hiv / aids has been recognized as one of the most important public health problems in the recent past , especially in asian countries such as malaysia , china , thailand , and iran . according to the world health organization 's ( who 's ) report of hiv
, iran is categorized as one among the countries with gradually accumulating levels of infection .
preventing hiv infection is one of the top priorities in 2010 to lead a healthy life .
three transmission ways have been identified for the disease : sexual activity with an infected person , contact with infected blood through sharing injection needles , and mother - to - infant infection . in order to prevent hiv transmission through sexual activities , which accounts for 85% of the disease ,
the three following options have been recommended : abstinence , faithfulness , and condom use , among which the first one is the safest . due to the lack of global access to aids treatment and also based on the fact that hiv / aids transmission requires a behavioral process , behavioral change interventions are the best approach to prevent the spread of the disease . since most health problems are closely related to human behavior , behavioral theories and models can provide insights into finding ways to prevent health problems such as hiv / aids .
most of the studies conducted have been based on cognitive - behavioral , health belief models , and theories such as social cognitive theory ( sct ) and theory of reasoned action ( tra ) .
considering the results , and in order to increase the efficiency of the models , a selective mixture of aforementioned theories has been employed in the present study . in his survey of aids - behavior change theories , noar ( 2007 ) mentioned 13 theories used in the studies , including belief- and intervention - based , message - driven , and aids - related theories , and other common hygienic behavior changes .
some researchers used a questionnaire based on behavior change theories or models such as motivation - behavioral skills model ( imb ) , social cognitive theory ( sct ) , and the theory of reasoned action ( tra ) .
furthermore , the constructs such as knowledge , attitude , self - efficacy ( se ) , behavioral intention ( bi ) , and high - risk sexual behavior were used in some studies .
therefore , given the cultural differences between the western countries and iran and the sensitive nature of the disease , the hiv / aids behavior change questionnaires derived from the previous studies conducted in non - islamic countries can not be applied here .
although the validity and reliability of the questionnaire has been confirmed in a previous study , this study was conducted only with male students . however , to our knowledge , no study has been carried out with female students so far . as females , in comparison with males ,
are physiologically more vulnerable to hiv / aids , female students were selected as the target group . considering the lack of appropriate tools and questionnaires , the study focused on designing and validating a culturally suitable sexual abstinence questionnaire among unmarried iranian female students .
the study was cross - sectional in design and was conducted from february to june 2010 .
the criteria based on which the participants were selected were as follows : age range of 15 - 25 years , single status , living alone , and residing in tehran for at least 1 year at the time of the study .
those with physical disability and those reluctant to participate in the study were excluded . for achieving an appropriate score maximum fitness and predicting the number of students , the participants were randomly selected from the three areas of humanities , engineering , and science at the university of tehran .
then , the participants were selected through cluster systematic sampling ( with each class as one cluster ) . for each question ,
a minimum of 10 samples were used according to munro 's method , and 348 female students were randomly selected to reach construct validity .
descriptive ( mean , standard deviation , and cronbach 's alpha ) and inductive statistics ( exploratory and confirmatory factor analysis ) functions of spss and amos ver . 16 were used to analyze the data .
a self - administered questionnaire was used which comprised the following four parts : socio - demographic characteristics , se regarding sexual abstinence , perceived benefits ( pb ) toward sexual abstinence , and behavioral intention ( bi ) .
the demographic information included age , residency region , family income , parents education , and previous knowledge about hiv .
there were four se questions about individual restraint , avoidance of risky situations , and the behavioral skills of saying no .
for unifying the results and facilitating analysis , the questions were designed with five options ranging from strongly agree to strongly disagree . for each item ,
a typical 5-point likert scale ranging from strongly disagree ( 1 ) to strongly agree ( 5 ) was used .
the scale of pb consisted of six items measuring individual and social benefits of abstinence , risky behavior avoidance , negative answer to risky offers , and high - risk situation avoidance .
furthermore , one question with regard to the features of female students in the studied society was added to the aforementioned questions .
bi questions consisted of four items based on the dual behavior theory of gibbons and gerrard and a domestic questionnaire designed by ghaffari et al .
these questions were about the bi of abstinence , a negative answer to risky advances , and avoidance of highly risky situations .
also , given the fact that the participants were young and prone to highly risky situations , one of the questions required them to give their own opinions about their willingness to avoid high - risk situations .
descriptive statistics , cronbach 's alpha , and exploratory and confirmatory factor analysis functions of spss and amos ver .
the study was approved by the ethics committee of tehran university and ethical principles were adhered to throughout the study . after the researchers explained the purpose and procedures of the study to the participants , they consented to participate in the study .
the study was cross - sectional in design and was conducted from february to june 2010 .
the criteria based on which the participants were selected were as follows : age range of 15 - 25 years , single status , living alone , and residing in tehran for at least 1 year at the time of the study .
those with physical disability and those reluctant to participate in the study were excluded . for achieving an appropriate score maximum fitness and predicting the number of students , the participants were randomly selected from the three areas of humanities , engineering , and science at the university of tehran .
then , the participants were selected through cluster systematic sampling ( with each class as one cluster ) . for each question ,
a minimum of 10 samples were used according to munro 's method , and 348 female students were randomly selected to reach construct validity .
descriptive ( mean , standard deviation , and cronbach 's alpha ) and inductive statistics ( exploratory and confirmatory factor analysis ) functions of spss and amos ver . 16 were used to analyze the data .
a self - administered questionnaire was used which comprised the following four parts : socio - demographic characteristics , se regarding sexual abstinence , perceived benefits ( pb ) toward sexual abstinence , and behavioral intention ( bi ) .
the demographic information included age , residency region , family income , parents education , and previous knowledge about hiv .
there were four se questions about individual restraint , avoidance of risky situations , and the behavioral skills of saying no .
these questions were also designed according to the iranian standardized general se questionnaire . for unifying the results and facilitating analysis ,
the questions were designed with five options ranging from strongly agree to strongly disagree . for each item ,
a typical 5-point likert scale ranging from strongly disagree ( 1 ) to strongly agree ( 5 ) was used .
the scale of pb consisted of six items measuring individual and social benefits of abstinence , risky behavior avoidance , negative answer to risky offers , and high - risk situation avoidance .
furthermore , one question with regard to the features of female students in the studied society was added to the aforementioned questions .
bi questions consisted of four items based on the dual behavior theory of gibbons and gerrard and a domestic questionnaire designed by ghaffari et al .
these questions were about the bi of abstinence , a negative answer to risky advances , and avoidance of highly risky situations .
also , given the fact that the participants were young and prone to highly risky situations , one of the questions required them to give their own opinions about their willingness to avoid high - risk situations .
descriptive statistics , cronbach 's alpha , and exploratory and confirmatory factor analysis functions of spss and amos ver .
the study was approved by the ethics committee of tehran university and ethical principles were adhered to throughout the study . after the researchers explained the purpose and procedures of the study to the participants , they consented to participate in the study .
in order to determine the face validity , the questionnaire was distributed to 30 students with similar characteristics .
they were asked to pinpoint the weaknesses and ambiguities of the questionnaire , comment on its clarity , rationality , brevity , and appropriateness , and finally , improve it .
content validity ratio ( cvr ) was applied to assess the extent of experts comment upon the clarity , rationality , brevity and appropriateness of itthen , the questionnaire was given to 20 specialists in the fields of health education , nursing , medicine , and psychology to take the experts ideas into account .
content validity was assessed by each panel member with a 3-item likert scale ( the items were  necessary ,   useful but not necessary ,  and  unnecessary  ) . in case
the number of questions was reduced to 50 after measuring the cvr . in order to verify the reliability of the questionnaire ,
cronbach 's alpha or the internal consistency for pb , bi , and se variables was found to be 0.87 , 0.77 , and 0.85 , respectively .
all these values indicate the desirable level of the scales . in order to determine the construct validity of the questionnaire ,
one way of investigating construct validity is by running a factor analysis for identifying clusters of questions related to the instruments .
this method helps the researcher to determine whether the available tool measures one construct or several ones .
the exploratory factor analysis using principal components analysis with varimax rotation was used to determine compliance and naming of the extracted factors . using all observations ( n = 348 ) , the factor analysis helped in identifying three decisive factors with a variance greater than 61% and 88% of kaiser  meyer 
olkin ( kmo ) , both of which are appropriate indicators of factor analysis . after inserting three retention factors in the orthogonal varimax rotation , each of the factors was given a name and estimated using the probability method .
based on the loadings , and also the content of questions , the three factors were identified as se , bi , and pb , respectively .
as presented in the chart , only the first three values have eigen values more than one .
six pb questions were omitted , and four se and four bi questions were used in the model ; at the final stage and after determining factor analysis , one se question was deleted .
the results of the exploratory factor analysis with varimax rotation after running exploratory factor analysis , in order to confirm the supposed factor structure of the measure as well as the contribution of each question in measuring the components of self - efficacy , bi and pb were analyzed using amos software .
the insignificance of the statistics indicated the model 's fitness with the data , but the pitfall of the statistics is that it is sensitive to the sample size , which means that with larger sample sizes , the possibility of the statistics being insignificant t decreases .
values less than 0.05 for the index root mean square error of approximation ( rmsea ) , values above 0.9 for goodness of fitness index ( gfi ) , and adjusted goodness of fitness index ( agfi ) were used as the criteria for model compliance with the observed data [ table 3 ]
. as it was stated , the model 's of the goodness of fitness indexes are all acceptable .
therefore , the confirmatory factor analysis also approved the construct validity of the questionnaire [ figure 1 ] .
structural equation fitness to model on the whole , 348 female students participated in the study
the characteristics of the study sample goodness fitness indexes of the sexual abstinence behavior of hiv / aids questionnaire the average of cvr for the entire questionnaire was 0.85 .
the cvr for the subscales of pb , bi , and se was calculated to be 0.83 , 0.84 , and 0.89 , respectively . the time needed for completing the questionnaire was about 6 min .
in order to verify the reliability of the questionnaire , cronbach 's alpha score was calculated .
cronbach 's alpha or the internal consistency for pb , bi , and se variables was found to be 0.87 , 0.77 , and 0.85 , respectively .
all these values indicate the desirable level of the scales . in order to determine the construct validity of the questionnaire ,
one way of investigating construct validity is by running a factor analysis for identifying clusters of questions related to the instruments .
this method helps the researcher to determine whether the available tool measures one construct or several ones .
the exploratory factor analysis using principal components analysis with varimax rotation was used to determine compliance and naming of the extracted factors . using all observations ( n = 348 ) , the factor analysis helped in identifying three decisive factors with a variance greater than 61% and 88% of kaiser  meyer 
olkin ( kmo ) , both of which are appropriate indicators of factor analysis . after inserting three retention factors in the orthogonal varimax rotation , each of the factors was given a name and estimated using the probability method .
based on the loadings , and also the content of questions , the three factors were identified as se , bi , and pb , respectively .
as presented in the chart , only the first three values have eigen values more than one .
six pb questions were omitted , and four se and four bi questions were used in the model ; at the final stage and after determining factor analysis , one se question was deleted .
the results of the exploratory factor analysis with varimax rotation after running exploratory factor analysis , in order to confirm the supposed factor structure of the measure as well as the contribution of each question in measuring the components of self - efficacy , bi and pb were analyzed using amos software .
the insignificance of the statistics indicated the model 's fitness with the data , but the pitfall of the statistics is that it is sensitive to the sample size , which means that with larger sample sizes , the possibility of the statistics being insignificant t decreases .
values less than 0.05 for the index root mean square error of approximation ( rmsea ) , values above 0.9 for goodness of fitness index ( gfi ) , and adjusted goodness of fitness index ( agfi ) were used as the criteria for model compliance with the observed data [ table 3 ] .
as it was stated , the model 's of the goodness of fitness indexes are all acceptable .
therefore , the confirmatory factor analysis also approved the construct validity of the questionnaire [ figure 1 ] .
the characteristics of the study sample goodness fitness indexes of the sexual abstinence behavior of hiv / aids questionnaire the average of cvr for the entire questionnaire was 0.85 .
the cvr for the subscales of pb , bi , and se was calculated to be 0.83 , 0.84 , and 0.89 , respectively . the time needed for completing the questionnaire was about 6 min .
considering that there is lack of valid and reliable questionnaire on the behavioral changes of hiv / aids among iranian females , we aimed to design an appropriate abstinence questionnaire and determine its validity and reliability .
this point has been taken into account to a lesser extent in the questionnaires developed in the western countries .
for example , some iranians believe that avoiding unsafe sexual encounters would give them better chances of getting married in the future .
other studies on the validity and reliability of domestic questionnaires have mainly investigated the knowledge of people and their behaviors and attitudes toward hiv , and reported the reliability of the scales .
for instance , in a study by khatoni et al . , face - to - face web - based training was employed to verify the content validity of nurses knowledge questionnaire by the experts , and also , the reliability of the questionnaire was confirmed through test  retest ( 0.9 ) .
furthermore , the cronbach 's alpha for the hiv / aids knowledge and attitude questionnaire developed by diclemente et al . was reported to be 0.72 . in the study conducted by nije - carr on hiv / aids knowledge , attitudes , and beliefs patient questionnaire ( hakabpq ) ,
also , the internal consistency of hiv - related knowledge , attitudes , and sexual risk - taking behaviors was reported to be 0.073 in the study by ugarte et al . in the study of koopman et al .
( 1990 ) , both the knowledge and belief instruments were indicated to have a high internal consistency , test  retest reliability , and successfully avoided ceiling effects .
the highest reported figure was 0.96 for the validity of st andrews sexual knowledge and attitudes instrument ( saskai ) , which was conducted among female employees by kappa test .
of course , the high internal consistency is a result of high level of similarity among the questions . in the study of hughes and admiraal
entitled  systematic review of hiv / aids knowledge measures ,  the results showed low reliability and a validity rate of hiv knowledge questionnaire .
in general , the measuring instruments of knowledge , attitudes , and beliefs about hiv do not have a high level of internal consistency and have rarely been tested by factor analysis .
lux and petoza designed a questionnaire based on which the cronbach 's alpha was estimated to be 0.64 and 0.79 for healthy sexual bi and se of sexual discussion , respectively . in another study conducted by mahoney thombs and ford , the cronbach 's alpha se subscale for using condoms
the scale of mukoma et al . , which was applied to evaluate school - based hiv / aids intervention in south african courtiers and tanzania , reported a cronbach 's alpha of higher than 0.5 .
regarding sexual behaviors , the cronbach 's alpha was lower than 0.5 , based on which the author verified the utility of the scales . in a similar study conducted by ghafari et al . , the alpha values for a 10-scale instrument about hiv / aids prevention were 0.69 , 0.78 , and 0.74 for se , pb , and bi , respectively , which were lower than those of the present instrument
. it is worth noting that the alpha values between 0.8 and 0.9 show a high internal consistency and the alpha values of 0.7 and higher present a good internal stability . in the present study ,
the cronbach 's alpha was between 0.77 and 0.87 , indicating a good internal correlation of the instrument . also , the reliability coefficient of the scale was approximately 0.85 , which is satisfactory when seen in the light of the studies listed .
there were three main measures of sexual behaviors : abstinence , number of sexual partners , and condom use , which were measured in some articles , the psychological measures of sexual abstinence instrument have not been mentioned .
one of the strengths of the study was using different methods of testing reliability and validity and exploratory and confirmatory factor analysis .
it should be noted that the questionnaire was optimal in terms of structure validity and scale clustering and the goodness of fitness indexes .
other researchers are suggested to work on the construction of theories of behavior change scale in islamic contexts as well as to research into different groups of adolescents , youth , and occupations with the risk of hiv / aids infection .
this study have showed that the sexual behavioral abstinence , and avoidance of high - risk situation questionnaire ( sbahaq ) questionnaire can be used as a valid and reliable tool to measure abstinence and avoidance of high - risk situations regarding hiv / aids infection .
however , it is recommended to test the validity of the tool in various communities such as students , scholars , etc .
 background : this study was designed to assess the validity and reliability of the designed sexual , behavioral abstinence , and avoidance of high - risk situation questionnaire ( sbahaq ) , with an aim to construct an appropriate development tool in the iranian population.materials and methods : a descriptive  analytic study was conducted among female undergraduate students of tehran university , who were selected through cluster random sampling . after reviewing the questionnaires and investigating face and content validity , internal consistency of the questionnaire was assessed by cronbach 's alpha . 
 explanatory and confirmatory factor analysis was conducted using spss and amos 16 software , respectively.results:the sample consisted of 348 female university students with a mean age of 20.69  1.63 years . 
 the content validity ratio ( cvr ) coefficient was 0.85 and the reliability of each section of the questionnaire was as follows : perceived benefit ( pb ; 0.87 ) , behavioral intention ( bi ; 0.77 ) , and self - efficacy ( se ; 0.85 ) ( cronbach 's alpha totally was 0.83 ) . 
 explanatory factor analysis showed three factors , including se , pb , and bi , with the total variance of 61% and kaiser  meyer  olkin ( kmo ) index of 88% . 
 these factors were also confirmed by confirmatory factor analysis [ adjusted goodness of fitness index ( agfi ) = 0.939 , root mean square error of approximation ( rmsea ) = 0.039].conclusion : this study showed the designed questionnaire provided adequate construct validity and reliability , and could be adequately used to measure sexual abstinence and avoidance of high - risk situations among female students . 
INTRODUCTION
MATERIALS AND METHODS
Participants and study design
Instruments
Statistical analysis
Ethical issues
RESULTS
Reliability
Demographic information
DISCUSSION
CONCLUSION