Sexual Risk Behavior Beliefs and Self-Efficacy Scales

Abstract

The Sexual Risk Behavior Beliefs and Self-Efficacy Scales (SRBBS) constitute a psychometrically validated, multidimensional instrument engineered to evaluate critical cognitive, normative, and behavioral self-efficacy determinants governing adolescent sexual decision-making, pregnancy risk, and the transmission of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). Developed under the auspices of the Centers for Disease Control and Prevention (CDC) within the programmatic evaluation of the Safer Choices intervention, the SRBBS synthesizes constructs from three seminal behavioral science frameworks: the Theory of Reasoned Action, Social Cognitive Theory, and the Health Belief Model. The battery comprises 22 self-administered items distributed across eight discrete subscales, organized under two overarching behavioral domains: Sexual Risk-Taking Behavior and Protective Behavior. The risk-taking domain encompasses Attitudes About Sexual Intercourse (ASI; 2 items), Norms About Sexual Intercourse (NSI; 2 items), and Self-Efficacy for Refusing Sex (SER; 3 items). The protective behavior domain incorporates Attitudes About Condom Use (ACU; 3 items), Norms About Condom Use (NCU; 3 items), Self-Efficacy in Communicating About Condoms (SECM; 3 items), Self-Efficacy in Using and Buying Condoms (SECU; 3 items), and Barriers to Condom Use (BCU; 3 items). Items are calibrated using either 3-point or 4-point Likert response formats. Psychometric evaluation in a diverse longitudinal cohort of 6,213 high school students established internal consistency estimates ranging from α = .61 to α = .87, robust confirmatory factor structures (RMSEA < .05), and pronounced concurrent and discriminative validity across sexual debut, recent sexual activity, and consistent barrier contraception use. The SRBBS serves as an essential measurement standard for adolescent public health surveillance, school-based intervention assessment, and behavioral research.

Keywords

Sexual Risk Behavior Beliefs and Self-Efficacy Scales, SRBBS, adolescent sexual health, condom use self-efficacy, sexual refusal self-efficacy, HIV prevention, STI prevention, Theory of Reasoned Action, Social Cognitive Theory, Health Belief Model, psychometrics, Safer Choices

Authors

The development and validation of the Sexual Risk Behavior Beliefs and Self-Efficacy Scales were conducted by a multidisciplinary team of public health researchers, behavioral scientists, and psychometricians:

• Karen Basen-Engquist, Ph.D., M.P.H. – University of Texas M.D. Anderson Cancer Center, Department of Behavioral Science, Houston, Texas, USA. Correspondence: [email protected].
• Louise C. Mâsse, Ph.D. – Center for Health Promotion Research and Development, University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas, USA.
• Karin Coyle, Ph.D. – ETR Associates (Education, Training, and Research), Scotts Valley, California, USA.
• Douglas Kirby, Ph.D. – ETR Associates, Scotts Valley, California, USA.
• Guy S. Parcel, Ph.D. – Center for Health Promotion Research and Development, University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas, USA.
• Stephen Banspach, Ph.D. – Division of Adolescent and School Health (DASH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA.
• Jesse Nodora, Dr.P.H. – Arizona Department of Health Services, Phoenix, Arizona, USA.

Purpose

The primary purpose of the Sexual Risk Behavior Beliefs and Self-Efficacy Scales is to provide an empirically grounded, psychometrically sound, and operationally parsimonious assessment tool capable of quantifying the key cognitive, social normative, and behavioral self-efficacy constructs that regulate adolescent sexual risk-taking and protective practices. Adolescence represents a critical developmental transition characterized by neurological maturation, emergent sexual desires, identity exploration, and shifting social reference points toward peer affiliations. During this window, individuals face heightened vulnerabilities to unintended adolescent pregnancy, human immunodeficiency virus (HIV), and an array of sexually transmitted infections including Chlamydia trachomatis, human papillomavirus (HPV), and herpes simplex virus (HSV). Effective prevention requires nuanced behavioral metrics that capture not merely whether an adolescent engages in intercourse, but the underlying psychological precursors that drive abstinence, delay of sexual debut, risk negotiation, and consistent condom prophylaxis.

Historically, sexual health surveys suffered from significant methodological limitations: they either relied upon single-item behavioral recall metrics (which fail to capture motivational readiness or psychological vulnerability) or utilized lengthy, cumbersome research inventories that could not be feasibly administered within crowded secondary school schedules. The SRBBS was engineered to overcome these challenges. Developed under Contract #200-91-0938 with the Centers for Disease Control and Prevention (CDC) to evaluate the multicomponent Safer Choices trial across California and Texas high schools, the scale fulfills three critical research and clinical needs:

1. Programmatic Outcome Evaluation: It serves as a sensitive evaluative benchmark for educational, community, and clinical interventions designed to alter adolescent sexual trajectories. By decomposing sexual decision-making into targeted cognitive targets (e.g., distinguishing between partner-communication efficacy versus logistical procurement efficacy), the instrument allows researchers to pinpoint exactly which intervention modules achieve behavioral change and which require pedagogical remediation.
2. Epidemiological and Public Health Surveillance: The parsimonious 22-item structure enables seamless integration into expansive public health surveillance batteries without imposing undue respondent burden, cognitive fatigue, or survey drop-out.
3. Targeted Clinical Assessment and Risk Stratification: In clinical settings, pediatric psychology services, and school-based health centers, individual subscale profiles enable health educators, clinical psychologists, and pediatricians to diagnose specific psychosocial vulnerabilities. For example, a clinician can discern whether an adolescent’s inconsistent condom use stems from peer-norm deficits, technical embarrassment regarding purchasing condoms, or an inability to verbally negotiate protective boundaries with an intimate partner.

Psychological Construct

The SRBBS measures eight interrelated psychological constructs bifurcated into two primary behavioral domains: Sexual Risk-Taking Behavior and Protective Behavior. Each construct represents an actionable psychological target grounded in cognitive-affective processing, social cognition, and behavioral competence.

Domain I: Sexual Risk-Taking Behavior

• Attitudes About Sexual Intercourse (ASI; 2 items): This dimension quantifies an individual’s personal evaluative posture and belief system regarding the developmental appropriateness and relational conditions under which sexual intercourse should take place. It assesses the degree to which an adolescent believes that individuals in their developmental peer group ought to postpone coitus until older adulthood, weighed against permissive attitudes regarding sex within steady adolescent romantic dating contexts. A lower score reflects prescriptive endorsement of abstinence or delay, whereas higher values indicate favorable, permissive appraisals of coital engagement.
• Norms About Sexual Intercourse (NSI; 2 items): This subscale measures perceived descriptive and subjective peer norms. Rather than gauging personal desire, it captures the respondent’s cognitive representation of their immediate peer group’s collective values and behavioral expectations. It evaluates whether the adolescent perceives their close social circle as endorsing coital postponement versus sanctioning sexual activity within steady romantic relationships. Social norms operate as potent behavioral primers during adolescence, functioning through mechanisms of social reward, peer sanction, and modeling.
• Self-Efficacy for Refusing Sexual Intercourse (SER; 3 items): Grounded in Albert Bandura’s social cognitive paradigm, SER quantifies an individual’s context-specific confidence in their behavioral execution capacity to resist sexual pressure across challenging scenarios. The scale presents high-pressure scenarios: encountering an attractive potential partner at an unstructured party, enduring sustained coital entreaties from a steady romantic partner when personal readiness has not been reached, and refusing to engage in intercourse when a partner actively refuses condom use. SER is not a static personality trait; it is a context-dependent perception of personal agency.

Domain II: Protective Behavior

• Attitudes About Condom Use (ACU; 3 items): ACU taps into personal normative standards and behavioral outcome expectations regarding consistent barrier protection. It assesses the strength of the respondent’s belief that condoms should universally accompany coitus among peers, testing whether this rule persists even when hormonal oral contraception is active (dual protection against STIs) or when intimate partners are well acquainted (countering the cognitive bias of perceived invulnerability in established relationships).
• Norms About Condom Use (NCU; 3 items): Mirroring the ACU construct, NCU measures the perceived peer normative consensus regarding condom utilization. It captures the degree to which an adolescent believes that their close social peer network endorses universal barrier protection under identical boundary conditions: general coitus, concomitant oral contraceptive pill usage, and long-term acquaintance between partners.
• Self-Efficacy in Communicating About Condoms (SECM; 3 items): This construct measures interpersonal communicative assertiveness and agency. It assesses an adolescent’s situational confidence to articulate the demand for barrier protection across distinct interpersonal dynamics: transitioning from non-condom intercourse to condom usage in an established relationship, initiating condom negotiation with a newly met partner, and successfully persuading a partner to utilize dual contraception when pregnancy prevention is already secured via birth control pills.
• Self-Efficacy in Buying and Using Condoms (SECU; 3 items): SECU gauges technical and operational behavioral competence. It evaluates the respondent’s confidence regarding three critical pragmatic competencies: deploying a condom correctly (or instructing an intimate partner in proper application technique), entering a commercial establishment to purchase condoms, and proactively maintaining logistical condom availability prior to unexpected sexual encounters.
• Barriers to Condom Use (BCU; 3 items): In accordance with the Health Belief Model, this construct measures perceived internal and psychosocial costs that impede protective action. It evaluates the acute emotional and reputational vulnerabilities associated with prophylactic management: store-based purchase embarrassment, interpersonal discomfort associated with physically carrying condoms, and anticipatory stigma regarding the social perception that carrying protection implies premeditated sexual intent.

Theoretical Framework

The architecture of the SRBBS rests upon a deliberate integration of three dominant theoretical models of health decision-making: the Theory of Reasoned Action (Fishbein & Ajzen, 1975), Social Cognitive Theory (Bandura, 1986), and the Health Belief Model (Rosenstock, 1974). Rather than treating adolescent sexual behavior as an irrational impulse, this theoretical synthesis models sexual decision-making as the product of cognitive representations, social expectations, perceived environmental barriers, and contextual self-efficacy beliefs.

From the Theory of Reasoned Action (TRA), the scale extracts the fundamental premise that volitional human behavior is directly governed by behavioral intentions, which are simultaneously determined by personal attitudes toward the behavior (evaluations of consequences) and subjective norms (perceptions of social normative pressure from significant referents). The SRBBS operationalizes this dual architecture in both behavioral domains. For risk-taking behavior, personal attitudes (ASI) and perceived peer norms (NSI) work synergistically to facilitate or inhibit sexual initiation. For protective behavior, condom attitudes (ACU) and condom norms (NCU) establish whether prophylaxis is perceived as socially required or deviant.

From Bandura’s Social Cognitive Theory (SCT), the developers integrated the construct of self-efficacy—the belief in one’s capabilities to organize and execute courses of action required to attain designated types of performances. Bandura established that possessing knowledge or holding positive attitudes is insufficient to guarantee behavioral execution, particularly in emotionally charged, socially pressurized interpersonal situations. The SRBBS breaks self-efficacy down into granular behavioral domains: refusing unwanted sexual advances (SER), interpersonal verbal negotiation (SECM), and pragmatic technical execution (SECU). This tri-part division reflects SCT’s emphasis on domain specificity, recognizing that an adolescent may feel highly capable of purchasing a condom in a commercial store while feeling completely incapacitated when attempting to demand its application with an emotionally manipulative partner.

Finally, the Health Belief Model (HBM) provides the framework for conceptualizing perceived barriers (BCU). The HBM posits that health-protective action occurs only when an individual perceives high susceptibility to and severity of a negative health outcome (e.g., HIV, STIs, adolescent pregnancy), perceives clear net benefits of action, and determines that the tangible and psychological barriers to taking that action do not outweigh the expected gains. In adolescent populations, perceived barriers rarely consist of financial costs; rather, they manifest as intense social anxiety, mortification during retail transactions, and fear of moralistic social sanction. By indexing retail embarrassment, carrying anxiety, and premeditation stigma, the BCU scale captures the critical inhibitory friction that prevents adolescents from translating theoretical protective intentions into physical practice.

Validity

The psychometric validity of the SRBBS was comprehensively established through a multi-stage empirical program involving qualitative focus-group testing, structural confirmatory factor analyses, and large-scale concurrent criterion validation among a multiethnic cohort of 6,213 high school students in Texas and California (Basen-Engquist et al., 1996).

Construct and Structural Validity

Construct validity was formally tested using Confirmatory Factor Analysis (CFA), bifurcated into two separate conceptual models: the Sexual Risk Behavior Model (comprising ASI, NSI, and SER) and the Protective Behavior Model (comprising ACU, NCU, SECM, SECU, and BCU). The analytical evaluation revealed that specifying correlated error terms between grammatically and semantically parallel attitude and norm items was necessary to account for method-specific variance. Once these paths were specified, both models exhibited exemplary goodness-of-fit indices: non-significant chi-square values, normally distributed standardized residuals, and a Root Mean Square Error of Approximation (RMSEA) < .05, demonstrating structural construct validity.

Concurrent Criterion Validity

Concurrent validity was examined by evaluating the scales’ capacity to discriminate between known behavioral groups across sexual initiation status, recent coital frequency, and condom compliance consistency:

• Sexual Inexperience vs. Experience: The sexual risk behavior subscales demonstrated robust discriminant capacity between virgins and sexually initiated students. Adolescents who had never experienced intercourse exhibited attitudes and perceived peer norms substantially less supportive of coitus compared to sexually experienced peers, yielding dramatic effect sizes of d = 1.09 for ASI and d = 0.90 for NSI (where effect size d = |Mean₁ − Mean₂| / Pooled SD). Furthermore, sexually abstinent students demonstrated significantly higher self-efficacy for refusing unwanted or unprotected intercourse than their sexually active peers (SER effect size d = 0.57).
• Recent Sexual Inactivity: In parallel comparisons between adolescents reporting coitus within the preceding 3 months versus those abstaining, identical directional patterns emerged across ASI, NSI, and SER.
• Condom Use Consistency: Among sexually active students, the protective behavior scales reliably separated consistent condom users (100% condom adherence during sexual encounters) from inconsistent or non-users. Consistent users exhibited significantly more positive attitudes toward condom use (ACU effect size d = 0.78) and perceived far more favorable peer norms (NCU effect size d = 0.56). Consistent users also scored significantly higher on communication self-efficacy (SECM d = 0.47) and technical/procurement self-efficacy (SECU d = 0.23). Concurrently, consistent users scored significantly lower on perceived barriers, experiencing less embarrassment and stigma surrounding procurement and possession (BCU effect size d = 0.20).

Convergent Validity with Demographic Indicators

Theoretical hypotheses regarding gender and developmental age differences were tested to assess convergent validity. In alignment with established developmental literature:

• Gender Associations: Adolescent females scored significantly higher than males on norms and attitudes discouraging early sexual debut, scored higher on self-efficacy in refusing intercourse (SER), held more favorable attitudes and peer norms regarding condom use (ACU and NCU), and exhibited greater interpersonal communication self-efficacy (SECM). Conversely, males scored higher on technical and purchasing self-efficacy (SECU).
• Age and Maturation Associations: Chronological age was positively associated with communicative and procurement self-efficacy, while negatively associated with restrictive sexual norms and attitudes. Interestingly, younger adolescents reported higher self-efficacy in refusing sex (SER) than older adolescents, reflecting the escalating relational, peer, and biological pressures toward sexual initiation that accompany late adolescence.

Reliability

The internal consistency reliability of the SRBBS was evaluated on the full multiethnic validation sample of N = 6,213 high school students from Texas and California (Basen-Engquist et al., 1996). Across all eight subscales, the instrument demonstrated acceptable to high internal consistency, particularly notable given the parsimonious length (2 to 3 items per scale) of each construct:

• Attitudes About Sexual Intercourse (ASI): Cronbach’s α = .78 (2 items)
• Norms About Sexual Intercourse (NSI): Cronbach’s α = .78 (2 items)
• Self-Efficacy for Refusing Sex (SER): Cronbach’s α = .70 (3 items)
• Attitudes About Condom Use (ACU): Cronbach’s α = .87 (3 items)
• Norms About Condom Use (NCU): Cronbach’s α = .84 (3 items)
• Self-Efficacy in Communicating About Condoms (SECM): Cronbach’s α = .66 (3 items)
• Self-Efficacy in Buying and Using Condoms (SECU): Cronbach’s α = .61 (3 items)
• Barriers to Condom Use (BCU): Cronbach’s α = .73 (3 items)

While the SECM (α = .66) and SECU (α = .61) scales yield lower coefficients relative to the attitude and norm scales, psychometric theory notes that Cronbach’s alpha is heavily dependent upon scale length; for 3-item behavioral scales capturing multidimensional practical tasks (e.g., SECU encompasses buying in a store, carrying, and correct technique), internal consistency values above .60 satisfy conventional benchmarks for field research. Furthermore, the translation of the battery into Spanish exhibited consistent structural stability across language administrations.

Factor Analysis

The factorial validity of the SRBBS was evaluated using structural equation modeling and confirmatory factor analysis (CFA) to verify whether the 22 observed items accurately mapped onto their theoretical latent constructs. Rather than pooling all items into an undifferentiated single model, the investigators analyzed two distinct structural models grounded in behavioral divergence: the Sexual Risk-Taking Behavior Model and the Protective Behavior Model.

Sexual Risk-Taking Behavior Model

The first structural model evaluated the three latent constructs governing sexual risk initiation: Attitudes About Sexual Intercourse (ASI; 2 indicators), Norms About Sexual Intercourse (NSI; 2 indicators), and Self-Efficacy for Refusing Sex (SER; 3 indicators). Initial iterations of the measurement model indicated localized strain caused by shared linguistic and semantic structures across attitude and norm items. Specifically, ASI1 (“I believe people my age should wait…”) and NSI1 (“Most of my friends believe people my age should wait…”) share an identical grammatical stem, as do ASI2 and NSI2 (“…OK for people my age to have sex with a steady boyfriend or girlfriend”). When paths specifying correlated error terms between these grammatically parallel pairs were incorporated into the model, the resulting measurement structure demonstrated fit:

• The model χ² became non-significant, indicating minimal discrepancy between observed and implied covariance matrices.
• Standardized residuals demonstrated normal distribution without localized outliers.
• The Root Mean Square Error of Approximation (RMSEA) fell below .05, establishing close model fit.
• All standardized factor loadings were statistically significant (p < .001), confirming that items served as robust operational indicators of their assigned latent variables.

Protective Behavior Model

The second structural model evaluated the five latent constructs governing prophylactic barrier behavior: Attitudes About Condom Use (ACU; 3 indicators), Norms About Condom Use (NCU; 3 indicators), Self-Efficacy in Communicating About Condoms (SECM; 3 indicators), Self-Efficacy in Buying and Using Condoms (SECU; 3 indicators), and Barriers to Condom Use (BCU; 3 indicators). As observed in the risk-taking model, strong methodological covariance existed between parallel attitude and norm indicators (e.g., ACU1 paired with NCU1, ACU2 with NCU2, and ACU3 with NCU3). Following the introduction of correlated error paths for these three parallel pairs:

• The confirmatory model fit indices met standard criteria: χ² was non-significant, residuals were normally distributed, and RMSEA remained < .05.
• Discriminant validity among the latent constructs was confirmed by inspecting latent inter-factor correlations, which demonstrated that while attitudes and norms correlated moderately with efficacy and barriers, each factor captured unique variance.
• Communication efficacy (SECM) and technical/procurement efficacy (SECU) loaded onto two distinct, correlated latent dimensions rather than collapsing into a singular generic self-efficacy factor, validating the separation of communicative versus logistical mastery.

Instrument / Measurement Tool

The Sexual Risk Behavior Beliefs and Self-Efficacy Scales consist of 22 items structured as follows:

• Instrument Type: Standardized self-report questionnaire / psychometric assessment battery.
• Target Population: Adolescents and young adults (validated primarily among high school students aged 14–18; adapted for middle school students in grades 7–8).
• Administration Format: Self-administered paper-and-pencil instrument (originally designed on optical-scan bubble forms) or computerized/web-based survey interface.
• Administration Time: The 22 SRBBS items require approximately 5 to 8 minutes to complete when administered independently. (Within the comprehensive 110-item Safer Choices Student Health Questionnaire, administration requires 30 to 45 minutes).
• Subscale Architecture & Item Count: Total of 22 items distributed across eight subscales:
  • Attitudes About Sexual Intercourse (ASI): 2 items (ASI1, ASI2)
  • Norms About Sexual Intercourse (NSI): 2 items (NSI1, NSI2)
  • Attitudes About Condom Use (ACU): 3 items (ACU1, ACU2, ACU3)
  • Norms About Condom Use (NCU): 3 items (NCU1, NCU2, NCU3)
  • Self-Efficacy for Refusing Sex (SER): 3 items (SER1, SER2, SER3)
  • Self-Efficacy in Communicating About Condoms (SECM): 3 items (SECM1, SECM2, SECM3)
  • Self-Efficacy in Buying and Using Condoms (SECU): 3 items (SECU1, SECU2, SECU3)
  • Barriers to Condom Use (BCU): 3 items (BCU1, BCU2, BCU3)
• Response Formats:
  • Attitude & Norm Scales (ASI, NSI, ACU, NCU): 4-point Likert scale:
    
    4 = Definitely Yes; 3 = Probably Yes; 2 = Probably No; 1 = Definitely No.
  • Self-Efficacy Scales (SER, SECM, SECU): 3-point Likert scale:
    
    1 = Not Sure at All; 2 = Kind of Sure; 3 = Totally Sure.
  • Barriers Scale (BCU): 4-point Likert scale:
    
    4 = I Strongly Agree; 3 = I Kind of Agree; 2 = I Kind of Disagree; 1 = I Strongly Disagree.
• Scoring Procedures:
  • Reverse Scoring: Items marked with an asterisk (ASI2 and NSI2) must be reverse-coded prior to subscale score calculation (i.e., recode 4 → 1, 3 → 2, 2 → 3, and 1 → 4).
  • Subscale Score Calculation: Sum the item responses within a subscale and divide by the number of completed items in that subscale (mean scoring method). This retains the original metric scale range:
    • ASI, NSI, ACU, NCU, and BCU scores range from 1.00 to 4.00.
    • SER, SECM, and SECU scores range from 1.00 to 3.00.
  • Interpretation:
    • Higher scores on ASI and NSI reflect beliefs and perceived peer norms favoring coital delay/abstinence.
    • Higher scores on ACU and NCU indicate favorable attitudes and perceived peer norms toward universal condom use.
    • Higher scores on SER, SECM, and SECU indicate greater self-efficacy.
    • Higher scores on BCU indicate greater perceived logistical, psychological, and social barriers to condom acquisition and possession.

Permissions & Fee and Test Year

The Sexual Risk Behavior Beliefs and Self-Efficacy Scales were developed in the mid-1990s as part of the federally funded Safer Choices project and formalized in psychometric literature in 1996 (Basen-Engquist et al., 1996; Coyle et al., 1996). The research was supported by the Centers for Disease Control and Prevention (CDC) under Contract #200-91-0938. As an instrument created under federal government research funding for public health advancement, the scale is generally accessible for non-commercial academic research, pedagogical evaluation, and institutional public health use without licensing fees. Researchers and evaluators utilizing the instrument should properly cite the primary development literature (Basen-Engquist et al., 1996; Coyle et al., 1996) and may contact the corresponding author regarding updates, permissions, or specialized translations:

Dr. Karen Basen-Engquist
University of Texas M.D. Anderson Cancer Center
Department of Behavioral Science – Box 243
1515 Holcombe Blvd, Houston, TX 77030
Email: [email protected]

References

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Basen-Engquist, K., Mâsse, L. C., Coyle, K., Kirby, D., Parcel, G. S., Banspach, S., & Nodora, J. (1996). Validity of scales measuring the psychosocial determinants of HIV/STD-related risk behavior in adolescents [Unpublished manuscript]. University of Texas Health Science Center at Houston.
• Basen-Engquist, K., Coyle, K. K., Parcel, G. S., Kirby, D., Banspach, S. R., Carvajal, S. C., & Baumler, E. (2001). Schoolwide education to promote condom use in high schools: Effects on knowledge, attitudes, and behaviors. Health Education & Behavior, 28(2), 181–196. https://doi.org/10.1177/109019810102800206
• Coyle, K. K., Kirby, D., Parcel, G., Basen-Engquist, K., Banspach, S., Rugg, D., & Weil, M. (1996). Safer Choices: A multi-component school-based HIV/STD and pregnancy prevention program for adolescents. Journal of School Health, 66(3), 89–94. https://doi.org/10.1111/j.1746-1561.1996.tb07917.x
• Fishbein, M., & Ajzen, I. (1975). Beliefs, attitudes, intentions, and behavior: An introduction to theory and research. Addison-Wesley.
• Kirby, D., Coyle, K. K., Baumler, E., & Parcel, G. S. (2004). Safer Choices: Reducing teen pregnancy, HIV, and STDs. In D. W. Haffner (Ed.), Exemplary sex education programs (pp. 45–58). William T. Grant Foundation.
• Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

Items of the Scale