Research | Open Access | Volume 9 (4): Article 171 | Published: 27 Oct 2026
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Table 1: Demographic and socioeconomic profile of undergraduate participants
Table 2: Sexual health and behavioural profile of undergraduate participants
Table 3: Crude and adjusted prevalence ratios for factors associated with risky sexual behaviour
Abner Massa1,&,*, Patience Muwanguzi1,&*, Laban Muteebwa2, Nusifah Nabukeera1, Racheal Nabunya3, Sarah Joselyn Nalubega3, Bridget Atuhaire3, Richard Muhindo1
1Department of Nursing, Makerere University School of Health Sciences, P. O. Box 7072, Kampala, Uganda, 2Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda, 3African Center for Health Equity Research and Innovation (ACHERI), P.O. Box 5259, Kampala, Uganda
*co-first and corresponding authors
&Corresponding author: Abner Massa, Email: massaabner7@gmail.com, Patience Muwanguzi, Email: pamuwanguzi@gmail.com, Department of Nursing, Makerere University School of Health Sciences, P. O. Box 7072, Kampala, Uganda, ORCID: https://orcid.org/0000-0003-0403-9327
Received: 29 Jun 2026, Accepted: 17 Oct 2026, Published: 27 Oct 2026
Domain: Reproductive and Adolescent Health
Keywords: Risky sexual behaviours, HIV, multiple sexual partners, condom use, early sexual debut, sexually active students
©Abner Massa et al. Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Abner Massa et al. Risky sexual behaviours and associated factors among undergraduates at a Ugandan public university. Journal of Interventional Epidemiology and Public Health. 2026; 9(4):171. https://doi.org/10.37432/jieph-d-26-00205
Introduction: Undergraduate students may engage in sexual practices that place them at risk of HIV, other sexually transmitted infections, unintended pregnancy and unsafe abortion. This study estimated how common risky sexual behaviour was and identified associated factors among students enrolled at a Ugandan public university.
Methods: A quantitative cross-sectional survey was carried out from 8 March to 5 April 2025. Undergraduate students were recruited consecutively and completed a self-administered questionnaire with fixed-response and free-text items. Data were analysed in Stata version 17.0. Continuous variables were summarised as medians with interquartile ranges, while categorical variables were presented as frequencies and percentages. Factors related to risky sexual behaviour were examined using modified Poisson regression with robust standard errors.
Results: Data from 414 undergraduates were analysed. The median age was 23 years (IQR: 22-25), and 270 (65.2%) participants were male. Fourth-year students accounted for the largest academic-year group (30.9%). Just over half lived off campus (55.1%) and the same proportion had an active scholarship (55.1%). Risky sexual behaviour was reported by 19.3% (95% CI: 15.1-24.4). Overall, 67.6% had been sexually active in the previous six months. Among sexually active students, 46.0% (95% CI: 40.2-52.0) did not use a condom at their most recent sexual encounter, and 27.3% (95% CI: 23.2-31.8) had more than one sexual partner during the previous six months. In the adjusted analysis, later sexual debut was associated with a lower prevalence of risky sexual behaviour (aPR 0.90; 95% CI: 0.85-0.95), while drug use just before sex was associated with a higher prevalence (aPR 1.68; 95% CI: 1.02-2.76).
Conclusion: About one-fifth of undergraduates met the study definition of risky sexual behaviour. Condom non-use and multiple partnerships were important areas of concern. Later sexual debut was associated with a lower prevalence of risky sexual behaviour, whereas drug use just before sex was associated with a higher prevalence. Universities should provide early, age-appropriate sexual health interventions, particularly for students entering their first year, and integrate youth-friendly HIV and STI services with condom and PrEP counselling, substance-use prevention and screening, and support for safer sexual decision-making.
Risky sexual behaviour (RSB) among young people remains a major public health issue because it can lead to HIV acquisition, other sexually transmitted infections (STIs) and unintended pregnancy. In 2023, an estimated 1.3 million people acquired HIV globally, with approximately 4,000 new infections each day; young people aged 15-24 years contributed an important share of these infections [1]. Prevention approaches for this age group must therefore respond to sexual risk while improving access to youth-friendly services [2].
University life can bring new autonomy, peer groups and relationship experiences. These changes may expose some students to condom non-use, multiple partnerships, transactional sex, alcohol use before sex and early sexual debut [3-5, 6]. Such behaviours increase the possibility of HIV and STI transmission and may result in unintended pregnancy and other reproductive health consequences [7].
Across African universities, estimates of risky sexual behaviour differ markedly. Studies have reported 38.2% in Ethiopia, 65.8% in Nigeria and 59.1% in Ghana [8-10]. These differences may be related to how samples were selected, how risky sexual behaviour was measured and the social contexts in which students live. UNAIDS data continue to show that young people aged 15-24 years bear a substantial burden of new HIV infections, reinforcing the need for prevention efforts designed for this age group [11].
Previous work has identified individual, social and contextual influences on sexual risk. Reported factors include peer influence, low perception of HIV risk, substance use, exposure to sexual content, inadequate sexual and reproductive health knowledge, male sex, early sexual debut, concurrent partnerships, limited parental guidance, social isolation and urban residence [8, 12-14]. Their effects may vary by setting because sexual behaviour is shaped by culture, norms, the institutional environment and access to services.
Ugandan data focused specifically on university students are still sparse. Existing work often examines broader youth groups or applies different measures of risky sexual behaviour, which makes direct comparison difficult [10]. This leaves university health services, policymakers and programme implementers with limited local evidence for designing targeted interventions.
Against this background, this study estimated the prevalence of risky sexual behaviour and examined associated factors among undergraduates at a Ugandan public university. The findings add context-specific evidence on sexual risk patterns and can support university sexual and reproductive health programming, policy and prevention activities for young adults.
Study design and setting
We conducted a cross-sectional study from 8 March to 5 April 2025 among undergraduate students at Makerere University in Kampala, Uganda. Makerere University is a large public university with about 38,000 students, including approximately 35,000 undergraduates and 3,000 postgraduates [15]. It has nine colleges and one school, covering health sciences, natural sciences, engineering, agriculture, business, social sciences, humanities, education, computing, veterinary medicine and law. Its large and diverse student population made it a suitable setting for examining sexual risk among undergraduates.
Data collection procedure
Data were collected through a self-administered questionnaire in KoboToolbox. The first page provided study information and was followed by an electronic consent page that participants completed before accessing the survey. The form was set to accept only one response per participant. Students were recruited consecutively: eligible students received the invitation and were asked to share the survey link with other undergraduates in their colleges or schools. The link was circulated through student social media channels, including end-to-end encrypted WhatsApp groups.
Inclusion and exclusion criteria
Undergraduate students were eligible if they were enrolled between 2020 and 2025, were at least 18 years old and provided informed consent. Students were not included if they were currently participating in, or had recently taken part in, another study on risky sexual behaviour, or if key study variables were missing.
Sample size and sampling procedure
Sample size was calculated using Cochran’s formula for cross-sectional studies [16]. Using a 95% confidence level, an expected prevalence of 22.7% [17] and a 5% margin of error, the minimum estimate was 270 participants. Applying a design effect of 1.52 to account for clustering by college or school [18] increased the target sample to 410 participants.
Data collection tools
Quantitative data were collected using a pre-tested semi-structured questionnaire in English that participants completed themselves. The instrument contained fixed-response and free-text items on demographic, socioeconomic and individual characteristics. It was developed after a review of relevant literature and programmed in KoboToolbox. Before the main survey, 30 students pretested the tool to assess clarity, order of questions and completeness. The research team shared the link through personal email and end-to-end encrypted WhatsApp platforms. Responses were anonymised on submission and stored in a password-protected online database accessible only to the research team. Participants could proceed to the survey only after providing consent. The questionnaire did not collect information on hormonal contraception use among female students or reasons for condom non-use; these omissions are acknowledged as limitations when interpreting pregnancy-related risk and the gap between condom access and condom use.
Variable definitions and measurement
Inconsistent condom use: In this analysis, inconsistent condom use meant reporting that no condom was used during the most recent sexual encounter in the six months before data collection.
Multiple sexual partners: Participants were considered to have multiple sexual partners if they reported more than one partner during the six months before the survey.
Risky sexual behaviour: Risky sexual behaviour was defined as a composite outcome. A participant was classified as having RSB when they reported both more than one sexual partner in the previous six months and no condom use at the most recent sexual encounter. This stricter composite definition was selected to identify students with concurrent partner-related and condom-related sexual risk. It should therefore be interpreted as a focused measure of higher-risk sexual behaviour, rather than as the full burden of all sexual and reproductive health risk. Number of partners was measured using the question, “How many sexual partners have you had in the past 6 months?” with response options of 0, 1, 2, 3 and 4+. Condom use was measured using the question, “Did you use a condom on your recent sexual encounter?” with Yes/No response options.
Early sexual debut: Early sexual debut referred to first sexual intercourse in their lifetime.
Age at sexual debut: Age at sexual debut was collected using the open-ended item, “At what age did you first have sexual intercourse?”
Data analysis
Data completeness was assessed prior to analysis to identify questionnaires with missing information on key study variables. Of the four hundred and twenty-three (423) questionnaires received, nine (9) had incomplete responses on key variables required for the analysis and were excluded. Following data cleaning and assessment of completeness, 414 questionnaires with complete information on the key study variables were included in the final analysis. The analysis was conducted in Stata version 17.0. Medians and interquartile ranges were used for continuous variables, while categorical variables were summarised using frequencies and percentages. The primary outcome was risky sexual behaviour, based on both multiple sexual partners and condom non-use at the most recent sexual encounter. We calculated the prevalence of risky sexual behaviour with a 95% confidence interval (CI). Among sexually active participants, we also calculated the proportions reporting multiple sexual partners and condom non-use with 95% CIs. Associations with risky sexual behaviour were assessed using modified Poisson regression with robust standard errors.
Unadjusted analyses first generated crude prevalence ratios (cPRs), 95% CIs and p-values. Variables with p<0.20 in the unadjusted analysis were considered for the adjusted model. Age was retained a priori because of its epidemiological relevance to sexual behaviour and to improve comparability with prior studies. Adjusted prevalence ratios (aPRs), 95% CIs and p-values were reported, and statistical significance was set at p<0.05.
Ethical considerations
The study protocol and data collection tools were approved by the School of Health Sciences Research and Ethics Committee (SHSREC) of Makerere University (Ref. No. MAKSHSREC-2024-792). All participants provided informed consent before taking part. The study procedures followed relevant ethical guidelines and were conducted in accordance with the Declaration of Helsinki.
Demographic characteristics of participants
Participants had a median age of 23 years (IQR: 22, 25), and 270 (65.2%) were male. Fourth-year students were the largest academic-year group (30.9%). Just over half lived off campus (55.1%), and the same proportion reported having a scholarship (55.1%). Most students were unmarried (91.1%) and not employed (85.8%) (Table 1).
Behavioural characteristics of participants
The median age at first sex was 20 years (IQR: 18 – 21). Overall, 280 participants (67.6%) reported sexual activity in the previous six months. Among those with available responses, 8.0% reported anal sex during that period. Most participants had ever tested for HIV (87.3%); among those who had tested, 71.3% had done so within the past 12 months. Health facilities were the most commonly reported site for the most recent HIV test, and 69.9% of those tested had disclosed their HIV status to a partner. Although 82.1% reported easy access to condoms, 19.1% reported an STI in the previous six months. Slightly more than half had heard of HIV PrEP, but only 10.9% of those aware of PrEP had ever used it (Table 2).
Prevalence of risky sexual behaviour
Risky sexual behaviour was reported by 19.3% of participants (95% CI: 15.1, 24.4). Among students who were sexually active, 46.0% (95% CI: 40.2, 52.0) did not use a condom during their most recent sexual encounter, while 27.3% (95% CI: 23.2, 31.8) had more than one sexual partner in the preceding six months.
Factors associated with risky sexual behaviour
We used modified Poisson regression with robust standard errors to examine factors related to risky sexual behaviour. In the unadjusted analyses, residence, year of study, age at sexual debut, ever used PrEP, never tested for HIV and drug use before sex had p-values below 0.20 and were therefore considered for the adjusted model. Age was also retained a priori because of its epidemiological relevance (Table 3).
In the adjusted model, age at sexual debut (aPR 0.90; 95% CI: 0.85, 0.95) and using drugs prior to sex (aPR 1.68; 95% CI: 1.02, 2.76) remained statistically significant (Table 3). A one-year increase in age at sexual debut corresponded to a 10% lower prevalence of risky sexual behaviour. Compared to those who did not use drugs before sex, students who reported using drugs before sex had a 68% higher prevalence of risky sexual behaviour.
How risky sexual behaviour is defined strongly affects prevalence estimates. Some studies classify participants as engaging in risky sexual behaviour when they report any one of several practices, including multiple partners, inconsistent condom use, forced sex, adverse childhood experiences or sexual debut before age 18. This study used a narrower composite measure that required both multiple partners and condom non-use at the most recent sexual encounter. This stricter definition may explain why the prevalence was lower than in some studies outside Uganda. It also means that some students with important sexual and reproductive health risks, such as condom non-use with one partner, multiple partnerships with condom use, recent STI, or pregnancy-related risk not captured by contraception data, may not have been classified as having RSB in the primary composite outcome.
Despite the lower composite prevalence, the individual behaviours remain important. Among sexually active students, 46.0% did not use a condom at the most recent sexual encounter and 27.3% had more than one partner in the previous six months. Similar behaviours have been reported in studies from China and Ethiopia, although estimates differ by setting [19, 20]. These practices increase exposure to STIs and HIV [21]. The finding that condom non-use occurred despite high reported access suggests that availability alone is not enough. University sexual health programmes should also address negotiation skills, risk perception, partner communication and practical barriers to condom use.
Sexual risk is shaped by a broad range of influences, including age, sex, substance use, adverse childhood experiences, poverty, sexual content exposure, religious attendance, peer norms and timing of sexual debut [2, 14, 6].
Peer influence may be particularly relevant in university settings because students often make decisions within new social networks. Studies from Ethiopia and elsewhere have reported higher odds of risky sexual behaviour among students exposed to peer pressure, while students with less peer pressure appear less likely to report risky sexual practices [22-24]. Although peer pressure was not retained in the final adjusted model in this study, it remains relevant for intervention planning.
In this study, the median age at sexual debut was 20 years (IQR: 18-21), which is higher than estimates from some settings. Research among students at Uganda Martyrs University reported earlier sexual debut among both male and female students [25], and studies in Ethiopia and China have also reported debut during adolescence or the late teenage years [19, 26]. Differences may reflect social norms, institutional context, sample composition and how sexual behaviour data were collected.
Later sexual debut was associated with lower prevalence of risky sexual behaviour. This aligns with evidence showing that early sexual debut can increase later exposure to unprotected sex, multiple partnerships and STIs [27, 28]. A review from Ethiopia also found a substantial burden of early sexual debut among students [29]. These findings support interventions that help adolescents and young adults delay sexual initiation where possible and, for those who are sexually active, make safer and better-informed decisions. Mentorship, comprehensive sexuality education, peer-led discussions and youth-friendly services may be useful strategies.
Students that had used drugs before sex had a higher risky sexual behaviour compared to their counterparts. This is because substance use has been reportedly associated with increased sexual risk taking through judgement impairment and tendencies to lower inhibitions, increasing the likelihood of unprotected sex and multiple sexual partners.
Orientation programmes should therefore include practical sexual health education, information on available services and guidance on navigating new social environments. The association between earlier sexual debut and risky sexual behaviour in this study is consistent with evidence showing higher risk among those who begin sex at younger ages [19].
This study has several limitations. The cross-sectional design prevents conclusions about temporal or causal relationships between explanatory variables and risky sexual behaviour. Sexual behaviour was self-reported and may have been affected by recall error or social desirability bias, although anonymous self-administration may have reduced this risk. Condom use was measured only at the most recent sexual encounter and may not reflect consistent condom use over time. The questionnaire did not collect hormonal contraception use among female students or reasons for condom non-use, which limits interpretation of unintended pregnancy risk and of the gap between condom access and condom use. Consecutive recruitment through an online survey may also limit generalisability to all undergraduates at Makerere University or students in other institutions, particularly because the total number of students exposed to the invitation was not known and a formal response rate could not be calculated. Nevertheless, the study offers useful context-specific evidence on sexual risk among undergraduates in a large Ugandan public university.
This study found that a meaningful proportion of undergraduates met the study definition of risky sexual behaviour. Condom non-use and multiple partnerships were the main behaviours contributing to sexual risk and may increase exposure to HIV and other STIs. Later sexual debut was associated with lower prevalence of risky sexual behaviour. On the other hand, having used drugs before sex was associated with higher prevalence of risky sexual behaviour. The findings support targeted, age-appropriate sexual health interventions, particularly for first-year students. Universities should strengthen prevention messages early, improve youth-friendly services, integrate confidential counselling services with substance-use prevention and screening programmes, and build students’ skills in safer decision-making and partner communication.
What is already known about the topic
What this study adds
Conceptualization: Abner Massa, Patience Muwanguzi, Nusifah Nabukeera
Methodology: Abner Massa, Patience Muwanguzi, Nusifah Nabukeera
Data curation: Abner Massa, Racheal Nabunya, Sarah Joselyn Nalubega, Bridget Atuhaire
Formal analysis: Abner Massa, Laban Muteebwa, Racheal Nabunya, Sarah Joselyn Nalubega, Bridget Atuhaire
Supervision: Patience Muwanguzi, Richard Muhindo
Project administration: Racheal Nabunya, Richard Muhindo
Software: Laban Muteebwa
Validation: Patience Muwanguzi, Richard Muhindo
Visualization: Nusifah Nabukeera
Writing – original draft: Abner Massa, Patience Muwanguzi
Writing – review & editing: Patience Muwanguzi, Laban Muteebwa, Nusifah Nabukeera, Racheal Nabunya, Sarah Joselyn Nalubega, Bridget Atuhaire, Richard Muhindo
| Variable / Categories | Frequency (N=414) | Percentage (%) |
|---|---|---|
| Age (years) | ||
| Median (IQR): 23 (22, 25) | 414 | 100.0 |
| Sex | ||
| Female | 144 | 34.8 |
| Male | 270 | 65.2 |
| Year of study | ||
| Year 1 | 9 | 2.2 |
| Year 2 | 89 | 21.5 |
| Year 3 | 93 | 22.5 |
| Year 4 | 128 | 30.9 |
| Year 5 | 9 | 2.2 |
| Residence status | ||
| On-Campus | 186 | 44.9 |
| Off-Campus | 228 | 55.1 |
| Have a study scholarship | ||
| Yes | 226 | 55.1 |
| No | 188 | 45.4 |
| Marital status | ||
| Married | 37 | 8.9 |
| Not married | 377 | 91.1 |
| Employment status | ||
| Employed | 59 | 14.2 |
| Not employed | 355 | 85.8 |
| Variable | Frequency (N=414) | Percentage (%) |
|---|---|---|
| Age at sexual debut (years) | Median (IQR): 20 (18 – 21) | |
| Sexally active in past 6 months | ||
| Yes | 280 | 67.6 |
| No | 134 | 32.4 |
| Ever tested for HIV | ||
| Yes | 280 | 67.6 |
| No | 134 | 32.4 |
| Recent HIV testing (past 12 months)* | ||
| Yes | 349 | 87.3 |
| No | 51 | 12.7 |
| Disclosure of HIV status to partner** | ||
| Yes | 271 | 71.3 |
| No | 51 | 12.7 |
| Place of most recent HIV testing*** | ||
| Community outreach | 41 | 11.7 |
| HIV self-testing | 84 | 23.9 |
| Had an STI in past 6 months | ||
| Yes | 79 | 19.1 |
| No | 335 | 80.9 |
| Used drugs just before sex*** | ||
| Yes | 88 | 21.3 |
| No | 326 | 78.7 |
| * N = 348. ** N = 322. *** N = 351. | ||
| Variable | cPR (95% CI) | P value | aPR (95% CI) | P value |
|---|---|---|---|---|
| Age (years) | 1.02 (0.98, 1.05) | 0.327 | 1.00 (0.97, 1.02) | 0.860 |
| Sex | ||||
| Female | Ref | |||
| Male | 0.92 (0.55, 1.52) | 0.737 | ||
| Marital status | ||||
| Married | Ref | |||
| Not Married | 0.74 (0.39, 1.43) | 0.372 | ||
| Residence | ||||
| On-campus residents | Ref | |||
| Off campus residents | 1.41 (0.84, 2.37) | 0.198 | 0.68 (0.39, 1.20) | 0.188 |
| Year of study | ||||
| Year 1 | Ref | |||
| Year 2 | 0.53 (0.26, 1.06) | 0.074 | 0.65 (0.32, 1.33) | 0.233 |
| Year 3 | 0.49 (0.24, 0.99) | 0.047 | 0.61 (0.27, 1.37) | 0.230 |
| Year 4 | 0.56 (0.30, 1.05) | 0.068 | 0.56 (0.28, 1.13) | 0.105 |
| Year 5 | 1.45 (0.56, 3.74) | 0.446 | 1.15 (0.35, 3.78) | 0.814 |
| Sponsorship status | ||||
| Sponsored | Ref | |||
| Self-sponsored | 0.85 (0.50, 1.35) | 0.445 | ||
| Employment status | ||||
| Employed | Ref | |||
| Not Employed | 0.98 (0.53, 1.81) | 0.949 | ||
| Age at sexual debut (years) | 0.93 (0.89, 0.98) | <0.001 | 0.90 (0.85, 0.95) | 0.004 |
| Used drugs just before sex | ||||
| Yes | 1.95 (1.21, 3.14) | 0.006 | 1.68 (1.02-2.76) | 0.043 |
| No | Ref | |||
| Ever used PrEP | ||||
| Yes | 1.79 (0.77, 4.13) | 0.175 | 1.03 (0.42-2.54) | 0.949 |
| No | Ref | |||
| Ever tested for HIV | ||||
| Yes | Ref | |||
| No | 1.87 (1.03, 3.40) | 0.039 | 0.72 (0.38-1.35) | 0.302 |
| Note: statistically significant variables are shown in bold. | ||||