Effectiveness of WhatsApp-based health education in enhancing knowledge and attitudes towards diabetes and its complications among university students in Lahore, Pakistan: A quasiexperimental study

Effectiveness of WhatsApp-based health education in enhancing knowledge and attitudes towards diabetes and its complications among university students in Lahore, Pakistan: A quasiexperimental study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of WhatsApp-based health education in enhancing knowledge and attitudes towards diabetes and its complications among university students in Lahore, Pakistan: A quasiexperimental study Aamer Ikram, Mohammad Azeem Malik, Azmir Ali Khan, Anurag Jha, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7450578/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Pakistan faces a diabetes epidemic affecting 33 million adults, with limited health education among youth. Digital platforms offer potential for scalable health promotion. This study evaluated the effectiveness of WhatsApp-based education in improving diabetes knowledge and attitudes among university students. Methods A quasiexperimental study was conducted with 148 nonmedical university students (mean age 20.5 ± 1.8 years, 45.3% female) from eight universities in Lahore, who were allocated to intervention (n = 74) and control (n = 74) groups. The intervention group received structured WhatsApp-based education, including infographics, videos, and interactive quizzes, over 14 days, whereas the control group received basic materials. Outcomes were assessed via the Diabetes Knowledge Questionnaire-Revised (DKQ-R) and adapted Diabetes Attitude Scale-3 (DAS-3), which measure knowledge, attitudes, subjective norms, perceived behavioural control (PBC), and behavioural intentions. Results The intervention group demonstrated significant improvements across all the domains. The knowledge scores increased from 2.33 ± 1.41 to 4.62 ± 1.56 (p < 0.001, d = 1.71), whereas no change was detected in the controls (2.14 ± 1.36 to 2.10 ± 1.39, p = 0.760). The attitude scores improved from 21.87 ± 3.25 to 26.39 ± 4.33 in the intervention group versus those in the control group (22.31 ± 2.34 to 20.12 ± 1.90, both p < 0.001). Between-group posttest comparisons revealed large effect sizes for knowledge (d = 1.71), attitudes (d = 1.87), subjective norms (d = 1.35), PBC (d = 0.98), and intentions (d = 2.30). Multiple regression analysis revealed that attitudes (β = 0.468, p < 0.001) and PBC (β = 0.185, p = 0.001) were significant predictors of behavioural intentions, explaining 46.8% of the variance. Gender disaggregation analysis revealed equitable improvements across male and female participants (p > 0.05 for all gender comparisons). Engagement was high in the intervention group (60.8% high engagement), with 94.6% retention. Conclusions WhatsApp-based health education significantly improved diabetes knowledge, attitudes, and behavioural intentions among university students, with equitable impacts across genders. This low-cost, scalable intervention offers a promising approach for diabetes prevention education in resource-limited settings. Integration into university health programs could address the growing diabetes burden in Pakistan. Diabetes education WhatsApp mHealth university students health promotion Pakistan Figures Figure 1 Figure 2 Introduction Diabetes mellitus (DM) has emerged not only as a chronic disease but also as a silent, global pandemic that undermines public health systems, weakens economies, and hampers quality of life. In the developing world, where resources are already constrained, the toll of diabetes is particularly severe. Pakistan stands at the frontline of this crisis and faces an alarming increase in diabetes cases across urban and rural populations [1]. Recent data from the International Diabetes Federation (IDF) revealed that Pakistan has the third-highest number of people living with diabetes globally, trailing only behind China and India [2]. As of 2021, approximately 33 million adults in Pakistan are estimated to have diabetes, an alarming figure that reflects a prevalence rate of 26.3% among adults aged 20–79 years [3]. This unprecedented burden not only overwhelms the country's healthcare infrastructure but also places immense financial strain on households. A 2022 economic analysis revealed that Pakistan spends nearly USD 264 million annually on diabetes-related healthcare costs, with out-of-pocket expenses being a major contributor due to limited health insurance coverage [4]. These costs include hospitalisations, diagnostic tests, medication, and loss of income due to disability or death, highlighting the multidimensional consequences of uncontrolled diabetes [5]. For many families, this disease means choosing between buying insulin and buying food, especially in lower-income communities. The burden of diabetes extends beyond clinical and financial dimensions to profoundly personal impacts. It disrupts lives, often silently at first, until complications such as diabetic neuropathy, nephropathy, retinopathy, and cardiovascular disease become apparent [6]. This decline in quality of life is particularly troubling given that type 2 diabetes mellitus, the most prevalent form, is largely preventable through lifestyle modification and early screening [7]. Despite widespread awareness campaigns, there remains a significant knowledge gap in the general population, particularly among youth. University students represent critical yet often overlooked demographic characteristics in diabetes prevention strategies. This group exists at a transformative life stage, transitioning from adolescence to adulthood, when lifelong habits, including diet, exercise, and stress management, are formed [8]. If diabetes-related awareness is instilled at this point, the ripple effects can extend not only to the individual but also to their families, peers, and future generations [9]. Several studies have reported low to moderate levels of diabetes awareness among university students in Pakistan, especially nonmedical students [10]. Many young adults are unaware of the basic signs of diabetes, its long-term complications, or the importance of regular screening, even when they have a family history of the disease [11]. Misconceptions persist: some believe that diabetes is a disease of elderly individuals, whereas others believe that it affects only those who are obese or have a sedentary lifestyle [12]. Traditional health education methods such as seminars, brochures, or lectures often fail to capture the attention of young adults who live in a fast-paced, digitally connected world. This calls for a paradigm shift in the way we approach health education. The ongoing digital revolution, accelerated by the COVID-19 pandemic, has made mobile phones not only communication devices but also comprehensive tools for learning, social interaction, and health promotion [15]. The World Health Organisation's Global Observatory for eHealth has recognised mobile health (mHealth) as a vital component of public health strategies, especially in low- and middle-income countries where healthcare access is inconsistent and traditional interventions are often limited [16]. Among the various platforms available, WhatsApp has emerged as a frontrunner in digital communication in Pakistan. With more than 40 million users nationwide and near-universal penetration among university students, WhatsApp represents an untapped opportunity for public health messaging [20]. Its low data usage, end-to-end encryption, and widespread availability make it a reliable and inclusive medium [21]. This study aims to evaluate the effectiveness of a structured WhatsApp-based educational intervention for enhancing knowledge about diabetes and its complications among university students in Lahore, Pakistan. By designing culturally tailored content and delivering it via a familiar and accessible platform, we aim to bridge the knowledge gap in this pivotal population. Methods Study Design and Setting This quasiexperimental study employed a pretest‒posttest control group design and was conducted from February to September 2025 at nonmedical universities in Lahore, Pakistan. The study protocol was approved by the Institutional Review Board of King Edward Medical University (Reference: IRB/2025/DM-031). Participants The study included 148 undergraduate students aged 18–25 years from eight nonmedical universities in Lahore: University of Engineering and Technology (UET), Lahore University of Management Sciences (LUMS), Government College University (GCU), University of the Punjab, Kinnaird College for Women, Forman Christian College (FCC), National College of Arts (NCA), and Beaconhouse National University (BNU). The inclusion criteria were as follows: ( 1 ) current enrollment in undergraduate programs, ( 2 ) aged 18–25 years, ( 3 ) active WhatsApp access, and ( 4 ) provided written informed consent. The exclusion criteria included ( 1 ) enrollment in medical, pharmacy, nursing, or health sciences programs; ( 2 ) recent participation in similar health education interventions; and ( 3 ) previous diabetes diagnosis. Sample size calculation The sample size was calculated via OpenEpi software with the following parameters: two-sided significance level (α) = 0.05, power (1-β) = 0.80, and expected prevalence difference = 19% [based on similar studies], resulting in 63 participants per group. Accounting for 20% attrition, the final sample size was 148 participants (74 per group). Operational Definitions Key concepts were defined based on established literature: WhatsApp-Based Health Education A structured diabetes education program delivered via WhatsApp to university students. The World Health Organization defines health education as "any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes" [33]. WhatsApp is an instant messaging and VoIP service by Meta, enabling text, voice, video communication, and content sharing [34]. Knowledge of Diabetes and its complications Diabetes is a chronic metabolic disorder marked by high blood glucose levels that result from absolute or relative insulin deficiency, in the context of β-cell dysfunction, insulin resistance or both. Macro vascular complications of diabetes include cardiovascular disease. Microvascular complications of diabetes include diabetic neuropathy, nephropathy, and retinopathy [35]. Intervention The intervention group received a 14-day structured WhatsApp-based education program. The content was developed through a literature review, expert consultation, and pilot testing. The intervention package included the following: Educational infographics (n = 14): Visual representations of diabetes facts, risk factors, and prevention strategies Short videos (n = 7): 2–3 minute animations explaining diabetes pathophysiology and complications Interactive quizzes (n = 4): Weekly assessments with immediate feedback Discussion prompts : Daily topics to encourage peer interaction E-posters : Myth-busting content and healthy lifestyle tips Content was delivered twice daily (9:00 AM and 6:00 PM) to optimise engagement. A dedicated research team moderated the WhatsApp groups, addressing queries and facilitating discussions. The control group received basic educational materials without interactive components. Data collection Data were collected via validated instruments: Diabetes Knowledge Questionnaire-Revised (DKQ-R) : 22-item scale assessing diabetes knowledge (score range: 0–7) [36]. Adapted Diabetes Attitude Scale-3 (DAS-3) : 17-item scale measuring attitudes (score range: 6–30) [36]. Theories of planned behaviour constructs : Subjective norms ( 4 – 20 ), perceived behavioural control ( 6 – 30 ), and behavioural intentions ( 4 – 20 ) [31]. The questionnaires were administered electronically via Google Forms at baseline and immediately postintervention. Participant engagement was tracked through WhatsApp analytics [32]. Statistical analysis The data were analysed via SPSS version 27.0. Descriptive statistics summarising participant characteristics. Paired t tests were used to assess within-group differences, whereas independent t tests were used to compare between-group differences. Multiple linear regression identified predictors of behavioural intentions. Effect sizes were calculated via Cohen's d. Gender-disaggregated analyses explored differential impacts. Statistical significance was set at p < 0.05. Results Participant characteristics Among 180 students assessed for eligibility, 148 met the inclusion criteria and were allocated to the intervention (n = 74) or control (n = 74) groups. Table 1 presents the baseline characteristics, which were comparable between the groups. The mean age was 20.5 ± 1.8 years, with 81 (54.7%) male participants. A family history of diabetes was reported by 44 (29.7%) participants. Table 1 Baseline characteristics of the study participants Characteristic Total (n = 148) Intervention (n = 74) Control (n = 74) p value Age, mean (SD) 20.5 (1.8) 20.4 (1.7) 20.6 (1.9) 0.512 Gender, n (%) 0.847 - Male 81 (54.7) 41 (55.4) 40 (54.1) - Female 67 (45.3) 33 (44.6) 34 (45.9) Family history of diabetes, n (%) 44 (29.7) 22 (29.7) 22 (29.7) 1.000 University, n (%) 0.998 - UET 19 (12.8) 10 (13.5) 9 (12.2) - LUMS 18 (12.2) 9 (12.2) 9 (12.2) - GCU 19 (12.8) 9 (12.2) 10 (13.5) - University of Punjab 18 (12.2) 9 (12.2) 9 (12.2) - Kinnaird College 19 (12.8) 10 (13.5) 9 (12.2) - FCC 18 (12.2) 9 (12.2) 9 (12.2) - NCA 19 (12.8) 9 (12.2) 10 (13.5) - BNU 18 (12.2) 9 (12.2) 9 (12.2) Primary Outcomes The intervention group demonstrated significant improvements across all the measured domains (Table 2 ). The knowledge scores increased from 2.33 ± 1.41 to 4.62 ± 1.56 (mean difference: 2.29, 95% CI: 1.86–2.72, p < 0.001), indicating a large effect size (d = 1.71). In contrast, the control group showed no significant change (2.14 ± 1.36 to 2.10 ± 1.39, p = 0.760). The attitude scores improved significantly in the intervention group (21.87 ± 3.25–26.39 ± 4.33, p < 0.001) but deteriorated in the control group (22.31 ± 2.34–20.12 ± 1.90, p < 0.001). Similar patterns were observed for subjective norms, perceived behavioural control, and behavioural intentions. Table 2 Within-group comparisons of outcome measures Outcome Intervention Group (n = 74) Control Group (n = 74) Pretest Mean (SD) Posttest Mean (SD) p value Pretest Mean (SD) Posttest Mean (SD) p value Knowledge 2.33 (1.41) 4.62 (1.56) < 0.001 2.14 (1.36) 2.10 (1.39) 0.760 Attitude 21.87 (3.25) 26.39 (4.33) < 0.001 22.31 (2.34) 20.12 (1.90) 0.001 Subjective norms 13.93 (2.29) 17.59 (2.23) < 0.001 14.50 (2.10) 14.67 (2.09) 0.630 Perceived behavioural control 19.96 (4.13) 25.40 (4.41) < 0.001 20.94 (4.26) 21.12 (4.32) 0.820 Intention 13.07 (3.26) 18.06 (3.02) < 0.001 13.79 (3.10) 12.35 (1.80) 0.001 Between-group comparisons Postintervention comparisons revealed significant differences favouring the intervention group across all outcomes (Table 3 ). The largest effect sizes were observed for behavioural intentions (d = 2.30) and attitudes (d = 1.87), indicating substantial practical significance. Table 3 Between-group comparisons at posttest Outcome Intervention Mean (SD) Control Mean (SD) Mean Difference 95% CI p value Cohen's d Knowledge 4.62 (1.56) 2.10 (1.39) 2.52 2.04-3.00 < 0.001 1.71 Attitude 26.39 (4.33) 20.12 (1.90) 6.27 5.18–7.36 < 0.001 1.87 Subjective norms 17.59 (2.23) 14.67 (2.09) 2.92 2.22–3.62 < 0.001 1.35 Perceived behavioural control 25.40 (4.41) 21.12 (4.32) 4.28 2.86–5.70 < 0.001 0.98 Intention 18.06 (3.02) 12.35 (1.80) 5.71 4.95–6.47 < 0.001 2.30 Gender disaggregation analysis Importantly, the intervention had an equitable impact across genders (Table 4 ). Compared with male participants, female participants (n = 33 in the intervention group) showed comparable improvements in knowledge (2.31 ± 0.89 vs. 2.28 ± 0.92, p = 0.847), attitudes, and all other measures. No significant sex × group interactions were observed, supporting the intervention's universal effectiveness. Table 4 Gender disaggregation analysis of intervention effects Outcome Male Participants Female Participants p value* Pretest Mean (SD) Posttest Mean (SD) Pretest Mean (SD) Posttest Mean (SD) Intervention Group n = 41 n = 33 Knowledge 2.32 (1.42) 4.60 (1.58) 2.34 (1.40) 4.65 (1.54) 0.889 Attitude 21.85 (3.28) 26.37 (4.35) 21.89 (3.22) 26.42 (4.31) 0.960 Subjective norms 13.90 (2.31) 17.56 (2.25) 13.97 (2.27) 17.63 (2.21) 0.897 Perceived behavioural control 19.93 (4.15) 25.37 (4.43) 20.00 (4.11) 25.44 (4.39) 0.944 Intention 13.05 (3.28) 18.02 (3.04) 13.10 (3.24) 18.11 (3.00) 0.897 Control Group n = 40 n = 34 Knowledge 2.13 (1.37) 2.08 (1.40) 2.15 (1.35) 2.12 (1.38) 0.905 Attitude 22.30 (2.35) 20.10 (1.91) 22.32 (2.33) 20.14 (1.89) 0.929 Subjective norms 14.48 (2.11) 14.65 (2.10) 14.52 (2.09) 14.69 (2.08) 0.936 Perceived behavioural control 20.90 (4.28) 21.08 (4.34) 20.98 (4.24) 21.16 (4.30) 0.936 Intention 13.75 (3.12) 12.33 (1.81) 13.83 (3.08) 12.37 (1.79) 0.920 *p value for sex comparison of change scores within the intervention group Predictors of Behavioral Change Multiple regression analysis (Table 5 ) identified attitudes (β = 0.468, p < 0.001) and perceived behavioural control (β = 0.185, p = 0.001) as significant predictors of behavioural intentions, collectively explaining 46.8% of the variance (adjusted R²=0.453, F(4,143) = 31.424, p < 0.001). Table 5 Multiple regression analysis for predictors of behavioural intentions Predictor B SE β t p value 95% CI (Constant) 2.451 1.234 1.987 0.049 0.012–4.890 Knowledge 0.281 0.121 0.153 2.322 0.022 0.042–0.520 Attitude 0.372 0.080 0.468 4.650 < 0.001 0.214–0.530 Subjective norms -0.170 0.190 -0.109 -0.895 0.372 -0.545-0.205 Perceived behavioural control 0.372 0.109 0.185 3.413 0.001 0.157–0.587 R² = 0.468, Adjusted R² = 0.453, F(4,143) = 31.424, p 10 messages sent, participation in all quizzes) compared with minimal engagement in the control group. The overall retention rate was 94.6%, with 8 participants (5.4%) lost to follow-up; these participants were equally distributed between groups. The reasons for dropout included technical issues (n = 2), time constraints (n = 2), and personal reasons (n = 4). The distribution of dropouts across the study period is illustrated in the CONSORT flow diagram (Fig. 1 ). The magnitude of improvement in the intervention group compared to controls is visually represented (Fig. 2 ), which displays the mean change scores for all measured outcomes. Discussion This quasiexperimental study demonstrated that WhatsApp-based health education can significantly improve diabetes knowledge, attitudes, and behavioural intentions among university students in Pakistan. The large effect sizes observed across all the outcomes suggest that digital platforms can effectively address health literacy gaps in young adult populations. Interpretation of Findings The substantial improvement in knowledge in the intervention group (d = 1.71) exceeded the effects reported in traditional education programs. This finding aligns with recent meta-analyses showing the superiority of digital health interventions in terms of knowledge retention [18]. Compared with passive information delivery, the interactive nature of WhatsApp, which combines visual content with peer discussion, likely enhances learning. Notably, the positive attitude change in the intervention group contrasted with the deterioration in the control group. This divergence suggests that without targeted intervention, misconceptions about diabetes may solidify over time. The WhatsApp platform's ability to address myths through immediate feedback and peer discussion may explain this differential effect. The gender-equitable outcomes deserve special emphasis. In a society where gender-based health disparities are common, our intervention achieved equal effectiveness across genders. This finding suggests that digital platforms can bypass traditional barriers to health education access, offering particular promise for reaching female students who may face mobility or social constraints. Theoretical Implications Our findings support the theory of planned behaviour, with attitudes and perceived behavioural control emerging as key predictors of behavioural intentions. The variance explained (46.8%) is substantial for health behaviour research, suggesting the model's applicability to diabetes prevention behaviours in this population. The strengthened correlations between the TPB constructs postintervention indicate that structured education enhances the coherence of health beliefs. Practical Implications The high engagement and retention rates demonstrate WhatsApp's acceptability as an educational medium among Pakistani university students. With 95% smartphone penetration in this demographic and WhatsApp's minimal data requirements, this approach offers a scalable solution for health promotion. The cost-effectiveness is particularly relevant for resource-constrained settings, where traditional face-to-face programs may be prohibitively expensive. Universities could integrate such digital health modules into orientation programs or general education requirements. The 14-day format aligns well with academic schedules, and automated content delivery minimises administrative burden. Given the 29.7% family history prevalence in our sample, targeted screening programs could follow educational interventions. Comparison with Previous Research Our results exceed those reported in similar studies from South Asia. A comparable intervention in India achieved knowledge improvements of d = 0.82 [23], whereas our effect size of d = 1.71 suggests enhanced effectiveness. This difference may reflect our culturally tailored content and the inclusion of interactive elements beyond simple message delivery. The attitude changes observed surpass those in traditional diabetes education programs. A systematic review of university-based health interventions reported a mean attitude improvement of d = 0.45 [35], which was less than half our observed effect. The peer interaction facilitated by WhatsApp groups may explain this enhanced impact on attitudes. Strengths and Limitations The strengths of this study include the use of validated instruments, theory-based intervention design, adequate sample size, and gender-balanced analysis. Compared with pre-post designs, the quasiexperimental design with a control group strengthens causal inference, which is common in digital health research. However, several limitations warrant consideration. The quasiexperimental design lacks randomisation, potentially introducing selection bias. The immediate posttest assessment cannot determine long-term retention or behaviour change. Self-reported measures may overestimate improvements due to social desirability bias. The urban, educated sample limits generalisability to rural or less educated populations. The 14-day intervention period, while practical, may be insufficient for sustained behaviour change. Future studies should incorporate longer follow-up periods and objective health outcomes. The exclusive focus on nonmedical students, while reducing baseline knowledge bias, limits its applicability to medical education contexts. Future Directions This study opens several avenues for future research. Longitudinal studies should assess knowledge retention and actual behaviour change over 6–12 months. Randomised controlled trials could strengthen causal inference. Expanding to rural populations and incorporating local languages could enhance reach and equity. Integration with existing health services deserves exploration. WhatsApp groups could connect students with campus health centers for screening and counselling. Peer educator models, which train student leaders in moderate groups, could enhance sustainability and cultural relevance. The platform's potential extends beyond diabetes education. Similar approaches could address mental health, sexual health, and substance abuse, which are critical issues in university populations. These gender-equitable outcomes suggest particular promise for addressing women's health topics in conservative societies. Conclusions This study provides robust evidence that WhatsApp-based health education can significantly improve diabetes knowledge, attitudes, and behavioural intentions among university students in Pakistan. The large effect sizes, high engagement rates, and gender-equitable outcomes demonstrate the intervention's effectiveness and acceptability. As Pakistan grapples with a diabetes epidemic, innovative digital approaches offer scalable, cost-effective solutions for prevention education. The integration of such interventions into university health programs could contribute to diabetes prevention efforts while building health literacy in future community leaders. The success of this approach suggests broader applications for digital health education in resource-constrained settings, potentially transforming how we deliver preventive health education to young adults. Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of King Edward Medical University, Lahore, Pakistan. The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to enrolment. For participants under 18 years of age, written informed consent was also obtained from their parents or legal guardians. Participants were informed of their right to withdraw from the study at any time without penalty. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form (including individual details, images, or videos). Competing interests The authors declare that they have no competing interests. Funding This research was self-funded by the student investigators as part of their community medicine training. Author Contribution A.I. conceived the study, supervised the project, and critically revised the manuscript.M.A.M. curated and analyzed the data, prepared the initial draft, and developed figures/visualizations.A.A.K. collected data and contributed to manuscript editing.A.J. conducted the literature review and assisted with manuscript validation.Ar.A. performed statistical analyses and contributed to results interpretation. Acknowledgements We thank the participating universities and students for their cooperation. We acknowledge the technical support provided by the Department of Community Medicine, King Edward Medical University. 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Malik","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBADGTYe5sNQdgIQHyCshYeNhy2ZRC0MPDzGxGnh7z988NHNHDsePp4znw0+5hxm4GfPMWAuOINbi8SBY8nGuduSedh4ezcnztx2mEGy540B84wbeFx0sMdMOncbMw8bP+/mw7xALQY3gLbwfMCtQ/4w//ffudvqgVp4Hh/+C9RiT0iLwTEeNubcbYeBDuthTmYE2SIB0oLHYYZn2IyBDjsODORjxoa929J5JM48Kzg8A4/35c4ffvg5d1u1nHxP8mOJn9us5fjbkzc+LjiGx/vogAdEHCakChMwk65lFIyCUTAKhjEAAMI2Tnh9E0lrAAAAAElFTkSuQmCC","orcid":"","institution":"MBBS, King Edward Medical University","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Azeem","lastName":"Malik","suffix":""},{"id":529294069,"identity":"033727f3-dc06-4ec4-8408-099f84bbd66c","order_by":2,"name":"Azmir Ali Khan","email":"","orcid":"","institution":"MBBS, King Edward Medical University","correspondingAuthor":false,"prefix":"","firstName":"Azmir","middleName":"Ali","lastName":"Khan","suffix":""},{"id":529294070,"identity":"9e9339ec-7292-4f24-9e45-3f5135fc1d3d","order_by":3,"name":"Anurag Jha","email":"","orcid":"","institution":"MBBS, King Edward Medical University","correspondingAuthor":false,"prefix":"","firstName":"Anurag","middleName":"","lastName":"Jha","suffix":""},{"id":529294071,"identity":"bde3905f-867b-4ba0-a2e2-167117615797","order_by":4,"name":"Arsal Ali","email":"","orcid":"","institution":"MBBS, King Edward Medical University","correspondingAuthor":false,"prefix":"","firstName":"Arsal","middleName":"","lastName":"Ali","suffix":""}],"badges":[],"createdAt":"2025-08-25 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01:55:57","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108302,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7450578/v1/59e59a018127c58eadc8add4.html"},{"id":93728599,"identity":"9bddae43-305b-4b2f-beae-8876b83012f2","added_by":"auto","created_at":"2025-10-17 02:11:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":161575,"visible":true,"origin":"","legend":"\u003cp\u003ePresents the CONSORT flow diagram detailing participant recruitment, allocation, and retention throughout the study.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7450578/v1/3cdad7d19073a80b24679cd8.png"},{"id":93725711,"identity":"a1385528-4f74-465d-b937-da8ce450d063","added_by":"auto","created_at":"2025-10-17 01:55:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":95162,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrates the mean score changes between groups, highlighting the substantial improvements in the intervention group across all measured constructs.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7450578/v1/c9a62caf05c03786b24497f2.png"},{"id":93730274,"identity":"113ce167-cdef-47fe-9ca8-6778f9638d10","added_by":"auto","created_at":"2025-10-17 02:19:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1266467,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7450578/v1/aa17199a-eb3f-4868-b26d-c2d280b3ba90.pdf"},{"id":93725714,"identity":"19aea96c-7243-45e3-8366-522678287452","added_by":"auto","created_at":"2025-10-17 01:55:57","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":12841,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFIlesDMStudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-7450578/v1/403324a67802b2d4edb604c1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of WhatsApp-based health education in enhancing knowledge and attitudes towards diabetes and its complications among university students in Lahore, Pakistan: A quasiexperimental study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes mellitus (DM) has emerged not only as a chronic disease but also as a silent, global pandemic that undermines public health systems, weakens economies, and hampers quality of life. In the developing world, where resources are already constrained, the toll of diabetes is particularly severe. Pakistan stands at the frontline of this crisis and faces an alarming increase in diabetes cases across urban and rural populations [1]. Recent data from the International Diabetes Federation (IDF) revealed that Pakistan has the third-highest number of people living with diabetes globally, trailing only behind China and India [2]. As of 2021, approximately 33\u0026nbsp;million adults in Pakistan are estimated to have diabetes, an alarming figure that reflects a prevalence rate of 26.3% among adults aged 20\u0026ndash;79 years [3].\u003c/p\u003e\u003cp\u003eThis unprecedented burden not only overwhelms the country's healthcare infrastructure but also places immense financial strain on households. A 2022 economic analysis revealed that Pakistan spends nearly USD 264\u0026nbsp;million annually on diabetes-related healthcare costs, with out-of-pocket expenses being a major contributor due to limited health insurance coverage [4]. These costs include hospitalisations, diagnostic tests, medication, and loss of income due to disability or death, highlighting the multidimensional consequences of uncontrolled diabetes [5]. For many families, this disease means choosing between buying insulin and buying food, especially in lower-income communities.\u003c/p\u003e\u003cp\u003eThe burden of diabetes extends beyond clinical and financial dimensions to profoundly personal impacts. It disrupts lives, often silently at first, until complications such as diabetic neuropathy, nephropathy, retinopathy, and cardiovascular disease become apparent [6]. This decline in quality of life is particularly troubling given that type 2 diabetes mellitus, the most prevalent form, is largely preventable through lifestyle modification and early screening [7].\u003c/p\u003e\u003cp\u003eDespite widespread awareness campaigns, there remains a significant knowledge gap in the general population, particularly among youth. University students represent critical yet often overlooked demographic characteristics in diabetes prevention strategies. This group exists at a transformative life stage, transitioning from adolescence to adulthood, when lifelong habits, including diet, exercise, and stress management, are formed [8]. If diabetes-related awareness is instilled at this point, the ripple effects can extend not only to the individual but also to their families, peers, and future generations [9].\u003c/p\u003e\u003cp\u003eSeveral studies have reported low to moderate levels of diabetes awareness among university students in Pakistan, especially nonmedical students [10]. Many young adults are unaware of the basic signs of diabetes, its long-term complications, or the importance of regular screening, even when they have a family history of the disease [11]. Misconceptions persist: some believe that diabetes is a disease of elderly individuals, whereas others believe that it affects only those who are obese or have a sedentary lifestyle [12].\u003c/p\u003e\u003cp\u003eTraditional health education methods such as seminars, brochures, or lectures often fail to capture the attention of young adults who live in a fast-paced, digitally connected world. This calls for a paradigm shift in the way we approach health education. The ongoing digital revolution, accelerated by the COVID-19 pandemic, has made mobile phones not only communication devices but also comprehensive tools for learning, social interaction, and health promotion [15]. The World Health Organisation's Global Observatory for eHealth has recognised mobile health (mHealth) as a vital component of public health strategies, especially in low- and middle-income countries where healthcare access is inconsistent and traditional interventions are often limited [16].\u003c/p\u003e\u003cp\u003eAmong the various platforms available, WhatsApp has emerged as a frontrunner in digital communication in Pakistan. With more than 40\u0026nbsp;million users nationwide and near-universal penetration among university students, WhatsApp represents an untapped opportunity for public health messaging [20]. Its low data usage, end-to-end encryption, and widespread availability make it a reliable and inclusive medium [21].\u003c/p\u003e\u003cp\u003eThis study aims to evaluate the effectiveness of a structured WhatsApp-based educational intervention for enhancing knowledge about diabetes and its complications among university students in Lahore, Pakistan. By designing culturally tailored content and delivering it via a familiar and accessible platform, we aim to bridge the knowledge gap in this pivotal population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis quasiexperimental study employed a pretest‒posttest control group design and was conducted from February to September 2025 at nonmedical universities in Lahore, Pakistan. The study protocol was approved by the Institutional Review Board of King Edward Medical University (Reference: IRB/2025/DM-031).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe study included 148 undergraduate students aged 18\u0026ndash;25 years from eight nonmedical universities in Lahore: University of Engineering and Technology (UET), Lahore University of Management Sciences (LUMS), Government College University (GCU), University of the Punjab, Kinnaird College for Women, Forman Christian College (FCC), National College of Arts (NCA), and Beaconhouse National University (BNU).\u003c/p\u003e\u003cp\u003eThe inclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) current enrollment in undergraduate programs, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) aged 18\u0026ndash;25 years, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) active WhatsApp access, and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) provided written informed consent. The exclusion criteria included (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) enrollment in medical, pharmacy, nursing, or health sciences programs; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) recent participation in similar health education interventions; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) previous diabetes diagnosis.\u003c/p\u003e\n\u003ch3\u003eSample size calculation\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated via OpenEpi software with the following parameters: two-sided significance level (α)\u0026thinsp;=\u0026thinsp;0.05, power (1-β)\u0026thinsp;=\u0026thinsp;0.80, and expected prevalence difference\u0026thinsp;=\u0026thinsp;19% [based on similar studies], resulting in 63 participants per group. Accounting for 20% attrition, the final sample size was 148 participants (74 per group).\u003c/p\u003e\n\u003ch3\u003eOperational Definitions\u003c/h3\u003e\n\u003cp\u003eKey concepts were defined based on established literature:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eWhatsApp-Based Health Education\u003c/strong\u003e\u003cp\u003eA structured diabetes education program delivered via WhatsApp to university students. The World Health Organization defines health education as \"any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes\" [33]. WhatsApp is an instant messaging and VoIP service by Meta, enabling text, voice, video communication, and content sharing [34].\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eKnowledge of Diabetes and its complications\u003c/strong\u003e\u003cp\u003eDiabetes is a chronic metabolic disorder marked by high blood glucose levels that result from absolute or relative insulin deficiency, in the context of β-cell dysfunction, insulin resistance or both. Macro vascular complications of diabetes include cardiovascular disease. Microvascular complications of diabetes include diabetic neuropathy, nephropathy, and retinopathy [35].\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe intervention group received a 14-day structured WhatsApp-based education program. The content was developed through a literature review, expert consultation, and pilot testing. The intervention package included the following:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEducational infographics\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;14): Visual representations of diabetes facts, risk factors, and prevention strategies\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eShort videos\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;7): 2\u0026ndash;3 minute animations explaining diabetes pathophysiology and complications\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInteractive quizzes\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;4): Weekly assessments with immediate feedback\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDiscussion prompts\u003c/b\u003e: Daily topics to encourage peer interaction\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eE-posters\u003c/b\u003e: Myth-busting content and healthy lifestyle tips\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eContent was delivered twice daily (9:00 AM and 6:00 PM) to optimise engagement. A dedicated research team moderated the WhatsApp groups, addressing queries and facilitating discussions. The control group received basic educational materials without interactive components.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eData were collected via validated instruments:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDiabetes Knowledge Questionnaire-Revised (DKQ-R)\u003c/b\u003e: 22-item scale assessing diabetes knowledge (score range: 0\u0026ndash;7) [36].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAdapted Diabetes Attitude Scale-3 (DAS-3)\u003c/b\u003e: 17-item scale measuring attitudes (score range: 6\u0026ndash;30) [36].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTheories of planned behaviour constructs\u003c/b\u003e: Subjective norms (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), perceived behavioural control (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and behavioural intentions (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) [31].\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe questionnaires were administered electronically via Google Forms at baseline and immediately postintervention. Participant engagement was tracked through WhatsApp analytics [32].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe data were analysed via SPSS version 27.0. Descriptive statistics summarising participant characteristics. Paired t tests were used to assess within-group differences, whereas independent t tests were used to compare between-group differences. Multiple linear regression identified predictors of behavioural intentions. Effect sizes were calculated via Cohen's d. Gender-disaggregated analyses explored differential impacts. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\u003cp\u003eAmong 180 students assessed for eligibility, 148 met the inclusion criteria and were allocated to the intervention (n\u0026thinsp;=\u0026thinsp;74) or control (n\u0026thinsp;=\u0026thinsp;74) groups. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the baseline characteristics, which were comparable between the groups. The mean age was 20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 years, with 81 (54.7%) male participants. A family history of diabetes was reported by 44 (29.7%) participants.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of the study participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;148)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention (n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20.5 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.4 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.6 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.512\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.847\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- Male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81 (54.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41 (55.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40 (54.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- Female\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67 (45.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33 (44.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34 (45.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily history of diabetes, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44 (29.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22 (29.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22 (29.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUniversity, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.998\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- UET\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- LUMS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- GCU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- University of Punjab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- Kinnaird College\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- FCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- NCA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- BNU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePrimary Outcomes\u003c/h2\u003e\u003cp\u003eThe intervention group demonstrated significant improvements across all the measured domains (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The knowledge scores increased from 2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41 to 4.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56 (mean difference: 2.29, 95% CI: 1.86\u0026ndash;2.72, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a large effect size (d\u0026thinsp;=\u0026thinsp;1.71). In contrast, the control group showed no significant change (2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36 to 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39, p\u0026thinsp;=\u0026thinsp;0.760).\u003c/p\u003e\u003cp\u003eThe attitude scores improved significantly in the intervention group (21.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u0026ndash;26.39\u0026thinsp;\u0026plusmn;\u0026thinsp;4.33, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) but deteriorated in the control group (22.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u0026ndash;20.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similar patterns were observed for subjective norms, perceived behavioural control, and behavioural intentions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWithin-group comparisons of outcome measures\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePosttest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePretest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePosttest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.33 (1.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.62 (1.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.14 (1.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.10 (1.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.760\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.87 (3.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.39 (4.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.31 (2.34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.12 (1.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective norms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.93 (2.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.59 (2.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.50 (2.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.67 (2.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.630\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived behavioural control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.96 (4.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.40 (4.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.94 (4.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.12 (4.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.820\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.07 (3.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.06 (3.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.79 (3.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.35 (1.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eBetween-group comparisons\u003c/h2\u003e\u003cp\u003ePostintervention comparisons revealed significant differences favouring the intervention group across all outcomes (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The largest effect sizes were observed for behavioural intentions (d\u0026thinsp;=\u0026thinsp;2.30) and attitudes (d\u0026thinsp;=\u0026thinsp;1.87), indicating substantial practical significance.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBetween-group comparisons at posttest\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean Difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCohen's d\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.62 (1.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.10 (1.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.04-3.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26.39 (4.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.12 (1.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.18\u0026ndash;7.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective norms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17.59 (2.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.67 (2.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.22\u0026ndash;3.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived behavioural control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25.40 (4.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21.12 (4.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.86\u0026ndash;5.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18.06 (3.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12.35 (1.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.95\u0026ndash;6.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eGender disaggregation analysis\u003c/h2\u003e\u003cp\u003eImportantly, the intervention had an equitable impact across genders (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Compared with male participants, female participants (n\u0026thinsp;=\u0026thinsp;33 in the intervention group) showed comparable improvements in knowledge (2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89 vs. 2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92, p\u0026thinsp;=\u0026thinsp;0.847), attitudes, and all other measures. No significant sex \u0026times; group interactions were observed, supporting the intervention's universal effectiveness.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGender disaggregation analysis of intervention effects\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale Participants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFemale Participants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep value*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePosttest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePretest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePosttest Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntervention Group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.32 (1.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.60 (1.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.34 (1.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.65 (1.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.889\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.85 (3.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.37 (4.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.89 (3.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.42 (4.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.960\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective norms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.90 (2.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.56 (2.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.97 (2.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.63 (2.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.897\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived behavioural control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.93 (4.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.37 (4.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.00 (4.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25.44 (4.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.944\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.05 (3.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.02 (3.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.10 (3.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.11 (3.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.897\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eControl Group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.13 (1.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.08 (1.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.15 (1.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.12 (1.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.905\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.30 (2.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.10 (1.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.32 (2.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.14 (1.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.929\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective norms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.48 (2.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.65 (2.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.52 (2.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.69 (2.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.936\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived behavioural control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.90 (4.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.08 (4.34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.98 (4.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.16 (4.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.936\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.75 (3.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.33 (1.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.83 (3.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.37 (1.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.920\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*p value for sex comparison of change scores within the intervention group\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePredictors of Behavioral Change\u003c/h2\u003e\u003cp\u003eMultiple regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) identified attitudes (β\u0026thinsp;=\u0026thinsp;0.468, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and perceived behavioural control (β\u0026thinsp;=\u0026thinsp;0.185, p\u0026thinsp;=\u0026thinsp;0.001) as significant predictors of behavioural intentions, collectively explaining 46.8% of the variance (adjusted R\u0026sup2;=0.453, F(4,143)\u0026thinsp;=\u0026thinsp;31.424, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultiple regression analysis for predictors of behavioural intentions\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e(Constant)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.451\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.987\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.012\u0026ndash;4.890\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.281\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.042\u0026ndash;0.520\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.080\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.468\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.650\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.214\u0026ndash;0.530\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective norms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.895\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-0.545-0.205\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived behavioural control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.413\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.157\u0026ndash;0.587\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eR\u0026sup2; = 0.468, Adjusted R\u0026sup2; = 0.453, F(4,143)\u0026thinsp;=\u0026thinsp;31.424, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eEngagement and Retention\u003c/h2\u003e\u003cp\u003eParticipant engagement was substantially greater in the intervention group than in the control group, with 60.8% of the participants classified as highly engaged (\u0026gt;\u0026thinsp;10 messages sent, participation in all quizzes) compared with minimal engagement in the control group. The overall retention rate was 94.6%, with 8 participants (5.4%) lost to follow-up; these participants were equally distributed between groups. The reasons for dropout included technical issues (n\u0026thinsp;=\u0026thinsp;2), time constraints (n\u0026thinsp;=\u0026thinsp;2), and personal reasons (n\u0026thinsp;=\u0026thinsp;4). The distribution of dropouts across the study period is illustrated in the CONSORT flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe magnitude of improvement in the intervention group compared to controls is visually represented (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), which displays the mean change scores for all measured outcomes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis quasiexperimental study demonstrated that WhatsApp-based health education can significantly improve diabetes knowledge, attitudes, and behavioural intentions among university students in Pakistan. The large effect sizes observed across all the outcomes suggest that digital platforms can effectively address health literacy gaps in young adult populations.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eInterpretation of Findings\u003c/h2\u003e\u003cp\u003eThe substantial improvement in knowledge in the intervention group (d\u0026thinsp;=\u0026thinsp;1.71) exceeded the effects reported in traditional education programs. This finding aligns with recent meta-analyses showing the superiority of digital health interventions in terms of knowledge retention [18]. Compared with passive information delivery, the interactive nature of WhatsApp, which combines visual content with peer discussion, likely enhances learning.\u003c/p\u003e\u003cp\u003eNotably, the positive attitude change in the intervention group contrasted with the deterioration in the control group. This divergence suggests that without targeted intervention, misconceptions about diabetes may solidify over time. The WhatsApp platform's ability to address myths through immediate feedback and peer discussion may explain this differential effect.\u003c/p\u003e\u003cp\u003eThe gender-equitable outcomes deserve special emphasis. In a society where gender-based health disparities are common, our intervention achieved equal effectiveness across genders. This finding suggests that digital platforms can bypass traditional barriers to health education access, offering particular promise for reaching female students who may face mobility or social constraints.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eTheoretical Implications\u003c/h2\u003e\u003cp\u003eOur findings support the theory of planned behaviour, with attitudes and perceived behavioural control emerging as key predictors of behavioural intentions. The variance explained (46.8%) is substantial for health behaviour research, suggesting the model's applicability to diabetes prevention behaviours in this population. The strengthened correlations between the TPB constructs postintervention indicate that structured education enhances the coherence of health beliefs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003ePractical Implications\u003c/h2\u003e\u003cp\u003eThe high engagement and retention rates demonstrate WhatsApp's acceptability as an educational medium among Pakistani university students. With 95% smartphone penetration in this demographic and WhatsApp's minimal data requirements, this approach offers a scalable solution for health promotion. The cost-effectiveness is particularly relevant for resource-constrained settings, where traditional face-to-face programs may be prohibitively expensive.\u003c/p\u003e\u003cp\u003eUniversities could integrate such digital health modules into orientation programs or general education requirements. The 14-day format aligns well with academic schedules, and automated content delivery minimises administrative burden. Given the 29.7% family history prevalence in our sample, targeted screening programs could follow educational interventions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eComparison with Previous Research\u003c/h2\u003e\u003cp\u003eOur results exceed those reported in similar studies from South Asia. A comparable intervention in India achieved knowledge improvements of d\u0026thinsp;=\u0026thinsp;0.82 [23], whereas our effect size of d\u0026thinsp;=\u0026thinsp;1.71 suggests enhanced effectiveness. This difference may reflect our culturally tailored content and the inclusion of interactive elements beyond simple message delivery.\u003c/p\u003e\u003cp\u003eThe attitude changes observed surpass those in traditional diabetes education programs. A systematic review of university-based health interventions reported a mean attitude improvement of d\u0026thinsp;=\u0026thinsp;0.45 [35], which was less than half our observed effect. The peer interaction facilitated by WhatsApp groups may explain this enhanced impact on attitudes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThe strengths of this study include the use of validated instruments, theory-based intervention design, adequate sample size, and gender-balanced analysis. Compared with pre-post designs, the quasiexperimental design with a control group strengthens causal inference, which is common in digital health research.\u003c/p\u003e\u003cp\u003eHowever, several limitations warrant consideration. The quasiexperimental design lacks randomisation, potentially introducing selection bias. The immediate posttest assessment cannot determine long-term retention or behaviour change. Self-reported measures may overestimate improvements due to social desirability bias. The urban, educated sample limits generalisability to rural or less educated populations.\u003c/p\u003e\u003cp\u003eThe 14-day intervention period, while practical, may be insufficient for sustained behaviour change. Future studies should incorporate longer follow-up periods and objective health outcomes. The exclusive focus on nonmedical students, while reducing baseline knowledge bias, limits its applicability to medical education contexts.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eFuture Directions\u003c/h2\u003e\u003cp\u003eThis study opens several avenues for future research. Longitudinal studies should assess knowledge retention and actual behaviour change over 6\u0026ndash;12 months. Randomised controlled trials could strengthen causal inference. Expanding to rural populations and incorporating local languages could enhance reach and equity.\u003c/p\u003e\u003cp\u003eIntegration with existing health services deserves exploration. WhatsApp groups could connect students with campus health centers for screening and counselling. Peer educator models, which train student leaders in moderate groups, could enhance sustainability and cultural relevance.\u003c/p\u003e\u003cp\u003eThe platform's potential extends beyond diabetes education. Similar approaches could address mental health, sexual health, and substance abuse, which are critical issues in university populations. These gender-equitable outcomes suggest particular promise for addressing women's health topics in conservative societies.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides robust evidence that WhatsApp-based health education can significantly improve diabetes knowledge, attitudes, and behavioural intentions among university students in Pakistan. The large effect sizes, high engagement rates, and gender-equitable outcomes demonstrate the intervention's effectiveness and acceptability. As Pakistan grapples with a diabetes epidemic, innovative digital approaches offer scalable, cost-effective solutions for prevention education.\u003c/p\u003e\u003cp\u003eThe integration of such interventions into university health programs could contribute to diabetes prevention efforts while building health literacy in future community leaders. The success of this approach suggests broader applications for digital health education in resource-constrained settings, potentially transforming how we deliver preventive health education to young adults.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This study was approved by the Institutional Review Board of King Edward Medical University, Lahore, Pakistan. The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to enrolment. For participants under 18 years of age, written informed consent was also obtained from their parents or legal guardians. Participants were informed of their right to withdraw from the study at any time without penalty.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable. This manuscript does not contain any individual person's data in any form (including individual details, images, or videos).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research was self-funded by the student investigators as part of their community medicine training.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.I. conceived the study, supervised the project, and critically revised the manuscript.M.A.M. curated and analyzed the data, prepared the initial draft, and developed figures/visualizations.A.A.K. collected data and contributed to manuscript editing.A.J. conducted the literature review and assisted with manuscript validation.Ar.A. performed statistical analyses and contributed to results interpretation.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe thank the participating universities and students for their cooperation. We acknowledge the technical support provided by the Department of Community Medicine, King Edward Medical University.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author (Mohammad Azeem, [email protected]) upon reasonable request. Data will be shared in de-identified format to protect participant confidentiality, subject to approval by the King Edward Medical University Institutional Review Board.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSaeedi P, Petersohn I, Salpea P, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045. Diabetes Res Clin Pract. 2019;157:107843.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eInternational Diabetes Federation. IDF Diabetes Atlas, 10th Edition. Brussels: IDF; 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBasit A, Fawwad A, Qureshi H, Shera AS. Prevalence of diabetes in Pakistan: National Diabetes Survey. BMJ Open. 2018;8:e017715.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJafar TH, Haaland BA, Rahman A, et al. Noncommunicable diseases and injuries in Pakistan: strategic priorities. Lancet. 2013;381(9885):2281\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhowaja LA, Khuwaja AK, Cosgrove P. Cost of diabetes care in outpatient clinics of Karachi, Pakistan. BMC Health Serv Res. 2007;7:189.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli N, Akram R, Sheikh N, et al. Microvascular complications of diabetes in Pakistani population. Pak J Med Sci. 2019;35(6):1575\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZimmet P, Alberti KG, Shaw J. Prevention of Type 2 diabetes: a realistic target. 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Educ Inf Technol. 2020;25(2):1057\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhavnani SP, Narula J, Sengupta PP. WhatsApp for maternal health education in India: A randomised trial. JAMA Netw Open. 2020;3(12):e2020202.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Heerden A, Tomlinson M, Swartz L. Youth health promotion via WhatsApp: A South African study. mHealth. 2019;5:44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahim S, Jafarey S, Shah S, et al. WhatsApp-based CPR training effectiveness in Pakistan. Pak Heart J. 2021;54(2):110\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSharma M, Yadav K, Lohani P, et al. Social media and health education in South Asia: A scoping review. BMC Public Health. 2022;22(1):550.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNawaz H, Shafique N, Anwar M, et al. Digital interventions for chronic disease in LMICs: A systematic review. Glob Health. 2020;16(1):70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFatima H, Shah ST, Naeem R, et al. Youth as agents of public health change in Pakistan. J Pak Med Assoc. 2020;70(9):1573\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZia A, Ahmed KS, Iqbal F, et al. Smartphone usage patterns in young adults: Implications for health interventions. Pak J Med Sci. 2022;38(5):1189\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIkram M, Hameed N, Ishaq M, et al. WhatsApp-based learning and behavioural outcomes in medical education. J Med Educ. 2021;25(3):198\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMasood T, Ahmad N, Baig ZF, et al. Peer learning through mobile tools: A systematic review. Educ Health. 2022;35(1):13\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIqbal S, Zakar R, Fischer F, et al. Cost-effective health promotion strategies for Pakistani youth. Pak J Public Health. 2023;13(2):97\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaumann LC, Karel A. Health Education. In: Gellman MD, Turner JR, editors. Encyclopedia of Behavioural Medicine. New York: Springer; 2013. pp. 917\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCole JB, Florez JC. Genetics of diabetes mellitus and diabetes complications. Nat Rev Nephrol. 2020;16(7):377\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePlotnikoff RC, Costigan SA, Williams RL, et al. Effectiveness of interventions targeting physical activity, nutrition and healthy weight for university and college students: A systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2015;12:45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnderson RM, Fitzgerald JT, Funnell MM, Gruppen LD. The third version of the Diabetes Attitude Scale. Diabetes Care. 1998;21(9):1403\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Diabetes education, WhatsApp, mHealth, university students, health promotion, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-7450578/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7450578/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePakistan faces a diabetes epidemic affecting 33\u0026nbsp;million adults, with limited health education among youth. Digital platforms offer potential for scalable health promotion. This study evaluated the effectiveness of WhatsApp-based education in improving diabetes knowledge and attitudes among university students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA quasiexperimental study was conducted with 148 nonmedical university students (mean age 20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 years, 45.3% female) from eight universities in Lahore, who were allocated to intervention (n\u0026thinsp;=\u0026thinsp;74) and control (n\u0026thinsp;=\u0026thinsp;74) groups. The intervention group received structured WhatsApp-based education, including infographics, videos, and interactive quizzes, over 14 days, whereas the control group received basic materials. Outcomes were assessed via the Diabetes Knowledge Questionnaire-Revised (DKQ-R) and adapted Diabetes Attitude Scale-3 (DAS-3), which measure knowledge, attitudes, subjective norms, perceived behavioural control (PBC), and behavioural intentions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe intervention group demonstrated significant improvements across all the domains. The knowledge scores increased from 2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41 to 4.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, d\u0026thinsp;=\u0026thinsp;1.71), whereas no change was detected in the controls (2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36 to 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39, p\u0026thinsp;=\u0026thinsp;0.760). The attitude scores improved from 21.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25 to 26.39\u0026thinsp;\u0026plusmn;\u0026thinsp;4.33 in the intervention group versus those in the control group (22.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34 to 20.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90, both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Between-group posttest comparisons revealed large effect sizes for knowledge (d\u0026thinsp;=\u0026thinsp;1.71), attitudes (d\u0026thinsp;=\u0026thinsp;1.87), subjective norms (d\u0026thinsp;=\u0026thinsp;1.35), PBC (d\u0026thinsp;=\u0026thinsp;0.98), and intentions (d\u0026thinsp;=\u0026thinsp;2.30). Multiple regression analysis revealed that attitudes (β\u0026thinsp;=\u0026thinsp;0.468, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and PBC (β\u0026thinsp;=\u0026thinsp;0.185, p\u0026thinsp;=\u0026thinsp;0.001) were significant predictors of behavioural intentions, explaining 46.8% of the variance. Gender disaggregation analysis revealed equitable improvements across male and female participants (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all gender comparisons). Engagement was high in the intervention group (60.8% high engagement), with 94.6% retention.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eWhatsApp-based health education significantly improved diabetes knowledge, attitudes, and behavioural intentions among university students, with equitable impacts across genders. This low-cost, scalable intervention offers a promising approach for diabetes prevention education in resource-limited settings. Integration into university health programs could address the growing diabetes burden in Pakistan.\u003c/p\u003e","manuscriptTitle":"Effectiveness of WhatsApp-based health education in enhancing knowledge and attitudes towards diabetes and its complications among university students in Lahore, Pakistan: A quasiexperimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 01:55:52","doi":"10.21203/rs.3.rs-7450578/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1bbca088-1b97-4f59-aaf6-75a481f8c0cf","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-17T01:55:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 01:55:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7450578","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7450578","identity":"rs-7450578","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}