to an R file.

Author Response: There is no specific rationale for extracting data to SPSS rather than directly to an R file. The NDHS datasets are available in SPSS. The research team is expert in using R program and the program had advantages of complex survey analysis.

6. Revise the statement "A P < 0.05 was used to define the statistical significance" to make it sound more professional and academic.

Author Response: The sentence has been revised on page 9, line 193-194.

Author Response: Based on the reviewers’ comments, we had revised the manuscript and added the information on using the multivariate logistic regression. The revised text is on Page 10, line 199-200.

Author Response: Thank you for the suggestion. We have specified how the data set was obtained and approval process on page 11, line 224- 227.

Results

1. Revise the following sentence “In terms of provinces, the Madhesh province, Bagmati province, and Lumbini province are among the most highly represented provinces.” Please clarify the province was highly representative for what?

Author Response: The sentence has been revised on page 11-12, line 236-237.

2. As of PLOS guidelines, the tables should be in-text, right below the text explaining the findings and all cells should be outlined.

Author Response: The tables have been inserted in- text below the text.

3. Please shorten the descriptive results and highlight the key findings only in the text instead of repeating all the results presented in the table.

Author Response: The descriptive results have been shortened as suggested.

Discussion

Author Response: Based on your suggestions, we have revised discussion and update text in the revised manuscript. The first paragraph has been revised on page 34, line 327- 331.

Author Response: Thank you for suggestion. Though there are not lots of such policies that could be directly linked to but we have mentioned about the laws regarding the protection of minors. However we had add the research gaps and recommendations for MOHP in page 38, line 427-432.

Author Response: Limitations has been added on page 38, line 434- 435.

Conclusion

Author Response: We have revised the conclusion and recommendations based on the reviewers feedback. Now the conclusion and recommendations is linked to the results section. The revised text is page 39, line 438-441.

REVIEWER 3 EVALUATION

Thank you, editor, for sending this manuscript review. This reviewer has following observation.

Except this major analytical issue, authors can improve syntax issues in writing and improve readability of the paper.

Authors Response: Thank you for your insightful comments. We agree that variables such as partner living arrangements, family planning use, age at marriage, number of children, and health-seeking practices for sexual and reproductive health are crucial from a policy and program perspective. However, during our analysis, we found that the sample size may not have been sufficient to thoroughly explore all the variables, for example condom use in last sex among youths, as the data was limited to do multivariate logistic regression.

Thank you for highlighting these important areas for improvement, and we revised our manuscript incorporating these suggestions.

2. Authors presented the yes percentage and total n of the row numbers in the same place. Please first put yes % and next column put total from which that row percentage was calculated.

Authors Response: Based on the feedback from the reviewers, we had revised the table. The revised table is added to the revised manuscript.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0315495.s002.docx^{(26.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0315495.r003

Decision Letter 1

Shalik Ram Dhital

15 May 2024

PONE-D-24-00348R1Assesssing the Drivers of Risky Sexual Behavior among youths and its social determinants in NepalPLOS ONE

Dear Dr. Kakchapati,

Please submit your revised manuscript by Jun 28 2024 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'.

We look forward to receiving your revised manuscript.

Kind regards,

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Comments from PLOS Editorial Office:

In contrast, you list premarital sex, recent sex, and multiple sexual partners, but do not examine unprotected sex. Your provide citations, but neither of these references define premarital sex or recent sex as risky sexual behaviours. Azene et al. (2022) define risky sexual behaviour as “having sex with multiple sexual partners, early initiation of sexual intercourse under the age of 18, and not using or inconsistent use of a condom.” Keto et al. (2020) mention “having multiple sexual partners, sexual intercourse with commercial sex workers, unprotected sexual intercourse, coerced sexual intercourse and sexual intercourse for reward.”

We request that you analyse outcome variables that are typically agreed upon as risky sexual behaviours (e.g., unprotected sex), and do not include premarital sex or recent sex as measures of risky sexual behaviour without thorough justification. Furthermore, your definition of pre-marital sex is restricted to “never-married youths who had ever had sexual intercourse”. This excludes respondents who were married at the time of the survey but had engaged in pre-marital sex. In addition, you define recent sexual activity as “having sexual intercourse in the last 12 months with a person who neither was their wife nor lived with them,” which seems to be measuring the same construct as premarital sex, only restricted to men and to the year prior to the survey.

2) Although you note that the “cross-sectional nature of the data collection limits the study from establishing a causal relationship,” you offer causal explanations for the correlations between the predictor and outcome variables. For example, the association between tobacco use and the outcome variables is explained as "tobacco products contain nicotine which impairs cognitive function of brain and lowers the decision-making process", with no evidence for this assertion, and without noting that both tobacco use and risky sexual behaviour may be the outcome of a third factor, such as impulsivity. We request that you limit your discussion and conclusions to observations that can reasonably be inferred from the data.

Additional Editor Comments:

Dear Authors,

Your revision version of this manuscript has improvement. However, There are still lacking few issues commented by reviewers 2 and 3. I have provided my comments in track change manuscript attached. Please go through my comments and also with reviewers comments.

I am looking forward to receiving your revised version.

Kind regards

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

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: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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6. Review Comments to the Author

Reviewer #1: The authors have addressed my comments and has revised the manuscripts. It is satisfactory and I recommend publication of this article.

Reviewer #2: Reviewer's Comments:

Specifically, the discussion should go beyond simply presenting results and delve into comparisons with other studies, highlighting similarities, differences, and contributing factors. Additionally, it should explore the implications of the findings for policy formulation and intervention strategies.

The literature review appears insufficient, with a lack of citations to support the discussion points. It is recommended to bolster the discussion with relevant references, particularly when mentioning legal frameworks or societal norms.

Please ensure to integrate potential recommendations or policy implications into each paragraph of the discussion. While it doesn't need to be extensive, a few lines with appropriate references are essential. Consider what the existing literature suggests and what interventions have been successful in Nepal. If local examples are lacking, draw upon effective interventions from global literature, particularly from LMICs. This addition will enrich the discussion and provide actionable insights for policymakers and practitioners.

For example,

adolescents and youths." When referencing the law, please ensure to provide a solid reference. You can cite various legal acts in Nepal by referring to the Nepal Law Commission for accurate information.

Please provide references for the sentences in lines 292-296, which discuss patriarchy and gender inequality. For example, "Females are expected to maintain their virginity till marriage" and "Females are at higher risk of experiencing sexual health consequences..." These statements should be supported by relevant studies or literature on the topic.

Please provide references for the paragraph from lines 298 to 304, which discusses migration and sexual health. Studies conducted in regions such as Gandaki, Karnali, and Sudurpashchim would be pertinent to support the assertions made in this paragraph. You can refer to higher migration rates and risky sexual behaviors, higher prevalence of STI/HIV in certain regions etc.

Lines 305-308, please provide references

For lines 309 to 314, if literature from Nepal is unavailable, please search for relevant global literature from LMICs. Look for studies that have similar findings regarding the topic discussed. If no such studies are available, explicitly state that these findings are unique to Nepal. Additionally, consider including suggestions on how to identify the specific group mentioned in lines 309 to 314 for targeted interventions, such as awareness programs. This could involve utilizing demographic data, community outreach, or other methods.

Limitations section lines 351-352

The authors have stated that "this study has some limitations," but have only included one sentence on the study design. There should be more limitations. Just two lines of limitation are too simplistic. How about the use of different variables? How about limitations of not including certain variables that would have been interesting? Also, you may add that despite the limitations, this study has its strengths too, and highlight the strengths as well to provide a more balanced perspective.

In terms of specific revisions on typos that need thorough proofreading:

Abstract

Line 25: There's a typo, an "e" after "prevalence of".

Introduction:

Line 67: Put all references inside one parenthesis, separated by commas or hyphens.

Line 72: Remove the redundant "in" after "NDHS" and "revealed".

Lines 67-71: Break down the lengthy sentence for better readability.

Line 96: Remove one of the duplicate "that" to avoid redundancy.

Line 121: Change "include" to "included".

Line 129: Unbold "partners".

Line 137: Change "used" to "use of media".

Line 142: Remove the closing parenthesis after "communication and data limitations".

Line 174: Remove the repetitive sentence about statistical analysis as it has already been explained earlier.

Line 187: Capitalize "janajati" to "Janajati".

Line 191: Remove the extra comma after "having six or more members".

Table 1: Keep the style consistent for age ("51%") versus occupation ("5.24"). Since the labeling specifies "%" at the top, it's unnecessary to repeat it after each number.

Table 2: Format the table appropriately.

Reviewer #3: Reviewer thanks authors for addressing comments. However, discussion section has still lacked articulation of findings with existing policies and plans, programs and strategies, and services. There are several tyos in the manuscript which needs careful editing. In addition, in the table if we write % in the tables, it is unnecessary to write % in every row, also no need to write province for each province in the table. These are very minor but needs careful editing and formatting of the texts, references, etc.

**********

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.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Rajendra Karkee

Reviewer #2: No

Reviewer #3: No

**********

Attachment

Submitted filename: Revised Manuscript with Track Changes.docx

pone.0315495.s003.docx^{(478.6KB, docx)}

PLoS One. 2025 Jan 3;20(1):e0315495. doi: 10.1371/journal.pone.0315495.r004

Author response to Decision Letter 1

28 Jun 2024

Dear Academic Editor

Dr. Shalik Ram Dhital

PLOS ONE

We would like to thank you and the reviewers for the thorough and constructive feedback on our manuscript titled “Assessing the drivers of sexual behaviour among youths and its social determinants in Nepal” [PONE-D-24-00348R1]. We have carefully considered all the comments from the reviewers and suggestions provided, and we believe that the revisions have significantly improved the quality of our manuscript. Below, we provide a detailed response to each point raised.

Comments from PLOS Editorial Office:

1) We are concerned that your definition of risky sexual behaviour is inconsistent with the definitions used elsewhere in the scientific literature. Although there is no single definitive list of risky sexual behaviours, most research includes unprotected sex, sex under the influence of drugs/alcohol, and multiple sexual partners. In contrast, you list premarital sex, recent sex, and multiple sexual partners, but do not examine unprotected sex. Your provide citations, but neither of these references define premarital sex or recent sex as risky sexual behaviours. Azene et al. (2022) define risky sexual behaviour as “having sex with multiple sexual partners, early initiation of sexual intercourse under the age of 18, and not using or inconsistent use of a condom.” Keto et al. (2020) mention “having multiple sexual partners, sexual intercourse with commercial sex workers, unprotected sexual intercourse, coerced sexual intercourse and sexual intercourse for reward.” We request that you analyse outcome variables that are typically agreed upon as risky sexual behaviours (e.g., unprotected sex), and do not include premarital sex or recent sex as measures of risky sexual behaviour without thorough justification. Furthermore, your definition of pre-marital sex is restricted to “never-married youths who had ever had sexual intercourse”. This excludes respondents who were married at the time of the survey but had engaged in pre-marital sex. In addition, you define recent sexual activity as “having sexual intercourse in the last 12 months with a person who neither was their wife nor lived with them,” which seems to be measuring the same construct as premarital sex, only restricted to men and to the year prior to the survey.

Authors Response: We appreciate the reviewers' thorough feedback and the opportunity to improve our manuscript. We understand the importance of aligning our definitions of risky sexual behavior with those commonly accepted in scientific literature. After careful consideration of your comments, we have made the following adjustments to our manuscript:

We agree with the reviewers' comments regarding the definition of risky sexual behaviors. Based on the reviewers’ suggestions, we agreed that our study doesn’t measure and match the risky sexual behaviors. So, to address this, we have revised the terminology from "risky sexual behaviors" to "sexual behaviors." Now, we will use sexual behaviors in the revised manuscript instead of risky sexual behavior. This change reflects a broader and more inclusive understanding of the sexual behaviors we are studying. The sexual behaviors definition include premarital sex, multiple sexual partners and recent sexual activity. While we acknowledge that premarital sex and recent sexual activity are not typically classified as "risky sexual behaviors" in the broader literature, we believe they are important to study within our specific cultural context. These behaviors can have significant social and health implications, and therefore warrant inclusion in our analysis as "sexual behaviors." We made the necessary changes to the overall manuscript. We believe these revisions address the reviewers' concerns and improve the clarity and rigor of our manuscript. Thank you for your valuable feedback, which has significantly improved our study.

Response: We appreciate the reviewers' valuable feedback and the opportunity to improve our manuscript. We understand the importance of appropriately interpreting the findings from cross-sectional data and the necessity of avoiding causal assertions without strong evidence. To address the reviewers' concerns, we have made the following adjustments to our manuscript:

We have emphasized the limitations of cross-sectional data in the discussion section, specifically noting that such data only allows for the identification of associations rather than causal relationships. This includes acknowledging that any observed associations between predictor and outcome variables cannot be used to infer causation. We have revised our discussion to ensure that all interpretations of the data are appropriately cautious and framed within the context of association rather than causation. We had addressed all the comments in the revised manuscript.

Reviewer #2: Reviewer's Comments:

The authors have made significant improvements in addressing previous comments. However, the discussion section still requires further improvement. It currently lacks depth, merely restating results without critical analysis or comparison with existing literature. Moreover, it fails to adequately address the policy implications of the findings. Specifically, the discussion should go beyond simply presenting results and delve into comparisons with other studies, highlighting similarities, differences, and contributing factors. Additionally, it should explore the implications of the findings for policy formulation and intervention strategies. The literature review appears insufficient, with a lack of citations to support the discussion points. It is recommended to bolster the discussion with relevant references, particularly when mentioning legal frameworks or societal norms. Please ensure to integrate potential recommendations or policy implications into each paragraph of the discussion. While it doesn't need to be extensive, a few lines with appropriate references are essential. Consider what the existing literature suggests and what interventions have been successful in Nepal. If local examples are lacking, draw upon effective interventions from global literature, particularly from LMICs. This addition will enrich the discussion and provide actionable insights for policymakers and practitioners.

Author Response: Thank you for your detailed and constructive feedback. We appreciate your efforts to help improve our manuscript and understand the need for a more in-depth discussion and are committed to enhancing this section to meet the required standards. Based on your suggestions, we have enriched the discussion by providing a more critical analysis of our findings. Specifically, we compare our results with those of other relevant studies, both locally and globally, to highlight similarities, differences, and contributing factors. And we also examine how our findings align or contrast with existing research on risky sexual behavior and its social determinants, drawing on studies from other LMICs to provide a broader context. To address the policy implications of our findings, we integrate potential recommendations and intervention strategies in the discussion section.

Reviewers comments

Lines 264-267 "Although we have existing laws intended at protecting minors from engaging in sexual activities but still there are prevalence of sexual activity which needs to be addressed through awareness programs targeting adolescents and youths." When referencing the law, please ensure to provide a solid reference. You can cite various legal acts in Nepal by referring to the Nepal Law Commission for accurate information.

Author Response: Thank you for the suggestion. The existing laws has been cited as suggested in page 24 line 283.

Author Response: Relevant literatures has been added which supports the statement in Page 25, lines 303 and 306.

Author Response: Thank you for the comments and suggestions. Related references which has shown prevalence of HIV/ STD among migrant workers has been added as suggested in Page 25 line 313 and 315.

Lines 305-308, please provide references

Author Response: Reference has been added in line 395.

Author Response: Thank you for comments and suggestions. We have added the references based on your suggestions. The targeted interventions have been added as suggested in Page 26 lines 325-330. .

Limitations section lines 351-352

Author Response: Thank you for your suggestions. Based on your feedback, we had added some limitations for the study. Additional limitations and strengths for the study have been added in Page 27-28 lines 360-365

Reviewer #3: Reviewer thanks authors for addressing comments. However, discussion section has still lacked articulation of findings with existing policies and plans, programs and strategies, and services.

Author Response:

There are several tyos in the manuscript which needs careful editing. In addition, in the table if we write % in the tables, it is unnecessary to write % in every row, also no need to write province for each province in the table. These are very minor but needs careful editing and formatting of the texts, references, etc.

Author Response: Typos error has been removed from Table 1.

Attachment

Submitted filename: Response to reviewers.docx

pone.0315495.s004.docx^{(22.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0315495.r005

Decision Letter 2

Shalik Ram Dhital

19 Jul 2024

PONE-D-24-00348R2Assesssing the Drivers of Sexual Behavior and its social determinants in Nepali Youth: Insights from NDHS 2022PLOS ONE

Dear Dr. Kakchapati,

Thank you for addressing most of the feedback provided by reviewers and editor. There are few minor issue you need to resolve before processing your paper. Please go through track change paper with my comments and address these issue and resubmit your final version two copies 1. track change and 2. a clean copy.

Looking forward to receiving your revised copy

Please submit your revised manuscript by Sep 02 2024 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'.

Kind regards

Shalik Dhital, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Comments from PLOS Editorial Office:

Thank you for taking our concerns into account when revising your manuscript. However, some of the issues remain. For example, you still state: "the use of any tobacco products, either cigarettes or electronic cigarettes (vape), or chewing tobacco can impair judgment leading to riskier decision-making and practicing risky activities like engaging in sexual behavior which they might avoid if sober." Please can you carefully revise your manuscript to remove all causal explanations for the correlations between the predictor and outcome variables, particularly where there is no evidence to support such causal relationships.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #2: Thank you for revising the manuscript and addressing all the comments. Most of the major comments are addressed and the current version of the manuscript is much better.

There are just a few final minor comments as follows:

Introduction

1. The authors are still including "premarital sex" as risky sexual behaviors at some places – please consider revising and removing “premarital sex” from risky sexual behavior. The authors must understand that premarital sex among two consenting adults is not risky, as long as it is safe and as long as they are aware. Sex among under aged people can still be risky even if they are married. Using a blanket term of “premarital sex” for risky sexual behavior creates stigma that is not helpful for public health interventions promoting healthy sexual behaviors among young people. The stigma surrounding premarital sex is also one of the reasons why early marriages are still prevalent in Nepal.

The risky behaviors related to sex goes beyond marital status. While the authors have been more careful with the terms linking “risky sexual behaviors” with “premarital sex”, it would be helpful for authors to review the manuscript carefully again and balance the tone wherever needed.

Therefore, please remove “premarital sex” from Line 47 of the revised file where it states

“Risky sexual behavior can be described as any sexual activity which has greater risk of having

sexually transmitted infections (STIs) and unintended pregnancy [1,2].It also includes having sexual relation with more than one partner, having intercourse at an early age or under 18 years, PREMARITAL SEX, engaging in sexual activity under the influence of drugs or alcohol, and not using condom [2,3]”

2. Line 63-67 - “This shift led to a more open attitude towards sexual behaviors and other risk behaviors, develop positive attitude in promoting discussions around sexual health, also increases their vulnerability to STIs/HIV [11], for example a previous study among the adolescents showed that 59% of the teenagers had just a moderate understanding of sexual and reproductive health [11,12].”

Please consider breaking the following sentence. It is too long and the message is unclear as it includes both positive and negative messages. It can instead be revised as the following (or something similar)

“This shift led to a more open attitude towards sexual behaviors and other risk behaviors increases their vulnerability to STIs/HIV [11], for example a previous study among the adolescents showed that 59% of the teenagers had just a moderate understanding of sexual and reproductive health. However, it has also enabled positive attitude in promoting discussions around sexual health which provides an opportunity for more effective intervention [11,12].”

3. Lines 67-72 -“Moreover, the Nepal Demographic and Health Survey (NDHS) in 2016 revealed that 50% of young women and 42% of young men aged 15-24 have ever had sex. Among never married youths, about one- fourth of men have ever had 70 sex while only smaller proportion of young women ever had sex. Three percent of the men had two or more sexual partners in the past twelve months with 9% reporting to have sexual intercourse with persons who were neither their wife nor in the relationship [13].”

This section can go up preceding the above section. Consider switching this section with lines 63-67. It will improve the flow of the paragraph.

4. Ethics statement - Please specify that “primary” data was approved by NHRC. The “secondary data” was accessed through the DHS program.

For the conclusion section - make it shorter, add a few lines reminding the readers of the key take away findings and just a line of two on recommendation grounded in the findings.

Reviewer #3: Thanks for the revised version. Authors made the suggested changes in the Table 1 only. But there is need of correction in the second column of all other tables.

**********

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.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

**********

Attachment

Submitted filename: Manuscript_edited by SRD.doc

pone.0315495.s005.doc^{(1.7MB, doc)}

PLoS One. 2025 Jan 3;20(1):e0315495. doi: 10.1371/journal.pone.0315495.r006

Author response to Decision Letter 2

16 Aug 2024

Dear Academic Editor

Dr. Shalik Ram Dhital

PLOS ONE

We would like to thank you and the reviewers for the thorough and constructive feedback on our manuscript titled “Assessing the Drivers of Risky Sexual Behaviour and its social determinants in Nepali Youth: Insights from NDHS 2022” [PONE-D-24-00348R1]. We have carefully considered all the comments from the reviewers and suggestions provided, and we believe that the revisions have significantly improved the quality of our manuscript. Below, we provide a detailed response to each point raised.

Comments from PLOS Editorial Office:

Introduction

Therefore, please remove “premarital sex” from Line 47 of the revised file where it states

“Risky sexual behavior can be described as any sexual activity which has greater risk of having sexually transmitted infections (STIs) and unintended pregnancy [1,2].It also includes having sexual relation with more than one partner, having intercourse at an early age or under 18 years, PREMARITAL SEX, engaging in sexual activity under the influence of drugs or alcohol, and not using condom [2,3]”

Response: Thank you for your comments and suggestions. We understand the importance of aligning our definitions of sexual behavior and based on your comments, the definition has been revised. Now our study doesn’t include premarital sex in the definition of risky sexual behavior. The text is revised in the updated manuscript as follows:

"Certain sexual activities may increase the likelihood of sexually transmitted infections (STIs) and unintended pregnancy [1,2] including having multiple sexual partners, participating in sexual activity under the influence of substances, and not using a condom [2,3]." The revised text is updated in Page 3, line 46-51.

Response: Thank you for the feedback and suggestions. We appreciate the reviewers' valuable feedback and the opportunity to improve our manuscript. We agreed with reviewers’ comments and add the reviewer statement in the revised manuscript. Please see Page 4, line 69-75

Response: Thank you for the suggestions. We acknowledge the reviewers’ comments and move the section above in the revised manuscript. We also added the latest NDHS data of 2022 in the revised manuscript. Please see Page 4, line 60-65

4. Ethics statement - Please specify that “primary” data was approved by NHRC. The “secondary data” was accessed through the DHS program.

Response: The ethics statement has been revised and updated as suggested.

5. Conclusion - Lines 366 to 375 serves as a paragraph on recommendation instead of conclusion. Therefore, please move this section above conclusion as the last paragraph of the main discussion section. For the conclusion section - make it shorter, add a few lines reminding the readers of the key take away findings and just a line of two on recommendation grounded in the findings.

Response: Thank you for your comments and suggestions. We had make the conclusion shorter and revised the recommendations at Page 24-25, 365-370.

Reviewer #3: Thanks for the revised version. Authors made the suggested changes in the Table 1 only. But there is need of correction in the second column of all other tables.

Response: Thank you for the suggestion. All the tables have been corrected and revised as suggested.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0315495.s006.docx^{(20.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0315495.r007

Decision Letter 3

Shalik Ram Dhital

28 Aug 2024

PONE-D-24-00348R3Assessing the Drivers of Risky Sexual Behaviour and its social determinants in Nepali Youth: Insights from NDHS 2022PLOS ONE

Dear Dr Kakchapati

Thank you for addressing reviewers comments. However, There is still minor revisions require in the manuscript. Therefore, We strongly suggest you thoroughly copyedit your manuscript for language usage, spelling, punctuation, and grammar. If you do

not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Please submit your revised manuscript by Oct 12 2024 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'.

Kind regards

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

Attachment

Submitted filename: Manuscript_Assessing the Drivers of.....doc

pone.0315495.s007.doc^{(2.8MB, doc)}

PLoS One. 2025 Jan 3;20(1):e0315495. doi: 10.1371/journal.pone.0315495.r008

Author response to Decision Letter 3

3 Oct 2024

To,

The Editor,

PLOS ONE

Subject: Response to the query from reviewers

Dear Editor,

Thank you for the evaluation from the reviewers on manuscript entitled on “Assessing the Drivers of Sexual Behavior and its social determinants in Nepali Youths”.

We have responded all of the queries and comments of the reviewers. Please see below for our response to each of the comments/queries. We have also shared the revised manuscript in track changes for your review and approval.

Thank you very much for reviewing our study. If you need further clarification on this, please do not hesitate to contact us.

Yours sincerely,

Dr. Sampurna Kakchapati

Response to reviewer

This is still not necessary as you have explained it in Method section. Please delete this last part

Author Response: We have checked this information and compare with NDHS 2022, it was fine

Please check thoroughly language of the whole paper and format final manuscript according to author guideline. Please read carefully the paper.

Author Response: We have checked thoroughly language of the whole paper and format final manuscript according to author guideline.

Some of the information is similar with your study as you used NDHS 2022 dataset. Please check and compare with your results.

Author Response: We have checked this information and compare with NDHS 2022, it was fine. Please see Page 4, lines 69-74.

Which study ? Where this has been done? Please specify.

Author Response: The information of the study is added in the revised manuscript added in page 5, lines 81-83

Please always use full form at first place of the paper.

Author Response: Yes, we have use full form in the first place of the manuscript. Please check page Page 4, line 55 and page 4, line 59

Write in full form as this is first time you are referring NHRC.

Author Response: Thank you for suggestions. We had use full form of NHRC at Page 9, line 182.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0315495.s008.docx^{(18KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0315495.r009

Decision Letter 4

Shalik Ram Dhital

16 Oct 2024

PONE-D-24-00348R4Assessing the Drivers of Sexual Behavior and its social determinants in Nepali YouthsPLOS ONE

Dear Dr. Kakchapati,

Thank you for sending this paper with the necessary modifications. However, there are still some minor errors, so I made track changes throughout the entire document. I also reviewed the language, as there were errors in multiple places. Please go through the revised paper using track changes to address all minor comments and language corrections. After that, please upload both a track change copy and a clean copy when you submit. Additionally, please ensure that the information about data availability criteria, funding sources, and competing interests is included in the paper. Please follow PLOS ONE Author Guidelines. For any queries please contact to plosone@plos.org

With Kind Regards

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

Attachment

Submitted filename: Manuscript_ Revised by Academic Editor.docx

pone.0315495.s009.docx^{(2.9MB, docx)}

PLoS One. 2025 Jan 3;20(1):e0315495. doi: 10.1371/journal.pone.0315495.r010

Author response to Decision Letter 4

3 Nov 2024

Dear Editor

Thank you for your feedback and the detailed track changes on our manuscript. We appreciate your efforts in reviewing the paper and addressing the necessary modifications. We have carefully gone through all your comments and suggestions, making the appropriate revisions to the document. Attached, you will find both the track changes copy and a clean version of the manuscript for your review.

If you have any further queries or require additional adjustments, please do not hesitate to reach out.

Thank you once again for your guidance.

Sampurna

Attachment

Submitted filename: Response to Reviewers.docx

pone.0315495.s010.docx^{(18KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0315495.r011

Decision Letter 5

Shalik Ram Dhital

12 Nov 2024

PONE-D-24-00348R5Assessing the Drivers of Sexual Behavior and its social determinants in Nepali YouthsPLOS ONE

Dear Dr. Kakchapati,

==============================

ACADEMIC EDITOR:

Dear Dr Kakchapati,

I hope you are doing well.

I would like to kindly remind you to address all of my previous comments and suggestions in the manuscript. In addition, thorough proofreading is essential to ensure the quality and clarity of the work. Please make sure to carefully review the document for any errors.

Once revisions have been made, I kindly ask you to submit two versions of the manuscript: (1) A track-changes version to highlight the changes made. and (2) A clean, revised version of the manuscript without any tracked changes.

Thank you for your attention to these details. I look forward to receiving the updated manuscript.

Kind regards

Shalik Ram Dhital, PhD

Academic Editor

==============================

Please submit your revised manuscript by Dec 27 2024 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'.

We look forward to receiving your revised manuscript.

Kind regards,

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments:

Dear Dr Kakchapati,

I hope you are doing well.

Thank you for your attention to these details. I look forward to receiving the updated manuscript.

Kind regards

Shalik Ram Dhital, PhD

Academic Editor

[Note: HTML markup is below. Please do not edit.]

Attachment

Submitted filename: Manuscript_ Revised by Academic Editor.docx

pone.0315495.s011.docx^{(2.9MB, docx)}

PLoS One. 2025 Jan 3;20(1):e0315495. doi: 10.1371/journal.pone.0315495.r012

Author response to Decision Letter 5

22 Nov 2024

To,

The Editor,

PLOS ONE

Subject: Response to the query from reviewers

Dear Editor,

Thank you for the evaluation from the reviewers on manuscript entitled on “Assessing the drivers of sexual behavior among youth and its social determinants in Nepal”.

Thank you very much for reviewing our study. If you need further clarification on this, please do not hesitate to contact us.

Yours sincerely,

Dr. Sampurna Kakchapati

Response to reviewer

Please keep each author’s ORCID number if available, and Corresponding author’s ORCID Number is mandatory

Author Response: We had added the ORCID number as suggested. It is mention after the acknowledgement section.

Please add one or two examples of psychological factors

Author Response: We had examples of psychological factors as suggested in revised manuscript.

Please check with NDHS data set to verify and make sure these two numbers must be corrected

Author Response: Yes, we check it and the NDHS datasets are corrected.

Please keep classification of family members in brackets consistent with Table below.

Author Response: We had added the classification of family members in brackets as suggested.

Please specify other terai caste.

Author Response: We had specified other terai caste as suggested

How did you get this number? Can you please mention it in sample size subsection in Method chapter too?

Author Response: The number include male and female youths who were unmarried. We had added this information in methods section.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0315495.s012.docx^{(18.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0315495.r013

Decision Letter 6

Shalik Ram Dhital

27 Nov 2024

Assessing the drivers of sexual behavior among youth and its social determinants in Nepal

PONE-D-24-00348R6

Dear Dr. Sampurna

Thank you for your revised paper and for addressing the previous queries.

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Shalik Ram Dhital, PhD

Academic Editor

PLOS ONE

PLoS One. doi: 10.1371/journal.pone.0315495.r014

Acceptance letter

Shalik Ram Dhital

20 Dec 2024

PONE-D-24-00348R6

PLOS ONE

Dear Dr. Kakchapati,

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Data Availability Statement

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Assessing the drivers of sexual behavior among youth and its social determinants in Nepal

Grishu Shrestha

Reecha Piya

Sampurna Kakchapati

Parash Mani Sapkota

Deepak Joshi

Sushil Chandra Baral

Roles

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Materials and methods

Data source

Study settings

Sample size

Study variables

Dependent variables

Independent variables

Statistical analysis

Ethics statement

Results

Table 1. Socio demographic characteristics of youths (N = 7,122).

Table 2. Factors associated with premarital sex among youths (N = 4426).

Table 3. Factors associated with recent sex among male youth (N = 1,842).

Table 4. Factors associated with multiple sexual partners among male youth (N = 1,842).

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

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Shalik Ram Dhital

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Author response to Decision Letter 0

Decision Letter 1

Shalik Ram Dhital

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Author response to Decision Letter 1

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Author response to Decision Letter 2

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Author response to Decision Letter 3

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Author response to Decision Letter 4

Decision Letter 5

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Author response to Decision Letter 5

Decision Letter 6

Shalik Ram Dhital

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Acceptance letter

Shalik Ram Dhital

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Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

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