Unsafe sexual practice and associated factors among adolescents in secondary schools in Gambella town, Ethiopia: a health belief model.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Public Health . 2026 Apr 22;26:1797. doi: 10.1186/s12889-026-27466-2 Unsafe sexual practice and associated factors among adolescents in secondary schools in Gambella town, Ethiopia: a health belief model Tariku Frissa 1 , Asrat Zewdie 1, ✉ , Dereje Oljira Donacho 2 , Benti Negero 3 Author information Article notes Copyright and License information 1 Department of Public Health, College of Health Science, Mattu University, Mattu, Ethiopia 2 Department of Health Informatics, College of Health Science, Mattu University, Mattu, Ethiopia 3 Department of Midwifery, College of Health Science, Mattu University, Mattu, Ethiopia ✉ Corresponding author. Received 2024 Apr 23; Accepted 2026 Apr 15; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . PMC Copyright notice PMCID: PMC13235138  PMID: 42015154 Abstract Background Unsafe sexual practices among adolescents represent a significant public health challenge due to their association with increased risk of sexually transmitted infections, including HIV, and unintended pregnancies. The burden remains substantial, contributing to adverse health outcomes, educational disruption and long-term socio-economic consequences. Multiple factors like inadequate sexual health knowledge, limited access to youth-friendly services, low utilisation of preventive methods, and social and behavioural determinants such as peer pressure, substance use, early sexual initiation and weak parental communication further exacerbate the problem. Methods An institution-based cross-sectional survey using a self-administered questionnaire was administered to 621 students who were selected using the systematic sampling technique. Unsafe sexual practice was measured using the self-reported behavioural indicators, including inconsistent condom use, multiple sexual partners, and early sexual initiation. The Health Belief Model (HBM) was used to assess psychosocial determinants of these behaviours. The HBM constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action) were measured using validated Likert-scale items. Composite scores were generated for each construct and analyzed to determine their association with unsafe sexual practices. Corresponding p-values and adjusted odds ratios with 95% confidence intervals have been added to improve clarity and statistical interpretation. Results The prevalence of unsafe sexual practices was 36.6% [95% CI: 32.8%–40.4%]. The study found that male sex (AOR = 2.38; 95% C.I.: 1.61–3.51, p < 0.001), age less than 18 years (AOR = 0.65, 95% C.I.: 0.43–0.97, p = 0.038), low perceived norms for abstinence [AOR = 0.6, 95% C.I.: 0.41–0.89, p = 0.013], low perceived norms for consistent condom use [AOR = 2.05, 95% C.I.: 1.39–3.03, p < 0.001], low perceived self-efficacy for condom use [AOR = 0.59, 95% C.I.: 0.40–0.86, p = 0.007], watching sex films [AOR = 1.5, 95% C.I.: 1.01–2.20, p = 0.047], chewing khat [AOR = 2.5, 95% C.I.: 1.57–4.07, p < 0.001], and drinking alcohol [AOR = 2.93, 95% C.I: 1.86–4.62, p < 0.001] were significantly associated with unsafe sexual practice among adolescents. Conclusion The study revealed that about two in five students engage in unsafe sexual practices, influenced by socio-demographic and behavioural factors, highlighting the need for collaboration between key stakeholders to mitigate risks and consequences. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-026-27466-2. Keywords: Unsafe sexual practice, Secondary school, Gambela, Health Belif model Background Adolescence, defined by the World Health Organization as the period between 10 and 19 years of age, is a critical developmental stage characterized by rapid physical, psychological, and social changes that may predispose young people to risky behaviors [ 1 ]. Unsafe sexual practices—such as early sexual debut, inconsistent or non-use of condoms, multiple sexual partners, and engagement with high-risk partners—remain a major public health concern among adolescents, particularly in developing countries [ 1 , 2 ]. These behaviors substantially increase the risk of sexually transmitted infections (STIs), including HIV/AIDS, unintended pregnancy, unsafe abortion, and their associated social, educational, and economic consequences [ 2 ]. Globally, adolescents constitute about 20% of the population, with nearly 90% living in low- and middle-income countries [ 3 ]. Sub-Saharan Africa bears a disproportionate share of the burden of adverse sexual and reproductive health outcomes among adolescents, including high rates of HIV infection, early pregnancy, and school dropout [ 4 , 5 ]. In this region, adolescents and youths account for approximately 20–30% of the total population, making unsafe sexual practices a significant public health and development challenge [ 5 ]. Secondary school students, in particular, are vulnerable due to experimentation, peer pressure, limited life experience, and a perceived sense of invulnerability [ 5 ]. Evidence from African countries shows that secondary school adolescents are frequently exposed to risky behaviors such as substance use, sexual coercion, and unsafe sex, often compounded by poor parent–child communication, limited access to accurate sexual health information, and weak youth-friendly services [ 4 – 6 ] Although several school- and community-based interventions—such as peer education, anti-AIDS clubs, and youth-friendly reproductive health services—have been implemented in Ethiopia, unsafe sexual practices among adolescents remain prevalent [ 6 ]. This suggests that existing interventions may not sufficiently address the behavioral, psychological, and contextual determinants of adolescent sexual behavior. Risky sexual behaviors among in-school adolescents are influenced by multiple interrelated factors, including developmental changes during adolescence, limited parental supervision and communication, peer pressure, substance use, and misperceptions about sexual risk [ 2 , 6 – 9 ]. These factors interact to increase adolescents’ vulnerability to unsafe sexual practices, including unprotected sex and multiple sexual partnerships [ 9 ]. Based on the Health Belief Model (HBM), this study aimed to assess unsafe sexual practices by examining how adolescents’ perceptions of susceptibility, severity, benefits, barriers, and self-efficacy—together with socio-demographic and behavioral factors—influence engagement in unsafe sexual behaviors [ 10 ]. The findings are expected to inform context-specific interventions and strengthen adolescent sexual and reproductive health programs in the region. Understanding these individual, social, and psychological determinants is essential for designing effective, theory-based interventions aimed at reducing unsafe sexual practices among adolescents, particularly in under-researched settings such as Gambella town. However, little is known about the concerns in less developed parts of Ethiopia, like the Gambella region. Specifically, information about the level of unsafe sexual practice and factors associated with unsafe sexual practice is limited in Gambella town. Importantly, secondary school adolescents, despite the fact that risk and vulnerability are high in this age group, have research gaps, particularly in the developing regions of Ethiopia, where there is limited information to mitigate the risks. This study is aimed at determining the level of unsafe sexual practices and the factors influencing such activities among adolescents. Methods Study area, design and period Institution-based cross-sectional study was conducted in Gambella town among high school students from May 1 to June 20, 2023. Gambella town is located 780 km from the capital city of Ethiopia, Addis Ababa. In the town, there are two secondary schools: Elay Secondary School and Gambella Secondary School. The total number of students in both schools in the 2022/2023 academic year was 3,915 [ 11 ]. Sample size determination The sample size was determined using the following formula: = 377, p was taken from a study conducted in Jimma zone, Ethiopia [ 9 ], which was 57% Z-value of 1.96 is at 95% CI, p: proportion of unsafe sexual practice from previous studies, and d: the margin of error is 5% with an expected non-response rate of 10% and a design effect of 1.5. The sample was calculated for each specific objective, and the higher sample was taken. The sample size for the second objective was calculated by considering different factors associated with unsafe sexual practice using the using the STATCALC of Epi info 7 for different variables with the following assumptions: two-sided confidence level: 95%, margin of error: 5%, ratio: 1:1 (assuming equal group sizes), and power: 80%, and the highest among these resulted in sample size of 270 subjects. Sample size of the first objective was higher (621), and was chosen and finally corrected for finite population. Eligibility criteria Both male and female adoleoecent (aged 10–19 years) students enrolled in selected highschools who provide assent, and whose parents provide informed consent (if under 18)and present during data collection period were included in the study. Students who were absent during data collection or unable to complete the questionnaire due to illness were excluded. Sampling technique Stratified sampling was first used to stratify participants by school and grade level to ensure representativeness. Simple random sampling was then applied within each stratum to select study participants. There are two secondary schools (grade 9th -12th ) in the town. Based on the number of sections in each grade (9-12th ), representative number of sections were determined. Then, sample size was proportionally allocated to each section based on the number of students. Finally, study participants were selected by simple random sampling technique using student registration as a sampling frame (Fig. 1 ). Fig. 1. Open in a new tab Schematic presentation of sampling procedures to assess unsafe sexual practice, and associated factors among adolescents in secondary schools, Gambella town, Ethiopia, 2023 Study variables Unsafe sexual practices were the outcome variable in this study. Independent variables were age, sex, educational status, family status, personality, peer pressure, substance abuse, perceived susceptibility to HIV/AIDS, perceived severity of HIV/AIDS, perceived benefit of safe sexual practice, perceived barriers to abstinence from sexual intercourse and condom use, and perceived self-efficacy for abstinence and condom use. Operational definition Unsafe sexual practice: presence of atleast one of the following: ever having sexual intercourse (premarital) and sexual practice during the last 12 months, having multiple sexual partners during the last 12 months or unprotected sex/not using condoms during sexual intercourse in the past 12 months. Data collection tools, procedures and quality assurance Data were collected using a self-administered questionnaire adapted from previously validated instruments [ 2 , 6 , 12 – 19 ]. Content validity was assessed by public health and reproductive health experts. The questionnaire was written in English first, then translated into Amharic, and then back to English to ensure consistency. The assessment mainly depended on the primary data collection method using a structured questionnaire. All secondary school students who were attending their education in Gambella town in this academic year (2022–2023)and who were in the class during data collection, were able to give informed consent, and were willing to participate in the study were included. The data collection tool was pre-tested in nearby schools outside of the study area with 31 students (5% of the sample size). The questionnaire was tested for clarity, acceptability, flow, and repetition in a similar setting, and appropriate modifications were made to the final version. The final version of the questionnaire was used for data collection. Structured self-administered questionnaires consisting of sociodemographics, risky sexual behavior, and unsafe sex practices were collected from each participant. The data collection was completed within two days to avoid contamination of the information. Before starting the questionnaire’s distribution, the respondents were briefed about the purpose of the study after getting their informed consent. A minimum of one facilitator who can speak the local language facilitates the data collection process per classroom. A total of four facilitators were selected; those facilitators, who are degree-holder nurses, were selected randomly from nearby health centers. Potential social desirability bias was minimized through anonymity and non-teacher data collectors. Reliability was assessed using appropriate statistical measures (Cronbach’s alpha). Perceived susceptibility to HIV/AIDS was assessed using multiple questions containing nine questions with yes/no answers. The value above the median was considered “yes”, and the value below the median was considered “no”. Similarly, the perceived severity of HIV/AIDS was measured using two questions and compiled, considering the computed variable, taking the media value and the value above the median value as yes and below the value as no. The perceived benefit of safe sexual practice was assessed using three questions using yes/no answers and computed with the median value, with values above the median as good and below the median as poor. Perceived barriers to practicing safer behavior were measured using scale measurements ranging from 1 to 5, where the value 1 indicates strongly disagreeing and the value 5 indicates strongly agreeing. The perceived barrier to practicing safer behavior was computed considering the mean value of the seven questions. The value was recategorized as high and low (i.e., above the mean high and below the mean low). Perceived self-efficacy for abstinence was measured using scale measurements ranging from 1 to 5, with a lower value of 1 for strongly disagreeing and the largest value of 5 for strongly agreeing. Perceived self-efficacy for condom use was measured using scale measurements ranging from 1 to 5, with a lower value of 1 for strongly disagreeing and the largest value of 5 for strongly agreeing. The perceived self-efficacy for practicing safer behavior was computed considering the mean value of the three questions. The value was recategorized as high and low (i.e., above the mean high and below the mean low). Data processing and analysis The collected data was coded, entered in EpiData software, and analysed using SPSS version 25. Descriptive statistics were computed to determine the magnitude of unsafe sexual practices and the factors associated with unsafe sexual practices. A univariate analysis was conducted to assess the association between dependent variables and independent variables with a cut point of a p-value less than 0.25, and variables below the cut point were analysed with a multivariate binary logistic regression analysis in the final model. The variables with a p-value less than 0.05 were reported as significant factors. Odds ratios and 95% confidence intervals were used to forecast risk probabilities. Results Socio-demographic characteristics A total of 621 students participated, with a response rate of 100%. The mean age of the respondents was 18.2 (SD: 1.9) years. The study involved students in grades 9–12, with 541 urban residents and 80 rural residents. The majority lived with their families, with 72.8% living with their families, 16.7% with relatives, and 1.5% in rented houses (Table 1 ). Table 1. Socio-demographic characteristics and risky behaviors among adolescents in secondary schools, Gambela, Ethiopia, 2023 Variables Categries Frequency Percentages Age category 15–19 20–24 219 402 35.3 64.7 Sex Male Female 261 360 42 58 Grade 9th 10th 11th 12th 252 133 125 111 40.6 21.4 20.1 17.9 Residence Urban Rural 541 80 87.1 12.9 Living Arrengements With family With relatives Rented house with peers 452 104 65 72.8 16.7 1.5 Father’s occupation Farmer Day laborer Employed worker Has own business 152 121 200 148 24.5 19.5 32.2 23.8 Mother’s occupation Housewife Daily laborer Employed worker Has own business 261 82 139 139 42 13.2 22.4 22.4 Watched sex film in the last 12 months Yes No 231 390 37.2 62.8 Chewed khat in the last 12 months Yes No 118 503 19 81 Drunk alcohol in the last 12 months Yes No 145 476 23.3 76.7 Open in a new tab Perceived susceptibility and perceived severity of HIV/AIDS The majority of participants (92.9%) believed that HIV can be transmitted through sexual intercourse, with 87.9% stating that multiple sexual partners increase the risk of infection. Overall, 81% of participants perceived susceptibility to HIV/AIDS and other sexually transmitted infections. The perceived severity of HIV/AIDS among the participants was: 470 (75.7%) perceived that HIV/AIDS has no cure, so that can lead to death, and 505 (81.3%) perceived that unwanted pregnancy and unsafe abortion can cause the death of women. The overall perceived severity was 412 (66.3%) (Table 2 ). Table 2. Perceived susceptibility to HIV/AIDS and perceived severity of HIV/AIDS among adolescents in secondary schools, Gambella Town, Ethiopia, 2023 Variable Response Frequancy(%) Perceived susceptibility HIV can be transmitted through sexual intercourse. Yes 577 (92.9) No 44 (7.1) Having sexual intercourse with multiple sexual partners can increase exposure to risk of getting HIV infection. Yes 546 (87.9) No 75 (12.1) Percieved benefits of abstinence as safer sexual practice Yes 501 (80.7) No 120 (19.3) Percieved benefits of condom use as safer sexual practice Yes 536 (86.3) No 85 (13.7) Percieved benefits of limiting sexual partners (being in mutual monogamy) as safer sexual practice Yes 435 (70) No 186 (30) A healthy looking person can have HIV infections in his/her blood. Yes 423 (68.1) No 198 (31.9) If you know a person very well and you trust him/her, you do not have to use condoms when you have sex with him/her. Yes 226 (36.4) No 395 (63.6) People who are in monogamous relation are not at risk for HIV infection, so that, they do not need to use condoms. Yes 249 (40.1) No 372 (59.9) Over all perceived susceptibility to HIV/AIDS High 503 (81) Low 118 (19) Perceived severity of sexual health risk HIV AIDS has no cure, so that can lead to death Yes 470 (75.7) No 151(24.3) Unwanted pregnancy and unsafe abortion can cause death of women Yes 505 (81.3) No 116 (18.7) Over all perceived severity of HIV/AIDS High 412 (66.3) Low 209 (33.7) Open in a new tab Perceived benefit of safe sexual practice (abstinence/ using condom) Majority of respondents, 510 (82.1%) perceived abstinence as one of the most effective methods of avoiding the risk of STIs and HIV/AIDS; 515 (82.9%) perceived consistent condom use as effectively preventing both the risks of STIs and unwanted pregnancy; and about half (49.5%) perceived dual methods as a dual protection option against HIV and unwanted pregnancy. The overall perceived benefit of safe sexual practice among the respondents was 546 (87.9%). Perceived social norms and attitude towards safer behavior (abstinence/ using condom) Regarding barriers to abstinence, only 32.7% of students agreed that peer pressure influences abstaining from sex. Similarly, 22.5% agreed that premarital sex is not against societal or religious norms, and 25% perceived premarital sex as a sign of maturity. For condom use, 35.1% agreed that condoms reduce sexual pleasure, and 28.5% believed condoms are ineffective in preventing pregnancy or STIs. Regarding partner communication, 35.5% agreed that condom use signals distrust, and 32.5% believed requesting condom use could cause conflict. Overall, perceived norms toward abstinence were low for 60.2% of respondents and high for 39.8%. Attitudes toward consistent condom use were low for 47.2% and high for 52.8%, while perceived norms for consistent condom use were low for 56.7% and high for 43.3% (Table 3 ). Table 3. Attitude and perceived social norms about safer sexual practice of abstinence and condom use among adolescents attending secondary schools, in Gambella Town, Ethiopia, 2023 Variable Categories Frequancy Percentage Mean value SD Overall Low High Perceived norms towards unsafe sexual practice Perceived peer norms about premarital sex SDA* 95 15.3 2.84 1.37 374 (60.2%) 247 (39.8%) DA 234 37.7 N 89 14.3 A 83 13.4 SA 120 19.3 Premarital sex is acceptable in the society/religion SDA 102 16.4 2.57 1.23 DA 276 44.4 N 103 16.6 A 66 10.6 SA 74 11.9 Premarital sex is a sign of maturity SDA 108 17.4 2.61 1.26 DA 261 42.0 N 97 15.6 A 77 12.4 SA 78 12.6 Attitude towards consistent use of condom Condom use reduces sexual pleasure SDA 68 11 3.12 1.21 293 (47.2%) 328 (52.8%) DA 113 18.2 N 222 35.7 A 113 18.2 SA 105 16.9 Condoms are not effective in preventing pregnancy and STIs SDA 100 16.1 2.65 1.24 DA 260 41.9 N 84 13.5 A 112 18.0 SA 65 10.5 Perceived norms to consistant condome use Condom use and perceived mistrust SDA 72 11.6 3.03 1.25 352 (56.7%) 269 (43.3%) DA 188 30.3 N 141 22.7 A 127 20.5 SA 93 15 Partner suspicion towards condom use request SDA 81 13 3.06 1.26 DA 175 28.5 N 163 26.2 A 104 16.7 SA 98 15.8 Open in a new tab Key: *SDA: Strongly disagree, DA: Disagree, N: Neutral, A: Agree, and SA: Strongly agree Perceived self-efficacy to avoid unsafe sexual practice More than half (55.4%)of the respondents demonstrated high perceived self-efficacy for abstaining from sexual intercourse. More than half (52.2%) of participants strongly agreed that they were confident in refusing sexual intercourse when pressured by friends, while 242 (39.0%) strongly agreed that they could effectively say no to sex in situations challenging abstinence. Perceived self-efficacy for condom use was comparatively lower. Among sexually active participants, 198 (31.9%) strongly agreed that they could negotiate condom use with a regular partner or refuse sex if their partner declined to use condoms. Similarly, 191 (31.1%) strongly agreed that they could convince a steady partner to consistently use condoms, and 189 (30.4%) strongly agreed that they could always use condoms even when another contraceptive method was being used. Overall, high perceived self-efficacy for condom use was reported by 283 (45.6%) of sexually active respondents (Table 4 ). Table 4. Perceived self-efficacy for abstinence and condom use to avoid unsafe sexual practice among adolescents attending secondary schools, in Gambella Town, Ethiopia, 2023 Variable Category Frequancy Percentage Mean value SD Overall Low High Perceived self-efficacy for abstinence refusal of sexual intercourse SDA 95 15.3 3.8 1.49 277 (44.6%) 344 (55.4%) DA 32 5.2 N 98 15.8 A 72 11.6 SA 324 52.2 Abstinence from sexual intercourse SDA 69 11.1 3.58 1.38 DA 67 10.8 N 163 26.2 A 80 12.9 SA 242 39 Perceived self-efficacy for condom use Ability of negotiation for condom use SDA 77 12.4 3.41 1.35 388 (54.4%) 283 (45.6%) DA 66 10.6 N 200 32.2 A 80 12.9 SA 198 31.9 Partener persuasion for condom use SDA 71 11.4 3.51 1.32 DA 59 9.5 N 168 27.1 A 130 20.9 SA 193 31.1 Consistent condom use SDA 95 15.3 3.30 1.42 DA 82 13.2 N 177 28.5 A 78 12.6 SA 189 30.4 Open in a new tab Key: SDA: Strongly disagree, DA: Disagree, N: Neutral, A: Agree, and SA: Strongly agree Unsafe sexual practice Of the total respondents, 251 (40.4%) reported ever having sexual intercourse. The median age at sexual debut was 16 years. Among sexually experienced students, 105 (41.8%) reported regretting their first sexual encounter, while 154 (61.4%) initiated sexual intercourse based on their own decision and 97 (38.6%) due to external influences. Condom use at first sexual intercourse was reported by only 140 (55.5%) respondents. Regarding recent sexual activity, 227 (90.4%) of those who had ever had sex reported sexual intercourse within the preceding 12 months. Among these, 110 (48.5%) reported inconsistent condom use, 124 (54.6%) had one sexual partner, and 103 (45.4%) reported having two or more sexual partners. Overall, 227 (36.6%) of the respondents engaged in unsafe sexual practices [95% CI: 32.8%–40.4%] (Table 5 ). Table 5. Unsafe sexual practice among adolescents attending secondary schools, in Gambella Town, Ethiopia, 2023 Variables Categories Frequancy Percentages Ever had sexual intercourse Yes No 251 370 40.4 59.6 Own decision to have sex for the first time ( n = 251) Yes No 154 97 61.4 38.6 Reason to have sexual intercourse in the first sexual contact ( n = 97) Alcohol use Kchat chewing Economic reason Peer presure Partner reinforcement 27 27 18 16 9 27.8 27.8 18.6 16.5 9.3 Condom used during this first time you had sexual intercourse ( n = 251) Yes No 140 111 55.8 44.2 Had sexual intercourse in the last 12 months ( n = 251) Yes No 227 24 90.4 9.6 Number of sexual partners in last 12 months ( n = 227) Only one Two or more 124 103 54.6 45.4 Condom use in the last time you had sexual intercourse* ( n = 227) Yes No 110 117 48.5 51.5 Unsafe sexual practice** ( n = 621) Yes No 227 394 36.6 63.4 Open in a new tab Key: * The frequency of condom use was’sometimes’ for all of them (110) who reported using condoms **If ever had sexual intercourse and had sexual intercourse in the last 12 months and condom unprotected sex, then Yes; otherwise, No Factors associated with unsafe sexual practice Bivariable logistic regression was performd to identify factors associated with unsafe sexual practice among adolescents. In this analysis, sex, residence, age category, perceived susceptibility, perceived severity of HIV/AIDS, perceived benefit of safe sexual practice, attitude toward consistent condom use, perceived norms of abstinence, perceived norms of consistent condom use, perceived self-efficacy for condom use, watching sex films, chewing khat, and drinking alcohol were selected as candidate variables for unsafe sexual practice at a p-value less than 0.25. In the multivariable logistic regression analysis, eight [ 8 ] variables were significant at a p-value less than 0.05. Accordingly, sex [AOR: 2.38, 95% C.I.: 1.61–3.51], age category [AOR: 0.65, 95% C.I.: 0.43–0.97], perceived norms to abstinence [AOR: 0.60, 95% C.I.: 0.41–0.89], perceived norms to consistent condom use [AOR: 2.05, 95% C.I.: 1.39–3.03], perceived self-efficacy for condom use [AOR: 0.59, 95% C.I.: 0.40–0.86], watching sex films [AOR: 1.50, 95% C.I.: 1.006-2.20], chewing khat [AOR: 2.53, 95% C.I.: 1.57–4.07], and drinking alcohol [AOR: 2.93, 95% C.I.: 1.86–4.62] were significantly associated with unsafe sexual practice. This finding shows that male students were more than two times more likely to have unsafe sexual practice than female students [AOR: 2.38, 95% C.I: 1.61–3.51], student age 18 years or above were 35% less likely to practice unsafe sexual practice than the age less than 18 [AOR: 0.65, 95% C.I: 0.43–0.97], students those watch sex film were1.5 more likely to practice unsafe sexual practice than their counter part [AOR: 1.50, 95% C.I: 1.006-2.20], students those chew khat were 2.5 times more likely practice unsafe sexual practice than their counter part [AOR: 2.53, 95% C.I: 1.57–4.07], and student those drink alcohol were 2.9 times more likely practice unsafe sexual practice than their counter part [AOR: 2.93, 95% C.I: 1.86–4.62]. Students who perceived low norms to abstinence were 40% less likely [AOR: 0.60, 95% C.I.: 0.41–0.89] to have unsafe sexual practices than those who perceived high norms to abstinence. Students who perceived low norms for consistent condom use were two times more likely [AOR: 2.05, 95% C.I.: 1.39–3.03] to practise unsafe sexual practices than those who perceived high norms for consistent condom use. Similarly, students who perceived low self-efficacy for condom use were 39% less likely [AOR: 0.59, 95% C.I.: 0.40–0.86] to practise unsafe sexual practices than their counterparts (Table 6 ). Table 6. Multivariable analysis factors associated with unsafe sexual practices among adolescents attending secondary schools in Gambela Town, Ethiopia, 2023 Varaibles Categories Unsafe sexual practice Crude OR Adjusted OR Yes No COR [95% C.I] AOR [95% C.I] P-Value Sex Male 129 132 2.61 [1.87–3.65] 2.38 [1.61–3.51] < 0.001* Female 98 262 1 1 Residence Urban 192 349 0.70 [0.44–1.138] 0.95 [0.55–1.65] 0.868 Rural 35 45 1 1 Age category Less than 18 58 161 0.49 [0.34–0.712] 0.65 [0.43–0.97] 0.038* 18 and above 169 233 1 1 Percieved Susseptablity High 194 309 1.62 [1.04–2.51] 1.49 [0.90–2.47] 0.120 Low 33 85 1 1 Percieved severity of HIV/AIDs High 141 271 0.74 [0.53–1.05] 1.04 [0.70–1.56] 0.822 Low 86 123 1 1 Percieved Benefit of safe sexual practice High 205 341 1.45 [0.856–2.45] 1.54 [0.86–2.79] 0.146 Low 22 53 1 1 Perceived norms to abstainance Low 115 259 0.53 [0.38–0.74] 0.60 [0.41–0.89] 0.013* High 112 135 1 1 Attitude to concestant condome use Low 99 194 0.79 [0.57–1.07] 1.17 [0.79–1.72] 0.436 High 128 200 1 1 Perceived norms to concestant condome use Low 149 203 1.79 [1.28–2.52] 2.05 [1.39–3.03] < 0.001* High 78 191 1 1 Perceived self-efficacy for condom use Low 109 229 0.66 [0.48–0.92] 0.59 [0.40–0.86] 0.007* High 118 165 1 1 Watch sex film Yes 114 117 2.39 [1.70–3.35] 1.50 [1.01–2.20] 0.047* No 113 277 1 1 Chew khat Yes 69 49 3.07 [2.04–4.64] 2.53 [1.57–4.07] < 0.001* No 158 345 1 1 Drink alcohol Yes 83 62 3.09 [2.105–4.53] 2.93 [1.86–4.62] < 0.001* No 144 332 1 1 Open in a new tab Key: *siginficant at p-value less than 0.05 Discussion This school-based study assessed the magnitude of unsafe sexual practice and its associated factors among secondary school students using constructs of the Health Belief Model (HBM). The findings indicate that unsafe sexual practice remains a substantial public health concern among adolescents in the study setting. In this study, 40.4% of students reported ever having sexual intercourse, with a median age at sexual debut of 16 years. This finding is consistent with previous studies conducted in Ethiopia and Nigeria, which report early initiation of sexual activity among adolescents [6,25–27]. Early sexual debut exposes adolescents to a higher risk of unsafe sexual practices, unintended pregnancy, and sexually transmitted infections (STIs), including HIV. More than one-third (36.6%) of respondents engaged in unsafe sexual practices. This prevalence is comparable with pooled estimates from a national meta-analysis in Ethiopia [ 20 ], but higher than reports from Nigeria [ 21 ], Arba Minch town in southern Ethiopia [ 13 ], and Aksum town in northern Ethiopia [ 22 ]. These discrepancies may be attributed to differences in study period, sociocultural context, and the distribution of behavioural risk factors across settings. Sociodemographic factors were significantly associated with unsafe sexual practice. Male students were more than twice as likely to engage in unsafe sexual practices compared to female students. This finding aligns with evidence from a systematic review in Ethiopia showing higher risk-taking behavior among male youths [ 20 ]. Gender norms that encourage sexual experimentation among males while discouraging similar behavior among females may partly explain this difference. Age was also a significant predictor; students aged 18 years or younger were less likely to practice unsafe sexual behaviors compared to older students. This finding is consistent with studies from South Africa, where older adolescents were more likely to engage in risky sexual practices [ 23 ]. Increased autonomy, exposure to substances, and peer influence among older adolescents may contribute to this pattern. Behavioral factors, including watching pornography, alcohol consumption, and khat chewing, were strongly associated with unsafe sexual practice. Students who reported watching pornographic films were more likely to engage in unsafe sexual practices, a finding consistent with pooled evidence from Ethiopia and studies conducted among high school students in Gondar [ 6 , 24 ]. Exposure to sexual content may normalize risky behaviors and reduce perceived susceptibility to adverse sexual health outcomes. Alcohol consumption was one of the strongest predictors of unsafe sexual practice. Students who consumed alcohol were nearly three times more likely to engage in unsafe sexual behaviors, consistent with findings from Gondar, Bahir Dar, and Kigali, Rwanda [ 17 , 24 , 25 ]. Alcohol may impair judgment and decision-making capacity, leading to unprotected intercourse or unintended sexual encounters. Similarly, khat chewing was significantly associated with unsafe sexual practice, which is supported by studies from Alamata, Dessie town, and Dessie Zuria woreda [ 14 , 18 ]. Risk behaviors often cluster together, and khat use may increase susceptibility to other substances, such as alcohol, thereby compounding sexual risk-taking behaviors [ 26 ]. HBM-related perceptions were also significantly associated with unsafe sexual practice. Students who perceived low social norms supporting consistent condom use were more likely to engage in unsafe sexual behaviors. Likewise, perceived self-efficacy for condom use showed a significant association, consistent with findings from western Nigeria [ 21 ]. These findings underscore the importance of enhancing adolescents’ confidence and social support for consistent condom use. Perceived norms regarding abstinence were also associated with unsafe sexual practice. Students who perceived abstinence as socially acceptable and positive were less likely to engage in unsafe sexual behaviors. In this study, low perceived norms for abstinence—defined by beliefs that premarital sex is common, socially acceptable, or a sign of maturity—were protective against unsafe sexual practice. This suggests that adolescents who critically perceive peer norms may resist pressure to engage in risky sexual behaviors. Similar findings have been reported elsewhere, highlighting the role of perceived norms in shaping abstinence behaviors [ 27 ]. Strengths and limitations The cross-sectional design limits the ability to establish causal relationships. Data were collected using self-administered questionnaires, which are subject to recall and social desirability bias, particularly for sensitive behaviors such as sexual practices and substance use. Additionally, the absence of interviewer guidance and the inability to apply complex skip patterns may have resulted in missing or misreported information. Despite these limitations, the study has notable strengths. A large sample size and random sampling technique were used to enhance representativeness. Rigorous data quality control measures were implemented to minimize bias and improve the reliability of the findings. The use of a theory-based framework (HBM) also strengthens the interpretation of behavioral and perceptual factors associated with unsafe sexual practice. Conclusions The study found that about two in five students in the setting engaged in unsafe sexual practices. Factors such as sex, age, perceived norms to abstain, constant condom use, self-efficacy for condom use, watching sex films, chewing khat, and drinking alcohol were significantly associated with unsafe sexual practices among adolescents in the study setting. The Gembella town education office, health office, and school communities are recommended to play their role in reducing behavioral factors around the school environment, in-school health education targeted to their age and gender, and reducing the vulnerability of school youths to unsafe sexual practices. Additionally, intensive interventional research is also important to mitigate the consequences of unsafe sexual practices among in-school youths. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1. (26.2KB, docx) Supplementary Material 2. (142KB, docx) Acknowledgements The authors are thankful to Mattu University’s Department of Public Health for their support, study participants, data collectors, supervisors, and the Gambella town education office for providing essential information and cooperation. Abbreviations AIDS Acquired Immunodefiency Syndrome AOR Adjusted Odds Ratio CI Confidence Interval COR Crude Odds Ratio HBM Health Belief Model HIV Human Immunodeficency Virus STI Sexually transmitted infection SPSS Statistical Package for Social Sciences USP unsafe sexual practice WHO World Health Organization Authors’ contributions TF and DOD have designed the survey, trained the research team, oversaw the fieldwork, and participated in drafting the manuscript. TF, DOD, AZ, and BN participated in the design of the survey, approved the survey, and oversaw the critical revision of the manuscript. All authors read and approved the final version of the manuscript. Funding The authors declare that there was no funding source for this research or for the publication of this article. The study was conducted, and all the authors are based in a low-income East African country, Ethiopia. Data availability The datasets used during the current study are available and can be accessed from the corresponding author upon reasonable request. Declarations Ethical approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethical Review Committee of College of Health Science of Mattu University. A connecting letter with Ref.no. RPG/325/15 written on June 14, 2023 was taken from Mattu University to Gambella town administration and health office. Each study participant was informed about the study’s purpose, data collection methods, anticipated benefit, and risk, and informed consent was obtained prior to data collection. In case of minors (participants under the age of 16), informed consent to participate in this study was obtained from the parents or legal guardian/next of kin and assent was obtained from the participants. 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