Sexual and reproductive health (SRH) is an important component of overall health and well-being, particularly among young adults attending universities. This stage of life involves significant physical, psychological, and social changes that may influence sexual health knowledge, attitudes, decision-making, and healthcare-seeking practices. Access to accurate information, appropriate counselling, and reproductive health services can help young people make informed decisions and prevent adverse health outcomes. However, social stigma, cultural sensitivities, concerns about confidentiality, and limited access to youth-friendly services may discourage university students from seeking professional advice about sexual and reproductive health. Understanding the factors that influence their health-seeking behavior is therefore essential for developing effective health education strategies and improving access to appropriate services.

The Theory of Planned Behavior (TPB), proposed by Ajzen, provides a theoretical framework for understanding the psychological factors that influence human behavior. According to this theory, behavioral intention is the most immediate predictor of an individual's behavior, while intention is influenced by three major constructs: attitude toward the behavior, subjective norms, and perceived behavioral control [1]. Attitude refers to an individual's positive or negative evaluation of performing a particular behavior. Subjective norms represent perceived social expectations and the influence of significant individuals, including family members, friends, and peers. Perceived behavioral control refers to an individual's perception of their ability to perform a behavior, considering available resources, opportunities, and potential barriers. These constructs may help explain why some university students seek professional sexual and reproductive health services while others hesitate or avoid seeking care.

The TPB has been widely applied to explain health-related decision-making and behavioral intentions. Ajzen's subsequent discussion of the theory emphasizes the importance of defining the target behavior, population, and context when applying TPB to a specific research problem [2]. Armitage and Conner, in their meta-analytic review, demonstrated that the theory provides a useful framework for explaining behavioral intentions and predicting behavior across different settings [3]. Similarly, Godin and Kok reviewed the application of TPB to health-related behaviors and highlighted its value in understanding the cognitive and social determinants of health decisions [4]. These findings support the use of TPB to investigate sexual and reproductive health-seeking behavior among university students, although the predictive value of individual constructs may vary according to the behavior being studied and the social context.

Sexual and reproductive health-seeking behavior is influenced not only by knowledge and individual attitudes but also by social expectations and perceived control over accessing services. For example, students who believe that obtaining professional advice about reproductive health is beneficial may have more favorable attitudes toward seeking care. Conversely, students who anticipate criticism, embarrassment, or disapproval from family members and peers may experience negative subjective norms. Similarly, students who perceive healthcare services as confidential, affordable, accessible, and respectful may report greater perceived behavioral control. Research applying the Theory of Reasoned Action and TPB to condom use has demonstrated the relevance of attitudes, normative influences, and behavioral intentions in understanding sexual health-related behavior [5]. These findings provide a theoretical basis for examining whether similar constructs are associated with broader sexual and reproductive health-seeking practices among university students.

In addition to explaining behavioral intentions, the TPB has informed interventions designed to improve sexual health-related behaviors. Tyson et al. examined TPB-based interventions aimed at reducing heterosexual risk behaviors, demonstrating the relevance of theory-driven approaches to sexual health promotion [6]. In the context of university students, understanding the relationship between attitudes, subjective norms, perceived behavioral control, and health-seeking behavior may help identify the psychological and social factors that could be addressed through educational interventions. Such interventions may include confidential counselling, peer education, accurate reproductive health information, and improved awareness of available healthcare services.

The availability and acceptability of healthcare services are also important determinants of whether young people translate their intentions into actual health-seeking behavior. Brittain et al. reviewed youth-friendly family planning services and highlighted the importance of providing services that respond to young people's needs and preferences [7]. Similarly, Mazur et al. examined approaches to assessing youth-friendly sexual and reproductive health services, emphasizing the relevance of service characteristics when evaluating the quality and suitability of healthcare for young people [8]. These findings suggest that favorable attitudes and strong behavioral intentions may not necessarily lead to service utilization when students face practical barriers, such as limited availability, concerns about privacy, or difficulty accessing appropriate providers.

The importance of understanding these factors is particularly relevant in developing countries, where young people's access to sexual and reproductive health information and services may be affected by social, economic, cultural, and institutional circumstances. Hindin and Fatusi discussed adolescent sexual and reproductive health in developing countries and emphasized the importance of contextually appropriate interventions [9]. Mmari and Sabherwal also reviewed risk and protective factors associated with adolescent sexual and reproductive health in developing countries, highlighting the importance of considering individual, interpersonal, and broader contextual influences [10]. Although university students differ from younger adolescents in their autonomy and healthcare needs, these findings provide a useful background for investigating the factors that may influence health-seeking behavior among young adults in Pakistan.

In Pakistan, examining sexual and reproductive health-seeking behavior among university students is important because decisions about seeking advice or services may be influenced by cultural expectations, family and peer attitudes, personal beliefs, and perceived access to confidential healthcare. Nevertheless, the influence of these factors should be investigated empirically rather than assumed to be uniform across all students or educational settings. Applying the TPB can provide a structured approach to examining the associations between students' attitudes, subjective norms, perceived behavioral control, and their sexual and reproductive health-seeking behavior.

Therefore, the present study aims to investigate the association between Theory of Planned Behavior constructs and sexual and reproductive health-seeking behavior among university students in Pakistan.

Specifically, the study will examine whether attitudes, subjective norms, and perceived behavioral control are associated with students' health-seeking behavior and, where measured, their behavioral intentions. The findings may help identify potentially modifiable factors associated with seeking appropriate sexual and reproductive healthcare and provide evidence to guide culturally appropriate health education, counselling, and student-support strategies in Pakistani universities.

A cross-sectional analytical study will be conducted among university students in Pakistan to investigate the association between Theory of Planned Behavior (TPB) constructs and sexual and reproductive health-seeking behavior. The study will be carried out at selected medical colleges over a period of 12 months, following approval from the relevant institutional ethics review committee. The target population will comprise male and female university students aged 18–29 years who are enrolled in undergraduate and provide informed consent to participate. Students who decline participation or submit substantially incomplete questionnaires will be excluded. The sample size will be calculated using an appropriate formula for estimating a proportion or detecting an association, considering the expected prevalence of health-seeking behavior, 95% confidence level, 5% margin of error, and an allowance for nonresponse. A minimum sample size of approximately 384 participants may be considered if the expected proportion is unknown and simple random sampling assumptions apply. Participants will be recruited using convenience sampling or stratified sampling, depending on access to the selected institutions and the availability of student enrollment lists. Data will be collected using a structured, self-administered questionnaire developed from the Theory of Planned Behavior and relevant published literature. The questionnaire will consist of sections covering sociodemographic characteristics, sexual and reproductive health knowledge and information sources, attitudes toward seeking sexual and reproductive healthcare, subjective norms, perceived behavioral control, behavioral intentions, and sexual and reproductive health-seeking behavior. Attitudes will assess participants' positive or negative evaluations of seeking professional advice or services, whereas subjective norms will measure perceived approval or disapproval from family members, friends, and other influential individuals. Perceived behavioral control will assess participants' perceived ability to seek healthcare in the presence of potential barriers, including cost, accessibility, privacy concerns, and embarrassment. Behavioral intention will measure willingness or plans to seek appropriate sexual and reproductive health information or professional services when needed. Health-seeking behavior will be assessed using predefined questions about relevant actions within a specified recall period, such as consulting a qualified healthcare professional or accessing appropriate reproductive health services. TPB constructs will be measured using a Likert-type response scale, and the questionnaire will be reviewed by subject experts and pilot-tested on a small group of students to assess clarity, cultural appropriateness, and reliability. Necessary modifications will be made before the main data collection. Data will be collected in a confidential and culturally sensitive manner, either through paper-based questionnaires or a secure online survey. Participation will be voluntary, and informed consent will be obtained before questionnaire administration. No directly identifying information will be collected unless essential to the approved protocol. Participants will be informed that they may decline to answer any question or withdraw from the study without penalty. Ethical approval will be obtained before recruitment, and all data will be stored securely with access restricted to the research team. The collected data will be entered, cleaned, and analyzed using IBM SPSS 21 Statistics. Descriptive statistics, including frequencies, percentages, means, and standard deviations, will be used to summarize participants' characteristics and study variables, as appropriate. The internal consistency of multi-item scales will be evaluated using Cronbach's alpha. Associations between categorical variables will be examined using the chi-square test or Fisher's exact test, as appropriate, while correlations between continuous or composite TPB scores and health-seeking behavior measures will be assessed using Pearson's or Spearman's correlation coefficients, depending on the data distribution and measurement properties. Multivariable regression analysis will be performed to examine the independent associations of attitudes, subjective norms, and perceived behavioral control with health-seeking behavior, adjusting for relevant sociodemographic variables. Logistic regression will be used if the primary outcome is binary, whereas linear or other suitable regression models will be selected for outcomes measured on an appropriate continuous or ordinal scale. Adjusted effect estimates with 95% confidence intervals will be reported, and a p-value of less than 0.05 will be considered statistically significant. Because the study will use a cross-sectional.

The study included 400 students, with 200 (50%) from HBS Medical College, Islamabad, and 200 (50%) from a medical college in Mirpur, AJK. The mean age was 22.00 ± 1.76 years. Of the participants, 214 (53.5%) were male and 186 (46.5%) were female. Most students lived in urban areas (64.3%) and with their families (53.3%).

Regarding sexual and reproductive health (SRH)-seeking behavior during the previous 12 months, 93 students (23.3%) reported seeking SRH-related services, while 307 (76.8%) did not. The proportion was 26.5% at HBS Medical College and 20.0% at the Mirpur institution; however, this difference was not statistically significant (p = 0.156).

The mean attitude score was 3.45 ± 0.72, followed by perceived behavioral control (3.06 ± 0.75), subjective norms (2.98 ± 0.78), and behavioral intention (2.61 ± 0.80). In the illustrative multivariable logistic regression, positive attitudes (adjusted OR = 1.61, p = 0.011), subjective norms (adjusted OR = 1.54, p = 0.011), and behavioral intention (adjusted OR = 1.65, p = 0.003) were significantly associated with SRH-seeking behavior. Perceived behavioral control was not significantly associated (p = 0.137). Urban residence was also significantly associated with SRH-seeking behavior (adjusted OR = 2.12, p = 0.008).

Comparison between institutions showed a significantly higher mean attitude score among students at HBS Medical College than among students at the Mirpur institution (3.53 ± 0.70 vs. 3.37 ± 0.72, p = 0.023). No statistically significant institutional differences were observed in subjective norms, perceived behavioral control, or behavioral intention (all p > 0.05).

Table 1. Reported SRH-seeking behavior during the previous 12 months

Table 2. Descriptive statistics of TPB construct scores

Table 3:  Multivariable logistic regression analysis

Table 4. Comparison of TPB scores between institutions

he present illustrative study examined the association between Theory of Planned Behavior (TPB) constructs and sexual and reproductive health (SRH)-seeking behavior among university students in Pakistan. The main finding was that only 23.3% of students reported seeking SRH-related services during the previous 12 months, suggesting a potential gap between students’ health needs and their use of available services. However, this percentage must not be interpreted as an actual estimate for Pakistani university students because the dataset was simulated. The relatively low reported use of SRH services may be discussed in relation to barriers identified in previous research, including concerns about confidentiality, embarrassment, stigma, limited awareness, and the perceived acceptability of seeking sexual health advice. Reviews of adolescent and youth-friendly health services have highlighted that service accessibility alone may not ensure utilization; young people also need confidential, acceptable, and supportive services [11,12]. In Pakistan, Ajmal et al. reported differences in sexual-health knowledge, attitudes, and information-seeking patterns among university students, highlighting the importance of appropriate sexual-health education [16]. The simulated regression results indicated that attitude was positively associated with SRH-seeking behavior (adjusted OR = 1.61, p = 0.011). This suggests that students with more favorable attitudes toward obtaining SRH information or services may be more likely to seek care. This interpretation is consistent with the TPB framework, in which attitudes contribute to behavioral intentions and subsequent behavior. The findings also support the relevance of educational approaches that improve students’ understanding of the benefits of preventive care and reduce misconceptions about SRH services [17,20]. Nevertheless, this association is illustrative only and must be tested using actual study data. Subjective norms were also positively associated with SRH-seeking behavior in the simulated analysis (adjusted OR = 1.54, p = 0.011). Subjective norms refer to the perceived approval or expectations of important people, such as friends, family members, and healthcare professionals. In a socially conservative setting, students may hesitate to seek SRH services if they anticipate criticism or feel that discussing these concerns is socially unacceptable. Research on adolescents in conservative societies has similarly highlighted the influence of family communication, social expectations, and peer influence on sexual-health-related decisions [20]. These findings suggest that culturally sensitive awareness programmes could help normalize appropriate health-seeking behavior without compromising students’ privacy. Perceived behavioral control was not significantly associated with SRH-seeking behavior in the simulated model (adjusted OR = 1.30, p = 0.137). Perceived behavioral control concerns an individual’s belief that they can access and use a service despite possible obstacles. Although students may feel capable of seeking care, practical barriers such as cost, distance, lack of confidential services, or uncertainty about where to obtain advice may prevent them from doing so. Reviews of youth SRH services have emphasized the importance of improving service delivery and creating more youth-friendly facilities [11,12]. The nonsignificant result should therefore not be interpreted as evidence that access barriers are unimportant; this relationship requires examination using real data. Behavioral intention showed a significant positive association with SRH-seeking behavior in the simulated results (adjusted OR = 1.65, p = 0.003). Within the TPB framework, intention represents a person’s readiness or plan to perform a behavior. The observed illustrative association is consistent with the theoretical expectation that stronger intentions are associated with a greater likelihood of acting. However, intentions do not always translate into behavior when practical or social barriers remain. Research on health education among university students in Pakistan has also examined changes in knowledge, perceptions, and intended contraceptive use, demonstrating the relevance of these constructs in this population [17]. Urban residence was positively associated with SRH-seeking behavior in the simulated analysis (adjusted OR = 2.12, p = 0.008). One possible explanation is that urban students may have greater access to health facilities and information sources. However, this is only a possible interpretation and cannot be established from the simulated data. Future research should measure service availability, travel distance, cost, awareness of services, and confidentiality concerns directly to determine whether these factors explain differences between urban and rural students. Comparison between the two institutions showed a higher mean attitude score among students at HBS Medical College, Islamabad, than among students at the Mirpur institution. The difference was statistically significant in the simulated analysis (p = 0.023), whereas differences in subjective norms, perceived behavioral control, and behavioral intention were not statistically significant. These results may illustrate how institutional environments or exposure to health information could influence attitudes. Nevertheless, the difference cannot be attributed to the institutions themselves without real observations and appropriate consideration of potential confounding factors. Overall, the illustrative findings demonstrate how the TPB framework can be used to investigate SRH-seeking behavior by considering attitudes, subjective norms, perceived behavioral control, and behavioral intention together. Previous research supports the importance of youth-friendly services, appropriate health education, and supportive social environments in improving access to SRH care [11,16,17]. Future interventions could combine confidential counselling, evidence-based educational sessions, information about available services, and training for healthcare providers. Actual study data are essential to determine which factors are statistically associated with SRH-seeking behavior among students in Pakistan.

The present study highlights the potential role of Theory of Planned Behavior (TPB) constructs in understanding sexual and reproductive health (SRH)-seeking behavior among university students in Pakistan. In the illustrative analysis, positive attitudes, subjective norms, and behavioral intention were significantly associated with SRH-seeking behavior, whereas perceived behavioral control was not statistically significant. Urban residence was also positively associated with service utilization. These findings suggest that future interventions could focus on improving SRH knowledge, promoting supportive social attitudes, strengthening students’ intentions to seek appropriate care, and providing confidential, accessible, and youth-friendly health services. Further studies using actual data from diverse universities are required to confirm these associations and guide evidence-based interventions.