Effect of a sexually transmitted infection prevention program on voluntary counseling and testing services utilization among university students: a quasi-experimental study

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Stutterheim, Rik Crutzen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8307772/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Low utilization of Voluntary Counseling and Testing (VCT) services increases the burden of sexually transmitted infections (STIs) and HIV, rates of late diagnosis, and delayed initiation of treatment and care. Low VCT utilization is particularly high among adolescents and young adults (AYA), including university students. This behavior is predicted by personal determinants, including low risk perception of STIs, attitude toward VCT, self-efficacy in using VCT services, and subjective norms. To positively influence these determinants among university students, a behavior change program was conducted at Universidade Católica de Moçambique (UCM). This study aimed to gain insight into the effect of the program on (determinants of) VCT service utilization among first-year students. Methods We used a quasi-experimental non-equivalent comparison group design. The study took place at UCM and Universidade Licungo (UniLicungo) intervention and control setting respectively. We included 481 and 338 participants from UCM and UniLicungo respectively. We collected data on VCT service utilization, risk perception, attitude, self-efficacy, and subjective norms at enrolment, three-month, and six-month follow-up using a self-administered structured questionnaire with closed-ended questions. We analysed data using analysis of variance (ANOVA) and logistic regression analysis. Results The analysis showed increases in perceived risk of acquiring STIs, including HIV (p < .001, 95% CI [.213, .439]) and in self-efficacy to seek and use VCT services (p < .001, 95% CI [.078, .285]) from enrolment to six-month follow-up. A positive effect on subjective norms was found from enrollment to three-month follow-up (p < .001, 95% CI [.072, .370]). No significant effect was observed on attitude toward VCT. VCT utilization at the intervention university increased from 46.90% at enrolment to 54.8% at three-month follow-up and to 57.80% at six-month follow-up. This apparent increase did not significantly differ from VCT utilization patterns at the control university. Conclusion Our study results suggest that the program may have positively influenced students' perceived risk of acquiring STIs, including HIV, and their confidence in seeking and using VCT services. These effects did not translate into increased VCT services utilization. Future research is recommended to identify other determinants and evaluate alternative strategies to improve VCT utilization among university students. Students STIs HIV Behavior Program Beira Figures Figure 1 Figure 2 Background Sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), represent significant global health threats with considerable political, social, economic, and public health impacts worldwide ( 1 – 3 ). Global estimates indicate that more than one million curable STIs are acquired daily ( 2 ). The WHO estimated that 374 million new cases occurred in 2020 ( 2 , 4 ). Among adolescents and young adults (AYA) aged 15–24 years in the Sub-Saharan Africa region, for example, the estimated prevalence ranges for curable STIs were 6.4%–11.6% for gonorrhea, 9%–17.8% for chlamydia, 10.5%–20.6% for trichomoniasis, and 2.2%–10.3% for syphilis ( 5 ). HIV has been described as the most prominent infection among STIs and remains a major global crisis ( 1 ). AYA account for approximately 1.100 of the 4000 daily new HIV infections ( 6 ). In Sub-Saharan Africa, 51% of new infections were reported in 2021 ( 7 ). Data from the national surveillance system in Mozambique reported an HIV prevalence of 5.4% among AYA aged 15 to 24 years in 2021 ( 8 ). This burden is particularly pronounced in Sofala province, where Beira city is located and where this study was conducted, with HIV prevalence among people aged 15 years and older reaching 13.2% in 2021 ( 8 ). Low utilization of Voluntary Counseling and testing (VCT) services contributes to increased prevalence of STI, including HIV, particularly among adolescents and young adults (AYA), including university students ( 9 ). This low utilization also increases the rate of late diagnosis of infection and delayed initiation of treatment and care to STIs, including HIV ( 10 ). In fact, in Sub-Saharan Africa, where approximately 86% (69–98%) of people with HIV know their status ( 11 ), only one in five adolescent girls with HIV (aged 15– 24) know their HIV status ( 12 ). Determinants of low VCT service utilization include not being sexually active, low risk perception of STIs including HIV, lack of knowledge about where to seek services, and limited comprehensive knowledge of HIV ( 13 , 14 ). Additionally, STI knowledge, perceived susceptibility, subjective norms about utilization of VCT services, attitudes toward VCT services, self-efficacy in ability to seek and use VCT services, and stigma toward VCT services utilization are potential predictors of VCT service utilization ( 15 , 16 ). Promotion of voluntary counseling and testing (VCT) services as a secondary preventive strategy for STIs, including HIV, is both useful and feasible. VCT is a behavioral intervention, not merely a simple diagnostic process ( 17 ). The VCT process guides individuals seeking confidential counseling toward informed decision-making regarding their STI/HIV status and helps them take appropriate action ( 9 ). Beneficial effects of VCT service utilization have been well documented, including increased safe sex practices, reduction in the number of sexual partners, increased abstinence choices ( 9 ), enhanced awareness of STIs and HIV, decreased stigma related to HIV, and improved access to care as a first step in the treatment pathway ( 10 , 16 ). UNAIDS reports that the world observed a decline in new HIV cases among adolescents and young adults (AYA) aged 15 to 24 years in 2022, attributing this reduction to targeted HIV prevention programs for this population ( 18 ). Recognizing the importance of contributing to this global goal, Universidade Católica de Moçambique (UCM) and its partners acknowledged that young people face significant challenges, including low self-esteem, lack of control over their sexuality, unintended pregnancies, acquisition of STIs including HIV, and sexual abuse ( 19 ). To address the impact of these challenges on STI and HIV preventive behaviors among students, UCM implemented a behavior change intervention grounded in a rights-based approach to sexuality education. The program consisted of life skills curricular lessons for first-year students, awareness activities addressing sexuality and STI/HIV prevention, and provision of VCT services across all faculties. The program had not been systematically evaluated since its introduction in 2012. Additionally, there is limited empirical evidence about programs aiming to improve VCT service use in Mozambique. This study set out to investigate the effect of the program on personal determinants of VCT service use (risk perception, attitude, self-efficacy, and subjective norms) and regular use of VCT services among first-year university students at UCM, using a quasi-experimental non-equivalent comparison group design. Hypothesis a) The program increased perceived risk for STIs, including HIV, attitude toward use of VCT services, self-efficacy to seek and use VCT services, and subjective norms in favor of VCT services use among university students in Beira, central Mozambique. b) The program increased the use of voluntary counseling and testing services among university students in Beira, central Mozambique. Methods Design and setting The trial design has been described in detail elsewhere ( 20 ). In summary, this study applied a hybrid type 1 approach to assess the effectiveness of a voluntary counseling and testing (VCT) services use intervention among university students while concurrently collecting data on the implementation process. This report focuses on the effect evaluation findings. In the effect evaluation study, we utilized a quasi-experimental non-equivalent comparison group design. We describe the methods in accordance with the TREND Statement ( 21 ) and CONSORT criteria ( 22 ). The study took place at the Universidade Católica de Mocambique (UCM ) and at the Universidade Licungo (UniLicungo). Both universities are located in Beira city, Sofala province, in the central region of Mozambique. UCM is a private, nonprofit institution, with faculties in the southern, central and northern regions of Mozambique. In Beira, there are two faculties and one e-learning Institute. The Faculty of Health Sciences and the Faculty of Economy and Management were involved in the study. UniLicungo is a public institution with faculties in two provinces (Sofala and Zambézia) at the central region of Mozambique. In Beira city, the university comprises two faculties and two schools, all of which were involved in the study. Participants The cohort comprised 819 first year undergraduate students enrolled at the UCM, and at the UniLicungo. We employed a clustered and random sampling strategy to select and consecutively enroll participants, from 22 classes (clusters). We enrolled 481 participants from seven classes at the intervention site (UCM) and 338 participants from 15 classes at the non-equivalent comparison group site (UniLicungo). Detailed information on the sample size calculation and sampling procedure is available in previous publications ( 20 , 23 ). Note that the unit of randomization in our study were classes, not participants. Eligibility criteria Students were eligible if they met the following criteria: a) first year undergraduate students studying at one of the two universities in faculties located in Beira city; b) being aged 16–25 years old; and c) resident in Beira city for the entire academic year. Data collection We obtained informed consent collectively at the enrolment visit, before distributing questionnaires to the class, though each candidate freely decided and sign the consent form individually. First year students who agreed to participate completed a self-administered structured questionnaire with closed-ended questions (available at https://www.frontiersin.org/journals/reproductive-health/articles/ 10.3389/frph.2021.745309/full#supplementary-material data sheet 3) at enrollment and at follow-up visits, three and six months later. We used codes (numbers) to identify each participant’s questionnaire and link the information from each visit. Data were collected between May 2021 to June 2022. More details on data collection, as well as a description of the questionnaire development, are published elsewhere ( 20 , 23 ). Program We describe the program summarily, following the guidelines of Hoffmann, Glasziou ( 24 ), Kok, Gottlieb ( 25 ). The intervention, detailed elsewhere ( 20 ), was titled “Take the opportunity to listen and to be listened to.” Acknowledging that STIs, including HIV, are prevalent among AYA in Mozambique ( 26 ), to effectively intervene, there is a need to change personal determinants of use of VCT services, for instance: knowledge, risk perception, attitude, self-efficacy and subjective norms ( 23 ). Hence, an ongoing intervention, based on the right-based approach to sexuality education ( 27 ), was designed and implemented at UCM, assuming that young people are challenged with several threats, for instance: low self-esteem, lower control over their own sexuality, acquiring STIs, including HIV, peer pressure and considerable degree of freedom. Therefore, the program set out to increase regular seeking and use of VCT services among university students, through improving personal determinants such as knowledge, risk perception, attitude, self-efficacy and subjective norms. The program consisted of three components: ( 1 ) curriculum lessons regarding STIs, including HIV, within the life skills subject for all first-year students at UCM; ( 2 ) sensitizing activities to increase the use of STI/HIV counseling and testing (VCT) services among students; and ( 3 ) provision of VCT services at all faculties in both sites. The behavior change methods, practical applications and the material used are available in the supplementary materials of Zango, Crutzen ( 20 ), https://www.frontiersin.org/journals/reproductive-health/articles/ 10.3389/frph.2021.745309/full#supplementary-material data sheet 2. The implementation team consisted of two health advisor, six life skills’ teachers and 32 volunteer students. Teachers’ Program Activities Life skills classes followed a student-centered learning approach. A teachers’ handbook and an equivalent students’ handbook were the basic didactic materials. The subject consisted of 64 hours, of which 34 were devoted to lectures and 30 to practical sessions. Approximately 50% of the content focused on sexual and reproductive health (SRH), with 16 hours specifically addressing STIs, including HIV. Nevertheless, for research purpose, the selected aspects to be changed were addressed in 16 hours of about two hours each, delivered twice a week in the first semester of the academic year. Volunteer Students’ Program Activities During the program, volunteer students provided four awareness sessions following the structure and sequence of the life skills module. Each session, focused on a specific issue, for instance, progression of HIV infection, symptoms of STIs, steps for seeking help, complications of untreated STIs, and adequate treatment of STIs including HIV. Health Advisors’ Program Activities. Health advisors offered counseling and testing services for STIs, including HIV, in a private room at each UCM faculty. Same services were ensured at the control site. These services were delivered in accordance with the national guideline ( 28 ), which distinguishes and recommends three main sequential steps of counseling: a) Pre-testing counseling, b) Counseling during the test/examination and c) Post-test counseling. During counseling session, clients discussed STIs including HIV acquisition and prevention with the health advisor (for more details see Supplementary File) in Zango, Crutzen ( 20 ). HIV testing was performed using Alere DetermineTM HIV1/2, an in vitro, visually read, qualitative immunoassay for the detecting antibodies to HIV-1 and HIV-2 in human whole blood. If antibodies were detected, the result was confirmed using Trinity Biotech UniGoldTM HIV test, considered the most specific test device. This test is also an in vitro, visually read, qualitative immunoassay for antibodies detection. Additionally, rapid plasma reagin (RPR) tests (Abbott biokit) was performed, to screen for Syphilis infection. Clients were also asked questions to screen for general STIs symptoms. STI diagnoses were made in accordance with the national guideline. In case of positive test result or identification of symptoms, clients were referred to the health center for treatment and follow-up if needed. Note that the COVID-19 pandemic significantly impacted our study implementation. Face-to-face activities at schools, including VCT services, were intermittently suspended during outbreak waves. This disruption affected the regular delivery of program activities by health advisors, volunteer students, and teachers. Outcomes The effect evaluation reported here aimed to measure the following outcomes: Changes in individual-level determinants of VCT services use; Use of VCT services; This paper focus on reporting changes in individual-level determinants of VCT services use, and the reported use of VCT services. We measured changes in personal determinants, known to influence VCT services use, namely risk perception, attitude, self-efficacy and subjective norms and reported VCT service use as detailed in our previous publication ( 23 ) at https://www.frontiersin.org/journals/reproductive-health/articles/ 10.3389/frph.2021.745309/full#supplementary-material data sheet 3. Items in the questionnaires were developed based on the change objectives by the research team for the purposes of evaluation, details in our previous publication ( 20 ) at https://www.frontiersin.org/journals/reproductive-health/articles/ 10.3389/frph.2021.745309/full#supplementary-material data sheet 1. Briefly, we used four questions to measure perceived risk for STIs by not using VCT services: first, we asked participants to select, from a list of five items, the consequences of not using VCT services; second, we asked them to indicate their score of agreement that using VCT services reduces transmission of STI including HIV on a five-point scale (1 strongly disagree… 5 strongly agree); third, we asked them to indicate the extent to which they are aware about the risk for STI/HIV infection, using a five-point scale (1 strongly unaware… 5 strongly aware); finally, we asked participants to rate their score of agreement, that they should get help from a health advisor soon for STI/HIV concerns (1 strongly disagree… 5 strongly agree). We measured attitude toward VCT service use (e.g. Using STI/HIV screening services is pleasant…), self-efficacy to seek and use VCT services (e.g. I am confident to tell my concerns about STI/HIV to the health provider…) and subjective norms on VCT services use (e.g. Other students like me usually go to the health provider for STI/HIV complaints…) using respectively eight, nine and four items with a seven-point Likert scale as described above. Use of VCT service was determined by the proportion of students who reported regular use of screening services. Hence wee asked participants if they had ever used VCT services (answer options: “yes”, “no” and “do not remember”). We also asked them to indicate when the last time was they visited a VCT service (“1–4 weeks ago”; “1–3 months ago”; “4–6 months ago”; “A year ago” and “do not remember”). We then converted answers into a binary variable, whereby all participants who selected “yes” to the first question were labelled as having previously used VCT services and who answered “no” or “do not remember” were considered to have not used VCT services. Statistical analysis For baseline data, we used descriptive statistics to summarize participants' characteristics. We assessed differences between groups at baseline using Pearson's chi-square test for categorical data and independent t-tests for numerical data, considering p < .05 as statistically significant. We compared enrolment characteristics between groups to identify important differences in prognostic variables that needed to be accounted for in the effect analysis model and results interpretation. Following recommendations from de Boer and colleagues, we report results from both crude and adjusted analysis ( 29 ). For the follow up measures, at three and six months, we compared data from the intervention and non-equivalent comparison group over time using analysis of variance (ANOVA) for repeated measures of personal determinants. These analyses deviate from the protocol for two reasons. First, with only one university per condition, we could not include university as a separate level while using condition as a predictor in the model (as the variable condition would be similar to university). Second, we defined change from baseline as posttest minus pretest, as participants from each group were random samples from their respective populations ( 30 ). In the repeated-measures ANOVA, we assessed both within-subjects and between-subject’s effects. We first evaluated within-subject effects, as this is a prerequisite for reporting between-subject results. For outcomes showing significant within-subjects effect (p < .05), we reported both crude and adjusted between-subject’s results. Cases with missing data were excluded from the repeated-measures ANOVA due to the requirements of the analysis. We used logistic regression analysis to determine the intervention's effect on VCT service use. First, we analyzed the effects of setting, time, and their interaction. We then ran an adjusted model that included age, sexual debut, and sexuality discussions with mother as covariates. Effect sizes were estimated using adjusted odds ratios (aOR) with 95% confidence intervals and the Nagelkerke R² coefficient. Results At the intervention university, 387 participants (80.46%) completed the follow-up questionnaires, and 315 (65.86%) completed the final assessment. At the control university, 272 participants (80.47%) completed the three-moth follow-up survey, and 285 (84.32%) completed the six-month follow-up. For the ANOVA analysis of quantitative outcomes, we included 532 participants (64.96% of the initial cohort): 285 from the intervention university and 247 from the control university. Due to missing data, 285 participants were excluded from this analysis. Table 1 presents baseline characteristics and comparisons between the two groups. Of the 481 participants enrolled from randomly selected classes at the intervention university, 327 (67.98%) were women, compared to 146 (43.20%) women at the comparison university. The difference in sex distribution was statistically significant (χ² = 49.99, p < .001). Table 1 Participants characteristics in intervention and control universities at enrollment Characteristics N (%) Statistics Intervention Control x 2 or t-test p-value Sex Man 154(32.00) 192(56.80) 49.99 < .001 * Women 327(68.00) 146(43.20) Age n = 473 n = 335 Mean (SD) 18.22(1.33) 20.17(2.00) 16.69 # < .001 * Discuss sexuality with father Frequently 31(7.90) 13(6.4) Never/rarely 360(92.10) 189(93.6) 0.43 .511 Discuss sexuality with mother Frequently 144(32.00) 77(25.8) Never/rarely 306(68.00) 222(74.20) 3.37 .066 Have boy/girlfriend Yes 394(82.40) 299(88.50) No 84(17.60) 39(11.50) 5.63 .018 * Number of sexually partners Mean (SD) 2.70(2.46) 2.92 (2.48) 1.09 # .275 Sexual debut Yes 267(68.50) 253(85.80) No 123(31.50) 42(14.20) 27.48 < .001 * Age at sexual debut Mean (SD) 19.81(2.47) 20.63(2.86) 3.78 # < .001 * # t test’s values instead of x 2 , because the variables are continuous. Hence, also mean and SD have been reported as descriptive information instead of frequencies. Participants from the two groups differed in other characteristics. The mean age was 18.22 (SD = 1.33) at the intervention university compared to 20.17 (SD = 2.00) at the control university (t = 16.69, p < .001). The prevalence of having a sexual partner was higher in the control group (299, 88.50%) than in the intervention university (384, 82.40%; χ² = 5.63, p = .018). Similarly, the prevalence of sexual debut was higher in the control group (253, 85.80%) than in the intervention university (267, 68.50%; χ² = 27.48, p < .001). Effects of the Intervention on Personal Determinants of VCT Service Use Table 2 presents the means, standard deviations, and within- and between-subjects effects, from the repeated measures ANOVA assessing the program’s effects on risk perception, attitudes, self-efficacy and subjective norms. Risk perception Mauchly's test indicated that the assumption of sphericity was met (χ² ( 2 ) = .869, p = .648). The program showed a significant within-subjects effect on risk perception scores (F( 2 ) = 25.61, p < .001, η² = .05) in the intervention group. Figure 1 illustrates the changes in mean scores per group over time. Post-hoc pairwise comparisons without adjustment revealed significant differences between enrollment and three-month follow-up (p < .001, 95% CI [.121, .304]), three-month and six-month follow-up (p = .012, 95% CI [.025, .203]), and enrollment and six-month follow-up (p < .001, 95% CI [.234, .419]). After Bonferroni adjustment, pairwise comparisons still showed significant differences between enrolment and three-month follow-up (p < .001, 95% CI [.101, .324]), three-month follow-up and six-month follow-up (p = .037, 95% CI [.005, .223]), and enrolment and six-month follow-up (p < .001, 95% CI [.213, .439]). Attitude Mauchly's test indicated that the assumption of sphericity was met (χ² ( 2 ) = 2.767, p = .251). The intervention showed no significant within-subjects effect on attitude scores toward VCT service use (F( 2 ) = 0.114, p = .893). Given this non-significant effect, post-hoc pairwise comparisons were not reported. Self-efficacy Mauchly's test indicated that the assumption of sphericity was met (χ² ( 2 ) = 3.885, p = .143). The program showed a significant within-subjects effect on self-efficacy scores for VCT service use (F( 2 ) = 8.729, p < .001, η² = .016). Post-hoc pairwise comparisons without adjustment revealed significant differences between enrollment and three-month follow-up (p = .022, 95% CI [.015, .193]), and between enrollment and six-month follow up (p < .001, 95% CI [.096, .266]). However, no significant difference was found between the three-month and six-month follow-up (p = .068, 95% CI [-.006, .160]). After Bonferroni adjustment, significant mean difference remained between enrollment and six-month follow-up (p < .001, 95% CI [.078, .285]). Subjective Norms Mauchly's test indicated that sphericity was not met, but the Greenhouse-Geisser epsilon was greater than .75 (ε = .961). Therefore, we applied the Huynh-Feldt correction (ε( 2 ) = .961). The program showed a significant within-subjects effect on subjective norms (F(1.933) = 6.811, p = .001, η² = .013). Post-hoc pairwise comparisons without adjustment showed significant differences between enrolment and three-month follow-up (p < .001, 95% CI .099, .343]), and between three months and six-month follow up (p = .026, 95% CI [-.225, − .014]). No significant difference was found between enrolment and six-month follow up (p = .112). After Bonferroni adjustment, significant differences remained between enrolment and three-month follow up (p < .001, 95% CI [.072, .370]. Effect of the program on VCT Service Utilization at University Logistic regression analysis to measure the intervention's effect over time on VCT service use likelihood at the intervention university (UCM) showed that the model was statistically significant compared to the null model (χ² ( 5 ) = 66.372, p < .001). The model explained 4.5% of the variation in VCT service use (Nagelkerke R² = .045) and predicted correctly 61.7% of cases. Setting was significant (p < .001), with the odds ratio (OR = 0.443, 95% CI [0.325, 0.603]) indicating that participants in the intervention setting were 55.7% less likely to use VCT services compared to those in the control setting. Neither changes over time (Table 3 ) nor the interaction between time and setting (Fig. 2 ) were significant. Table 2 Effect of the intervention on personal determinants, Beira city central Mozambique, 2021 Outcome Mean (SD) Effect Intervention Control Within subjects Between subjects F (p-value) F (p-value) Risk perception n = 285 n = 247 enrolment 4.76 (1.00) 4.57(.98) 25.61 (< .001) * 7.45 (.007) * 3 months follow up 4.94(1.06) 4.82(1.06) 6 months follow up 5.14(1.07) 4.84(1.03) Attitude enrolment 6.33(.75) 6.22(.92) 0.11 (.893) 3.65 (.057) 3 months follow up 6.33(.79) 6.19(1.02) 6 months follow up 6.30(.72) 6.22(.91) Self-efficacy enrolment 5.71(1.04) 5.81 (1.10) 8.73 (< .001) * 0.43 (.513) 3 months follow up 5.85(1.01) 5.89(1.05) 6 months follow up 5.94(.93) 5.95(1.02) Subjective norms enrolment 4.66(1.27) 4.86(1.35) 6.81 (.001) * 5.19 (.020) * 3 months follow up 4.86(1.19) 5.10(1.28) 6 months follow up 4.78(1.25) 4.94(1.39) In the analysis of the effects of age, sexuality discussions with mother, and sexual debut, the model was significant (χ² ( 8 ) = 102.872, p < .001) and explained 8.8% of the variation in VCT service use (Nagelkerke R² = .088). The model predicting correctly 64.7% of cases. Four variables showed significant effects: setting (p = .007), age (p = .005), sexual debut (p < .001), and sexuality discussions with mother (p < .001) (Table 4 ). Table 3 Effect of the program on use of VCT services, considering time and setting and interaction between the two variables Variable Coefficient (B) S-E OR (Exp (B)) 95% CI p-value Setting Control Intervention − .815 .158 .442 .325 − .603 < .001 Time Enrolment 3 months follow up .152 .176 1.164 .825–1.642 .388 6 months follow up .279 .175 1.322 .937–1.866 .112 interaction Setting*time .713 Nagelkerke R 2 = .045 Table 4 Effect of the program on use of VCT services, considering other variables Variable Coefficient (B) S-E OR (Exp (B)) 95% CI p-value Setting Control Intervention − .534 .196 .586 .399 − .861 < .001* Time Enrolment 3 months follow up .143 ..203 1.154 .776–1.716 .480 6 months follow up .307 .203 1.359 .913–2.023 .130 Interaction Setting * time .800 Age .099 .035 1.104 1.030–1.183 .005* Discuss sex with mother .488 .122 1.629 1.282–2.069 < .001* Sex debut .649 .134 1.911 1.470–2.485 < .001* Nagelkerke R 2 = .088 Discussion This study examined changes in individual-level determinants of, and utilization of voluntary counseling and testing (VCT) services among university students in Beira city, Mozambique, following implementation of a sexually transmitted infection prevention program. While the program did not appear to increase VCT service utilization, positive improvements were observed in perceived risk of acquiring sexually transmitted infections, including HIV, and in self-efficacy for seeking and using VCT services. Perceived risk of acquiring STIs, including HIV, increased from enrolment to three-month follow-up and was maintained at six-month follow-up at the intervention university. However, increased risk perception was also observed among participants at the control university. This could potentially be attributed to students' possible exposure to similar national or local prevention program implemented during the study period (i.e. confounding), or to heightened awareness resulting from completion of the baseline risk assessment questionnaire (i.e. the Hawthorne effect). Nonetheless, the positive effect of program on STI and HIV risk perception observed in this study aligns with findings from previous intervention studies focusing on VCT service utilization among adolescents and young adults, including university students ( 31 – 35 ). Self-efficacy increased throughout the study period at the intervention university, which could facilitate decision-making regarding preventive behaviors, including utilization of VCT services ( 36 , 37 ), as well as consistent engagement in preventive behaviors ( 38 ). Similar to risk perception, self-efficacy for seeking and using VCT services also increased at the control university throughout the study period. This may be explained by the age demographics of this population, as participants at the control university were relatively older than those at the intervention university. Age and other demographic characteristics have been identified as predictors of confidence in one's ability to engage in STI and HIV preventive behaviors ( 39 ). Consequently, the intervention did not demonstrate a difference between conditions on VCT-seeking self-efficacy, which is consistent with findings by Yao, Fu ( 40 ). The program did not increase students' actual reported use of VCT services during the study period. This may be attributed to the exceptional contextual conditions under which the program was implemented, characterized by COVID-19-related restrictions that limited face-to-face delivery of various social services, including VCT services, and educational activities at all levels during program implementation and evaluation. The contextual circumstances of implementation compromised several key components of program fidelity. For instance, participants were advised to seek VCT services at alternative venues since the intervention university's facilities were not providing these services during the suspension of face-to-face activities. Life skills lectures originally planned for classroom delivery were conducted via Zoom or other online platforms, while some awareness sessions were shortened to accommodate educational priorities. Similar compromises in implementation fidelity and their association with reduced effectiveness in STI and HIV prevention behaviors have been documented by Rosenberg, Gichane ( 41 ), who evaluated a one-year small-group behavioral intervention among adolescents and young women, albeit focusing on different HIV-related behaviors. Similar challenges in increasing VCT service utilization at universities have been reported by Gobind and Ukpere ( 42 ), who evaluated the effectiveness of workplace-based VCT program within South African universities. Their findings demonstrated that awareness of VCT availability does not necessarily translate to increased testing uptake among academic community members, with only 40.9% of participants reporting having been tested at the university during the study period. In the present study, VCT service uptake at the intervention university increased from 46.90% at enrollment to 54.8% at three-month follow-up and to 57.80% at six-month follow-up. However, this apparent increase did not significantly differ from utilization patterns at the comparison university. Beyond the contextual constraints, other factors may have contributed to the limited effect on VCT service utilization. Focus group discussions conducted during the process evaluation (results to be reported elsewhere in more detail, Zango et al.,) revealed that students did not understand from the life skills lessons that they should establish a personal schedule for regular VCT service use. Participants also acknowledged that curriculum-based content for preventive behavior change was insufficient, as students primarily focused on passing the course rather than applying the content in practice. Similar findings have been reported in previous evaluation studies ( 43 , 44 ), where authors reported limited effectiveness of their interventions in increasing VCT service utilization. They argued that content acquired through curriculum-based educational programs is often perceived as serving academic requirements rather than being integrated into actual behavior change. Additionally, these findings may be explained by the influence of other factors, such as age and sexual debut. Participants at the control university were older and predominantly sexually active, which may have contributed to the relatively higher likelihood of VCT service use in this group. The influence of age and sexual debut on VCT service utilization has been documented in previous studies ( 13 , 23 , 45 – 48 ). The findings indicate that a standalone program for VCT service use might not be sufficient. There is a possible need to complement the program and provision of VCT services with additional activities. Several approaches are recommended to complement programs´ activities in a university setting or other community in order to improve AYA use of sexual and reproductive health services in general, including VCT services: community-based VCT services ( 49 ), mobile VCT service delivery, community testing combined with facilitated linkage to care ( 50 ), multicomponent interventions, counseling based on cognitive behavioral therapy, and communication campaign interventions ( 51 ), A review by Zanoni, Elliott ( 52 ) concluded that stand-alone interventions are less likely to address all barriers to VCT service use among AYA across all settings. Therefore, they recommend implementing multiple components and expanding mobile health technology, alternate venue testing, including self-testing combined with well-designed linkage to care strategies. Limitations The findings of this study should be interpreted in light of a few limitations in study design and implementation. First, we applied a quasi-experimental study design, which may be subject to several threats described in the literature as potential sources of bias ( 53 – 55 ). The relevant threats to our study included selection bias (due to non-random assignment of participants), history effects (external events occurring during the study period), attrition bias (differential dropout between intervention and control groups), testing bias (related to the effect of pretesting on posttest scores), instrumentation bias (due to changes in measuring methods at follow-up assessments), intervention fidelity issues (which might arise from changes in intervention components delivery), and spontaneous remissions (changes in intervention outcomes that might have occurred spontaneously). To minimize the effects of these threats, we used recommended mitigation strategies ( 53 , 55 , 56 ). We minimized the effect of selection bias by using a comparison group identified based on major characteristics (university first-year students living in Beira city). The effects of history, maturation, testing, and spontaneous remission biases were addressed using a pre-posttest comparison group approach. Attrition was minimized by monitoring dropouts and maintaining low intervention and data collection burden. Instrumentation and intervention fidelity issues were minimized through training and monitoring of all data collectors and the data collection process, as well as all implementers and the implementation process, respectively. We recognize that traditionally, randomized controlled trials have been recommended as the gold standard for causal inferences in the health sciences field, especially when considering inclusion criteria requirements for systematic review and meta-analysis studies ( 57 , 58 ). Nevertheless, a quasi-experimental non-equivalent comparison group design was chosen because this design combines some advantages of full experimental designs with those of non-experimental studies, offering distinct advantages compared to randomized controlled trials. Particularly, this design limits some threats to external validity ( 57 ). We also decided to apply a quasi-experimental non-equivalent comparison group design because the intervention was already in full implementation, meaning that it would have been unjustifiable and unfeasible to apply a full experimental study design with random allocation of participants. This would have implied excluding some classes or students from the intervention at UCM, while they shared the same environment and policies. Hence, using a similar educational setting as a non-equivalent comparison group was a rational and acceptable approach to evaluate the program's effect with limited biases ( 20 ). Conclusion The study findings showed that the intervention did not increase VCT service utilization among first-year university students. However, a positive effect was observed only in perceived risk of acquiring sexually transmitted infections, including HIV, associated with non-use of VCT services and in self-efficacy in ability to use VCT. Future research is recommended to evaluate the effectiveness of alternative strategies to change determinants of VCT service utilization among first-year university students and improve VCT service utilization among this population. Additionally, alternative determinant should be considered as potential in influencing use of VCT services, hence, future researchers are needed to identify more determinants and evaluate alternative strategy to change. Abbreviations AYA Adolescents and young adults ANOVA Analysis of variance aOR adjusted Odds Ratio CI Confidence interval DNAM Direccão Nacional de Assistência Médica HIV Human immunodeficiency virus INS Instituto Nacional de Saúde MISAU Ministério de Saúde SD Standard deviation SRH Sexual and reproductive health STIs Sexually transmitted infections UCM Universidade Católica de Moçambique UM University of Maastricht UNAIDS Joint United Nations Program on HIV/AIDS UniLicungo Universidade Licungo VCT Voluntary counseling and testing WHO World Health Organization Declarations Ethical approval and consent to participate The study protocol obtained ethical approval from the local ethical assessment committee of Sofala ( Comité Interinstitucional para Bioética de Sofala —CIBS), in accordance with the Declaration of Helsinki and local administrative authorization. All study participants were enrolled to the study after signing the informed consent. Consent for publication Not applicable. Availability of data The datasets generated and/or analyzed during the current study are not publicly available because the ethical approval letter does not include public availability of the dataset but, are available from the corresponding author on reasonable request. Competing interest No competing interest were disclosed. Funding The firs author is supported by the Nuffic, NICHE program grant number: 30606015N, led by the Maastricht University as scholarship for her PhD program. Obtaining this scholarship did not include peer-review of the study protocol. Author’s contribution AZ and RC developed the research protocol, conducted the study and performed the data analysis and interpretation of the results. AZ, RC and SS were the major contributors in writing the manuscript. RC reviewed the first draft. All authors contributed and reviewed the final manuscript of the paper and have agreed to the final text. 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09:05:22","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":202971,"visible":true,"origin":"","legend":"","description":"","filename":"Zangoetal.2021.SuplementarymaterialDataSheet26.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8307772/v1/4b0734bea9cea598a412cfb7.pdf"},{"id":100595548,"identity":"bcb19f1c-860f-407c-a26c-20e97e16a33c","added_by":"auto","created_at":"2026-01-19 13:48:46","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":354363,"visible":true,"origin":"","legend":"","description":"","filename":"Zangoetal.2021.SuplementarymaterialDataSheet36.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8307772/v1/81344fa16edf14f78afd3d4c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of a sexually transmitted infection prevention program on voluntary counseling and testing services utilization among university students: a quasi-experimental study","fulltext":[{"header":"Background","content":"\u003cp\u003eSexually transmitted infections (STIs), including human immunodeficiency virus (HIV), represent significant global health threats with considerable political, social, economic, and public health impacts worldwide (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Global estimates indicate that more than one million curable STIs are acquired daily (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The WHO estimated that 374\u0026nbsp;million new cases occurred in 2020 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Among adolescents and young adults (AYA) aged 15\u0026ndash;24 years in the Sub-Saharan Africa region, for example, the estimated prevalence ranges for curable STIs were 6.4%\u0026ndash;11.6% for gonorrhea, 9%\u0026ndash;17.8% for chlamydia, 10.5%\u0026ndash;20.6% for trichomoniasis, and 2.2%\u0026ndash;10.3% for syphilis (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHIV has been described as the most prominent infection among STIs and remains a major global crisis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). AYA account for approximately 1.100 of the 4000 daily new HIV infections (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In Sub-Saharan Africa, 51% of new infections were reported in 2021 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Data from the national surveillance system in Mozambique reported an HIV prevalence of 5.4% among AYA aged 15 to 24 years in 2021 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This burden is particularly pronounced in Sofala province, where Beira city is located and where this study was conducted, with HIV prevalence among people aged 15 years and older reaching 13.2% in 2021 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLow utilization of Voluntary Counseling and testing (VCT) services contributes to increased prevalence of STI, including HIV, particularly among adolescents and young adults (AYA), including university students (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This low utilization also increases the rate of late diagnosis of infection and delayed initiation of treatment and care to STIs, including HIV (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In fact, in Sub-Saharan Africa, where approximately 86% (69\u0026ndash;98%) of people with HIV know their status (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), only one in five adolescent girls with HIV (aged 15\u0026ndash; 24) know their HIV status (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDeterminants of low VCT service utilization include not being sexually active, low risk perception of STIs including HIV, lack of knowledge about where to seek services, and limited comprehensive knowledge of HIV (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Additionally, STI knowledge, perceived susceptibility, subjective norms about utilization of VCT services, attitudes toward VCT services, self-efficacy in ability to seek and use VCT services, and stigma toward VCT services utilization are potential predictors of VCT service utilization (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePromotion of voluntary counseling and testing (VCT) services as a secondary preventive strategy for STIs, including HIV, is both useful and feasible. VCT is a behavioral intervention, not merely a simple diagnostic process (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The VCT process guides individuals seeking confidential counseling toward informed decision-making regarding their STI/HIV status and helps them take appropriate action (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Beneficial effects of VCT service utilization have been well documented, including increased safe sex practices, reduction in the number of sexual partners, increased abstinence choices (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), enhanced awareness of STIs and HIV, decreased stigma related to HIV, and improved access to care as a first step in the treatment pathway (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUNAIDS reports that the world observed a decline in new HIV cases among adolescents and young adults (AYA) aged 15 to 24 years in 2022, attributing this reduction to targeted HIV prevention programs for this population (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Recognizing the importance of contributing to this global goal, \u003cem\u003eUniversidade Cat\u0026oacute;lica de Mo\u0026ccedil;ambique\u003c/em\u003e (UCM) and its partners acknowledged that young people face significant challenges, including low self-esteem, lack of control over their sexuality, unintended pregnancies, acquisition of STIs including HIV, and sexual abuse (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). To address the impact of these challenges on STI and HIV preventive behaviors among students, UCM implemented a behavior change intervention grounded in a rights-based approach to sexuality education.\u003c/p\u003e \u003cp\u003eThe program consisted of life skills curricular lessons for first-year students, awareness activities addressing sexuality and STI/HIV prevention, and provision of VCT services across all faculties. The program had not been systematically evaluated since its introduction in 2012. Additionally, there is limited empirical evidence about programs aiming to improve VCT service use in Mozambique. This study set out to investigate the effect of the program on personal determinants of VCT service use (risk perception, attitude, self-efficacy, and subjective norms) and regular use of VCT services among first-year university students at UCM, using a quasi-experimental non-equivalent comparison group design.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis\u003c/strong\u003e \u003cp\u003ea) The program increased perceived risk for STIs, including HIV, attitude toward use of VCT services, self-efficacy to seek and use VCT services, and subjective norms in favor of VCT services use among university students in Beira, central Mozambique.\u003c/p\u003e \u003cp\u003eb) The program increased the use of voluntary counseling and testing services among university students in Beira, central Mozambique.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and setting\u003c/h2\u003e \u003cp\u003eThe trial design has been described in detail elsewhere (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In summary, this study applied a hybrid type 1 approach to assess the effectiveness of a voluntary counseling and testing (VCT) services use intervention among university students while concurrently collecting data on the implementation process. This report focuses on the effect evaluation findings. In the effect evaluation study, we utilized a quasi-experimental non-equivalent comparison group design. We describe the methods in accordance with the TREND Statement (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and CONSORT criteria (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study took place at the \u003cem\u003eUniversidade Cat\u0026oacute;lica de Mocambique\u003c/em\u003e (UCM\u003cem\u003e)\u003c/em\u003e and at the \u003cem\u003eUniversidade Licungo\u003c/em\u003e (UniLicungo). Both universities are located in Beira city, Sofala province, in the central region of Mozambique. UCM is a private, nonprofit institution, with faculties in the southern, central and northern regions of Mozambique. In Beira, there are two faculties and one e-learning Institute. The Faculty of Health Sciences and the Faculty of Economy and Management were involved in the study. UniLicungo is a public institution with faculties in two provinces (Sofala and Zamb\u0026eacute;zia) at the central region of Mozambique. In Beira city, the university comprises two faculties and two schools, all of which were involved in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe cohort comprised 819 first year undergraduate students enrolled at the UCM, and at the UniLicungo. We employed a clustered and random sampling strategy to select and consecutively enroll participants, from 22 classes (clusters). We enrolled 481 participants from seven classes at the intervention site (UCM) and 338 participants from 15 classes at the non-equivalent comparison group site (UniLicungo). Detailed information on the sample size calculation and sampling procedure is available in previous publications (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Note that the unit of randomization in our study were classes, not participants.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eStudents were eligible if they met the following criteria: a) first year undergraduate students studying at one of the two universities in faculties located in Beira city; b) being aged 16\u0026ndash;25 years old; and c) resident in Beira city for the entire academic year.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe obtained informed consent collectively at the enrolment visit, before distributing questionnaires to the class, though each candidate freely decided and sign the consent form individually. First year students who agreed to participate completed a self-administered structured questionnaire with closed-ended questions (available at https://www.frontiersin.org/journals/reproductive-health/articles/\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/frph.2021.745309/full#supplementary-material\u003c/span\u003e\u003cspan address=\"10.3389/frph.2021.745309/full#supplementary-material\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e data sheet 3) at enrollment and at follow-up visits, three and six months later. We used codes (numbers) to identify each participant\u0026rsquo;s questionnaire and link the information from each visit. Data were collected between May 2021 to June 2022. More details on data collection, as well as a description of the questionnaire development, are published elsewhere (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eProgram\u003c/h3\u003e\n\u003cp\u003eWe describe the program summarily, following the guidelines of Hoffmann, Glasziou (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), Kok, Gottlieb (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The intervention, detailed elsewhere (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), was titled \u0026ldquo;Take the opportunity to listen and to be listened to.\u0026rdquo; Acknowledging that STIs, including HIV, are prevalent among AYA in Mozambique (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), to effectively intervene, there is a need to change personal determinants of use of VCT services, for instance: knowledge, risk perception, attitude, self-efficacy and subjective norms (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHence, an ongoing intervention, based on the right-based approach to sexuality education (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), was designed and implemented at UCM, assuming that young people are challenged with several threats, for instance: low self-esteem, lower control over their own sexuality, acquiring STIs, including HIV, peer pressure and considerable degree of freedom. Therefore, the program set out to increase regular seeking and use of VCT services among university students, through improving personal determinants such as knowledge, risk perception, attitude, self-efficacy and subjective norms.\u003c/p\u003e \u003cp\u003eThe program consisted of three components: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) curriculum lessons regarding STIs, including HIV, within the life skills subject for all first-year students at UCM; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) sensitizing activities to increase the use of STI/HIV counseling and testing (VCT) services among students; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) provision of VCT services at all faculties in both sites. The behavior change methods, practical applications and the material used are available in the supplementary materials of Zango, Crutzen (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), https://www.frontiersin.org/journals/reproductive-health/articles/\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/frph.2021.745309/full#supplementary-material\u003c/span\u003e\u003cspan address=\"10.3389/frph.2021.745309/full#supplementary-material\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e data sheet 2. The implementation team consisted of two health advisor, six life skills\u0026rsquo; teachers and 32 volunteer students.\u003c/p\u003e \u003cp\u003eTeachers\u0026rsquo; Program Activities\u003c/p\u003e \u003cp\u003eLife skills classes followed a student-centered learning approach. A teachers\u0026rsquo; handbook and an equivalent students\u0026rsquo; handbook were the basic didactic materials. The subject consisted of 64 hours, of which 34 were devoted to lectures and 30 to practical sessions. Approximately 50% of the content focused on sexual and reproductive health (SRH), with 16 hours specifically addressing STIs, including HIV. Nevertheless, for research purpose, the selected aspects to be changed were addressed in 16 hours of about two hours each, delivered twice a week in the first semester of the academic year.\u003c/p\u003e \u003cp\u003eVolunteer Students\u0026rsquo; Program Activities\u003c/p\u003e \u003cp\u003eDuring the program, volunteer students provided four awareness sessions following the structure and sequence of the life skills module. Each session, focused on a specific issue, for instance, progression of HIV infection, symptoms of STIs, steps for seeking help, complications of untreated STIs, and adequate treatment of STIs including HIV.\u003c/p\u003e \u003cp\u003eHealth Advisors\u0026rsquo; Program Activities.\u003c/p\u003e \u003cp\u003eHealth advisors offered counseling and testing services for STIs, including HIV, in a private room at each UCM faculty. Same services were ensured at the control site. These services were delivered in accordance with the national guideline (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), which distinguishes and recommends three main sequential steps of counseling: a) Pre-testing counseling, b) Counseling during the test/examination and c) Post-test counseling.\u003c/p\u003e \u003cp\u003eDuring counseling session, clients discussed STIs including HIV acquisition and prevention with the health advisor (for more details see Supplementary File) in Zango, Crutzen (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). HIV testing was performed using Alere DetermineTM HIV1/2, an in vitro, visually read, qualitative immunoassay for the detecting antibodies to HIV-1 and HIV-2 in human whole blood. If antibodies were detected, the result was confirmed using Trinity Biotech UniGoldTM HIV test, considered the most specific test device. This test is also an in vitro, visually read, qualitative immunoassay for antibodies detection.\u003c/p\u003e \u003cp\u003eAdditionally, rapid plasma reagin (RPR) tests (Abbott biokit) was performed, to screen for Syphilis infection. Clients were also asked questions to screen for general STIs symptoms. STI diagnoses were made in accordance with the national guideline. In case of positive test result or identification of symptoms, clients were referred to the health center for treatment and follow-up if needed.\u003c/p\u003e \u003cp\u003eNote that the COVID-19 pandemic significantly impacted our study implementation. Face-to-face activities at schools, including VCT services, were intermittently suspended during outbreak waves. This disruption affected the regular delivery of program activities by health advisors, volunteer students, and teachers.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe effect evaluation reported here aimed to measure the following outcomes:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eChanges in individual-level determinants of VCT services use;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUse of VCT services;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis paper focus on reporting changes in individual-level determinants of VCT services use, and the reported use of VCT services. We measured changes in personal determinants, known to influence VCT services use, namely risk perception, attitude, self-efficacy and subjective norms and reported VCT service use as detailed in our previous publication (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) at https://www.frontiersin.org/journals/reproductive-health/articles/\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/frph.2021.745309/full#supplementary-material\u003c/span\u003e\u003cspan address=\"10.3389/frph.2021.745309/full#supplementary-material\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e data sheet 3.\u003c/p\u003e \u003cp\u003eItems in the questionnaires were developed based on the change objectives by the research team for the purposes of evaluation, details in our previous publication (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) at https://www.frontiersin.org/journals/reproductive-health/articles/\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/frph.2021.745309/full#supplementary-material\u003c/span\u003e\u003cspan address=\"10.3389/frph.2021.745309/full#supplementary-material\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e data sheet 1. Briefly, we used four questions to measure perceived risk for STIs by not using VCT services: first, we asked participants to select, from a list of five items, the consequences of not using VCT services; second, we asked them to indicate their score of agreement that using VCT services reduces transmission of STI including HIV on a five-point scale (1 strongly disagree\u0026hellip; 5 strongly agree); third, we asked them to indicate the extent to which they are aware about the risk for STI/HIV infection, using a five-point scale (1 strongly unaware\u0026hellip; 5 strongly aware); finally, we asked participants to rate their score of agreement, that they should get help from a health advisor soon for STI/HIV concerns (1 strongly disagree\u0026hellip; 5 strongly agree).\u003c/p\u003e \u003cp\u003eWe measured attitude toward VCT service use (e.g. Using STI/HIV screening services is pleasant\u0026hellip;), self-efficacy to seek and use VCT services (e.g. I am confident to tell my concerns about STI/HIV to the health provider\u0026hellip;) and subjective norms on VCT services use (e.g. Other students like me usually go to the health provider for STI/HIV complaints\u0026hellip;) using respectively eight, nine and four items with a seven-point Likert scale as described above.\u003c/p\u003e \u003cp\u003eUse of VCT service was determined by the proportion of students who reported regular use of screening services. Hence wee asked participants if they had ever used VCT services (answer options: \u0026ldquo;yes\u0026rdquo;, \u0026ldquo;no\u0026rdquo; and \u0026ldquo;do not remember\u0026rdquo;). We also asked them to indicate when the last time was they visited a VCT service (\u0026ldquo;1\u0026ndash;4 weeks ago\u0026rdquo;; \u0026ldquo;1\u0026ndash;3 months ago\u0026rdquo;; \u0026ldquo;4\u0026ndash;6 months ago\u0026rdquo;; \u0026ldquo;A year ago\u0026rdquo; and \u0026ldquo;do not remember\u0026rdquo;). We then converted answers into a binary variable, whereby all participants who selected \u0026ldquo;yes\u0026rdquo; to the first question were labelled as having previously used VCT services and who answered \u0026ldquo;no\u0026rdquo; or \u0026ldquo;do not remember\u0026rdquo; were considered to have not used VCT services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFor baseline data, we used descriptive statistics to summarize participants' characteristics. We assessed differences between groups at baseline using Pearson's chi-square test for categorical data and independent t-tests for numerical data, considering p\u0026thinsp;\u0026lt;\u0026thinsp;.05 as statistically significant. We compared enrolment characteristics between groups to identify important differences in prognostic variables that needed to be accounted for in the effect analysis model and results interpretation. Following recommendations from de Boer and colleagues, we report results from both crude and adjusted analysis (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor the follow up measures, at three and six months, we compared data from the intervention and non-equivalent comparison group over time using analysis of variance (ANOVA) for repeated measures of personal determinants. These analyses deviate from the protocol for two reasons. First, with only one university per condition, we could not include university as a separate level while using condition as a predictor in the model (as the variable condition would be similar to university). Second, we defined change from baseline as posttest minus pretest, as participants from each group were random samples from their respective populations (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the repeated-measures ANOVA, we assessed both within-subjects and between-subject\u0026rsquo;s effects. We first evaluated within-subject effects, as this is a prerequisite for reporting between-subject results. For outcomes showing significant within-subjects effect (p\u0026thinsp;\u0026lt;\u0026thinsp;.05), we reported both crude and adjusted between-subject\u0026rsquo;s results. Cases with missing data were excluded from the repeated-measures ANOVA due to the requirements of the analysis.\u003c/p\u003e \u003cp\u003eWe used logistic regression analysis to determine the intervention's effect on VCT service use. First, we analyzed the effects of setting, time, and their interaction. We then ran an adjusted model that included age, sexual debut, and sexuality discussions with mother as covariates. Effect sizes were estimated using adjusted odds ratios (aOR) with 95% confidence intervals and the Nagelkerke R\u0026sup2; coefficient.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAt the intervention university, 387 participants (80.46%) completed the follow-up questionnaires, and 315 (65.86%) completed the final assessment. At the control university, 272 participants (80.47%) completed the three-moth follow-up survey, and 285 (84.32%) completed the six-month follow-up. For the ANOVA analysis of quantitative outcomes, we included 532 participants (64.96% of the initial cohort): 285 from the intervention university and 247 from the control university. Due to missing data, 285 participants were excluded from this analysis.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents baseline characteristics and comparisons between the two groups. Of the 481 participants enrolled from randomly selected classes at the intervention university, 327 (67.98%) were women, compared to 146 (43.20%) women at the comparison university. The difference in sex distribution was statistically significant (χ\u0026sup2; = 49.99, p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\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\u003eParticipants characteristics in intervention and control universities at enrollment\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=\"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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e or t-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154(32.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e192(56.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e49.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e327(68.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e146(43.20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.22(1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.17(2.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.69\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss sexuality with father\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(7.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003eNever/rarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e360(92.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e189(93.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.511\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss sexuality with mother\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144(32.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77(25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003eNever/rarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e306(68.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e222(74.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHave boy/girlfriend\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e394(82.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e299(88.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84(17.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(11.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.018\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of sexually partners\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.70(2.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.92 (2.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.09\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual debut\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e267(68.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e253(85.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123(31.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42(14.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at sexual debut\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.81(2.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.63(2.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.78\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003csup\u003e*\u003c/sup\u003e\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# t test\u0026rsquo;s values instead of x\u003csup\u003e2\u003c/sup\u003e, because the variables are continuous. Hence, also mean and SD have been reported as descriptive information instead of frequencies.\u003c/p\u003e \u003cp\u003eParticipants from the two groups differed in other characteristics. The mean age was 18.22 (SD\u0026thinsp;=\u0026thinsp;1.33) at the intervention university compared to 20.17 (SD\u0026thinsp;=\u0026thinsp;2.00) at the control university (t\u0026thinsp;=\u0026thinsp;16.69, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The prevalence of having a sexual partner was higher in the control group (299, 88.50%) than in the intervention university (384, 82.40%; χ\u0026sup2; = 5.63, p\u0026thinsp;=\u0026thinsp;.018). Similarly, the prevalence of sexual debut was higher in the control group (253, 85.80%) than in the intervention university (267, 68.50%; χ\u0026sup2; = 27.48, p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEffects of the Intervention on Personal Determinants of VCT Service Use\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the means, standard deviations, and within- and between-subjects effects, from the repeated measures ANOVA assessing the program\u0026rsquo;s effects on risk perception, attitudes, self-efficacy and subjective norms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRisk perception\u003c/h2\u003e \u003cp\u003eMauchly's test indicated that the assumption of sphericity was met (χ\u0026sup2; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;.869, p\u0026thinsp;=\u0026thinsp;.648). The program showed a significant within-subjects effect on risk perception scores (F(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;25.61, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, η\u0026sup2; = .05) in the intervention group. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the changes in mean scores per group over time. Post-hoc pairwise comparisons without adjustment revealed significant differences between enrollment and three-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.121, .304]), three-month and six-month follow-up (p\u0026thinsp;=\u0026thinsp;.012, 95% CI [.025, .203]), and enrollment and six-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.234, .419]). After Bonferroni adjustment, pairwise comparisons still showed significant differences between enrolment and three-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.101, .324]), three-month follow-up and six-month follow-up (p\u0026thinsp;=\u0026thinsp;.037, 95% CI [.005, .223]), and enrolment and six-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.213, .439]).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAttitude\u003c/h2\u003e \u003cp\u003eMauchly's test indicated that the assumption of sphericity was met (χ\u0026sup2; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;2.767, p\u0026thinsp;=\u0026thinsp;.251). The intervention showed no significant within-subjects effect on attitude scores toward VCT service use (F(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;0.114, p\u0026thinsp;=\u0026thinsp;.893). Given this non-significant effect, post-hoc pairwise comparisons were not reported.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSelf-efficacy\u003c/h2\u003e \u003cp\u003eMauchly's test indicated that the assumption of sphericity was met (χ\u0026sup2; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;3.885, p\u0026thinsp;=\u0026thinsp;.143). The program showed a significant within-subjects effect on self-efficacy scores for VCT service use (F(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;8.729, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, η\u0026sup2; = .016). Post-hoc pairwise comparisons without adjustment revealed significant differences between enrollment and three-month follow-up (p\u0026thinsp;=\u0026thinsp;.022, 95% CI [.015, .193]), and between enrollment and six-month follow up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.096, .266]). However, no significant difference was found between the three-month and six-month follow-up (p\u0026thinsp;=\u0026thinsp;.068, 95% CI [-.006, .160]). After Bonferroni adjustment, significant mean difference remained between enrollment and six-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.078, .285]).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubjective Norms\u003c/h2\u003e \u003cp\u003eMauchly's test indicated that sphericity was not met, but the Greenhouse-Geisser epsilon was greater than .75 (ε\u0026thinsp;=\u0026thinsp;.961). Therefore, we applied the Huynh-Feldt correction (ε(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;.961). The program showed a significant within-subjects effect on subjective norms (F(1.933)\u0026thinsp;=\u0026thinsp;6.811, p\u0026thinsp;=\u0026thinsp;.001, η\u0026sup2; = .013). Post-hoc pairwise comparisons without adjustment showed significant differences between enrolment and three-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI .099, .343]), and between three months and six-month follow up (p\u0026thinsp;=\u0026thinsp;.026, 95% CI [-.225, \u0026minus;\u0026thinsp;.014]). No significant difference was found between enrolment and six-month follow up (p\u0026thinsp;=\u0026thinsp;.112). After Bonferroni adjustment, significant differences remained between enrolment and three-month follow up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.072, .370].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEffect of the program on VCT Service Utilization at University\u003c/h2\u003e \u003cp\u003eLogistic regression analysis to measure the intervention's effect over time on VCT service use likelihood at the intervention university (UCM) showed that the model was statistically significant compared to the null model (χ\u0026sup2; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;66.372, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The model explained 4.5% of the variation in VCT service use (Nagelkerke R\u0026sup2; = .045) and predicted correctly 61.7% of cases. Setting was significant (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), with the odds ratio (OR\u0026thinsp;=\u0026thinsp;0.443, 95% CI [0.325, 0.603]) indicating that participants in the intervention setting were 55.7% less likely to use VCT services compared to those in the control setting. Neither changes over time (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) nor the interaction between time and setting (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) were significant.\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\u003eEffect of the intervention on personal determinants, Beira city central Mozambique, 2021\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEffect\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWithin subjects\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetween subjects\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF (p-value)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF (p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk perception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\u003eenrolment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.76 (1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.57(.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e25.61 (\u0026lt;\u0026thinsp;.001)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e7.45 (.007)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.94(1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.82(1.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.14(1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.84(1.03)\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\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eenrolment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.33(.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.22(.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.11 (.893)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3.65 (.057)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.33(.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.19(1.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.30(.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.22(.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-efficacy\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eenrolment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.71(1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.81 (1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e8.73 (\u0026lt;\u0026thinsp;.001)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.43 (.513)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.85(1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.89(1.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.94(.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.95(1.02)\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\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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eenrolment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.66(1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.86(1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e6.81 (.001)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e5.19 (.020)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.86(1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.10(1.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.78(1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.94(1.39)\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\u003eIn the analysis of the effects of age, sexuality discussions with mother, and sexual debut, the model was significant (χ\u0026sup2; (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;102.872, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and explained 8.8% of the variation in VCT service use (Nagelkerke R\u0026sup2; = .088). The model predicting correctly 64.7% of cases. Four variables showed significant effects: setting (p\u0026thinsp;=\u0026thinsp;.007), age (p\u0026thinsp;=\u0026thinsp;.005), sexual debut (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and sexuality discussions with mother (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\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\u003eEffect of the program on use of VCT services, considering time and setting and interaction between the two variables\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\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoefficient (B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eS-E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (Exp (B))\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.442\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.325 \u0026minus;\u0026thinsp;.603\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnrolment\u003c/p\u003e \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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.825\u0026ndash;1.642\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.388\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.322\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.937\u0026ndash;1.866\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einteraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSetting*time\u003c/p\u003e \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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.713\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNagelkerke R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.045\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \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\u003eEffect of the program on use of VCT services, considering other variables\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\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoefficient (B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eS-E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (Exp (B))\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.399 \u0026minus;\u0026thinsp;.861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnrolment\u003c/p\u003e \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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e..203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.776\u0026ndash;1.716\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.480\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.913\u0026ndash;2.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInteraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSetting * time\u003c/p\u003e \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=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.030\u0026ndash;1.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.005*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss sex with mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.282\u0026ndash;2.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex debut\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.911\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.470\u0026ndash;2.485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNagelkerke R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.088\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined changes in individual-level determinants of, and utilization of voluntary counseling and testing (VCT) services among university students in Beira city, Mozambique, following implementation of a sexually transmitted infection prevention program. While the program did not appear to increase VCT service utilization, positive improvements were observed in perceived risk of acquiring sexually transmitted infections, including HIV, and in self-efficacy for seeking and using VCT services.\u003c/p\u003e \u003cp\u003ePerceived risk of acquiring STIs, including HIV, increased from enrolment to three-month follow-up and was maintained at six-month follow-up at the intervention university. However, increased risk perception was also observed among participants at the control university. This could potentially be attributed to students' possible exposure to similar national or local prevention program implemented during the study period (i.e. confounding), or to heightened awareness resulting from completion of the baseline risk assessment questionnaire (i.e. the Hawthorne effect). Nonetheless, the positive effect of program on STI and HIV risk perception observed in this study aligns with findings from previous intervention studies focusing on VCT service utilization among adolescents and young adults, including university students (\u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSelf-efficacy increased throughout the study period at the intervention university, which could facilitate decision-making regarding preventive behaviors, including utilization of VCT services (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), as well as consistent engagement in preventive behaviors (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Similar to risk perception, self-efficacy for seeking and using VCT services also increased at the control university throughout the study period. This may be explained by the age demographics of this population, as participants at the control university were relatively older than those at the intervention university. Age and other demographic characteristics have been identified as predictors of confidence in one's ability to engage in STI and HIV preventive behaviors (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Consequently, the intervention did not demonstrate a difference between conditions on VCT-seeking self-efficacy, which is consistent with findings by Yao, Fu (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe program did not increase students' actual reported use of VCT services during the study period. This may be attributed to the exceptional contextual conditions under which the program was implemented, characterized by COVID-19-related restrictions that limited face-to-face delivery of various social services, including VCT services, and educational activities at all levels during program implementation and evaluation.\u003c/p\u003e \u003cp\u003eThe contextual circumstances of implementation compromised several key components of program fidelity. For instance, participants were advised to seek VCT services at alternative venues since the intervention university's facilities were not providing these services during the suspension of face-to-face activities. Life skills lectures originally planned for classroom delivery were conducted via Zoom or other online platforms, while some awareness sessions were shortened to accommodate educational priorities. Similar compromises in implementation fidelity and their association with reduced effectiveness in STI and HIV prevention behaviors have been documented by Rosenberg, Gichane (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), who evaluated a one-year small-group behavioral intervention among adolescents and young women, albeit focusing on different HIV-related behaviors. Similar challenges in increasing VCT service utilization at universities have been reported by Gobind and Ukpere (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), who evaluated the effectiveness of workplace-based VCT program within South African universities. Their findings demonstrated that awareness of VCT availability does not necessarily translate to increased testing uptake among academic community members, with only 40.9% of participants reporting having been tested at the university during the study period. In the present study, VCT service uptake at the intervention university increased from 46.90% at enrollment to 54.8% at three-month follow-up and to 57.80% at six-month follow-up. However, this apparent increase did not significantly differ from utilization patterns at the comparison university.\u003c/p\u003e \u003cp\u003eBeyond the contextual constraints, other factors may have contributed to the limited effect on VCT service utilization. Focus group discussions conducted during the process evaluation (results to be reported elsewhere in more detail, Zango et al.,) revealed that students did not understand from the life skills lessons that they should establish a personal schedule for regular VCT service use. Participants also acknowledged that curriculum-based content for preventive behavior change was insufficient, as students primarily focused on passing the course rather than applying the content in practice. Similar findings have been reported in previous evaluation studies (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), where authors reported limited effectiveness of their interventions in increasing VCT service utilization. They argued that content acquired through curriculum-based educational programs is often perceived as serving academic requirements rather than being integrated into actual behavior change.\u003c/p\u003e \u003cp\u003eAdditionally, these findings may be explained by the influence of other factors, such as age and sexual debut. Participants at the control university were older and predominantly sexually active, which may have contributed to the relatively higher likelihood of VCT service use in this group. The influence of age and sexual debut on VCT service utilization has been documented in previous studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR46 CR47\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe findings indicate that a standalone program for VCT service use might not be sufficient. There is a possible need to complement the program and provision of VCT services with additional activities. Several approaches are recommended to complement programs\u0026acute; activities in a university setting or other community in order to improve AYA use of sexual and reproductive health services in general, including VCT services: community-based VCT services (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), mobile VCT service delivery, community testing combined with facilitated linkage to care (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), multicomponent interventions, counseling based on cognitive behavioral therapy, and communication campaign interventions (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e), A review by Zanoni, Elliott (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) concluded that stand-alone interventions are less likely to address all barriers to VCT service use among AYA across all settings. Therefore, they recommend implementing multiple components and expanding mobile health technology, alternate venue testing, including self-testing combined with well-designed linkage to care strategies.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe findings of this study should be interpreted in light of a few limitations in study design and implementation. First, we applied a quasi-experimental study design, which may be subject to several threats described in the literature as potential sources of bias (\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). The relevant threats to our study included selection bias (due to non-random assignment of participants), history effects (external events occurring during the study period), attrition bias (differential dropout between intervention and control groups), testing bias (related to the effect of pretesting on posttest scores), instrumentation bias (due to changes in measuring methods at follow-up assessments), intervention fidelity issues (which might arise from changes in intervention components delivery), and spontaneous remissions (changes in intervention outcomes that might have occurred spontaneously). To minimize the effects of these threats, we used recommended mitigation strategies (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe minimized the effect of selection bias by using a comparison group identified based on major characteristics (university first-year students living in Beira city). The effects of history, maturation, testing, and spontaneous remission biases were addressed using a pre-posttest comparison group approach. Attrition was minimized by monitoring dropouts and maintaining low intervention and data collection burden. Instrumentation and intervention fidelity issues were minimized through training and monitoring of all data collectors and the data collection process, as well as all implementers and the implementation process, respectively.\u003c/p\u003e \u003cp\u003eWe recognize that traditionally, randomized controlled trials have been recommended as the gold standard for causal inferences in the health sciences field, especially when considering inclusion criteria requirements for systematic review and meta-analysis studies (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Nevertheless, a quasi-experimental non-equivalent comparison group design was chosen because this design combines some advantages of full experimental designs with those of non-experimental studies, offering distinct advantages compared to randomized controlled trials. Particularly, this design limits some threats to external validity (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe also decided to apply a quasi-experimental non-equivalent comparison group design because the intervention was already in full implementation, meaning that it would have been unjustifiable and unfeasible to apply a full experimental study design with random allocation of participants. This would have implied excluding some classes or students from the intervention at UCM, while they shared the same environment and policies. Hence, using a similar educational setting as a non-equivalent comparison group was a rational and acceptable approach to evaluate the program's effect with limited biases (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study findings showed that the intervention did not increase VCT service utilization among first-year university students. However, a positive effect was observed only in perceived risk of acquiring sexually transmitted infections, including HIV, associated with non-use of VCT services and in self-efficacy in ability to use VCT. Future research is recommended to evaluate the effectiveness of alternative strategies to change determinants of VCT service utilization among first-year university students and improve VCT service utilization among this population. Additionally, alternative determinant should be considered as potential in influencing use of VCT services, hence, future researchers are needed to identify more determinants and evaluate alternative strategy to change.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAYA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdolescents and young adults\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnalysis of variance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eaOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eadjusted Odds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDNAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDirecc\u0026atilde;o Nacional de Assist\u0026ecirc;ncia M\u0026eacute;dica\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman immunodeficiency virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eINS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstituto Nacional de Sa\u0026uacute;de\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMISAU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinist\u0026eacute;rio de Sa\u0026uacute;de\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual and reproductive health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTIs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexually transmitted infections\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUCM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversidade Cat\u0026oacute;lica de Mo\u0026ccedil;ambique\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversity of Maastricht\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNAIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJoint United Nations Program on HIV/AIDS\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUniLicungo\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversidade Licungo\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVoluntary counseling and testing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol obtained ethical approval from the local ethical assessment committee of Sofala (\u003cem\u003eComité Interinstitucional para Bioética de Sofala\u003c/em\u003e—CIBS), in accordance with the Declaration of Helsinki and local administrative authorization. All study participants were enrolled to the study after signing the informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available because the ethical approval letter does not include public availability of the dataset but, are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo competing interest were disclosed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe firs author is supported by the Nuffic, NICHE program grant number: 30606015N, led by the Maastricht University as scholarship for her PhD program. Obtaining this scholarship did not include peer-review of the study protocol.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAZ and RC developed the research protocol, conducted the study and performed the data analysis and interpretation of the results. AZ, RC and SS were the major contributors in writing the manuscript. RC reviewed the first draft. All authors contributed and reviewed the final manuscript of the paper and have agreed to the final text.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge Professor NdV (in memory), he contributed to the study design and protocol development. Professor dra. Khátia Rebeca Munguambe, she has provided her advice on the protocol development; Professor Dr. Leonardo Chavane, he has supported the protocol conception and provided national guidelines for STI/HIV counseling testing and treatment services of Mozambique. We would also like to acknowledge, the deans of the faculties at \u003cem\u003eUniversidade Católica de Moçambique\u003c/em\u003e and \u003cem\u003eUniversidade Licungo\u003c/em\u003e, they have supported the implementation of the study at their institution and the students by their availability to participate in the study and respond to the study requirements.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eElendu C, Amaechi DC, Elendu ID, Elendu TC, Amaechi EC, Usoro EU, et al. Global perspectives on the burden of sexually transmitted diseases: A narrative review. 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J Clin Epidemiol. 2017;89:21\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarquinio C, Kivits J, Minary L, Coste J, Alla F. Evaluating complex interventions: perspectives and issues for health behaviour change interventions. Psychol Health. 2015;30(1):35\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Students, STIs, HIV, Behavior, Program, Beira","lastPublishedDoi":"10.21203/rs.3.rs-8307772/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8307772/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLow utilization of Voluntary Counseling and Testing (VCT) services increases the burden of sexually transmitted infections (STIs) and HIV, rates of late diagnosis, and delayed initiation of treatment and care. Low VCT utilization is particularly high among adolescents and young adults (AYA), including university students. This behavior is predicted by personal determinants, including low risk perception of STIs, attitude toward VCT, self-efficacy in using VCT services, and subjective norms. To positively influence these determinants among university students, a behavior change program was conducted at \u003cem\u003eUniversidade Cat\u0026oacute;lica de Mo\u0026ccedil;ambique\u003c/em\u003e (UCM). This study aimed to gain insight into the effect of the program on (determinants of) VCT service utilization among first-year students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe used a quasi-experimental non-equivalent comparison group design. The study took place at UCM and \u003cem\u003eUniversidade Licungo\u003c/em\u003e (UniLicungo) intervention and control setting respectively. We included 481 and 338 participants from UCM and UniLicungo respectively. We collected data on VCT service utilization, risk perception, attitude, self-efficacy, and subjective norms at enrolment, three-month, and six-month follow-up using a self-administered structured questionnaire with closed-ended questions. We analysed data using analysis of variance (ANOVA) and logistic regression analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis showed increases in perceived risk of acquiring STIs, including HIV (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.213, .439]) and in self-efficacy to seek and use VCT services (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.078, .285]) from enrolment to six-month follow-up. A positive effect on subjective norms was found from enrollment to three-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [.072, .370]). No significant effect was observed on attitude toward VCT. VCT utilization at the intervention university increased from 46.90% at enrolment to 54.8% at three-month follow-up and to 57.80% at six-month follow-up. This apparent increase did not significantly differ from VCT utilization patterns at the control university.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur study results suggest that the program may have positively influenced students' perceived risk of acquiring STIs, including HIV, and their confidence in seeking and using VCT services. These effects did not translate into increased VCT services utilization. Future research is recommended to identify other determinants and evaluate alternative strategies to improve VCT utilization among university students.\u003c/p\u003e","manuscriptTitle":"Effect of a sexually transmitted infection prevention program on voluntary counseling and testing services utilization among university students: a quasi-experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 09:05:16","doi":"10.21203/rs.3.rs-8307772/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-27T22:06:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185372614540680541219652890935385414979","date":"2026-01-18T11:57:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T15:41:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-19T09:10:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-19T05:43:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-18T12:01:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-12-18T11:51:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f27ac605-b5a2-43be-abda-ca96b361e34f","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T09:05:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 09:05:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8307772","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8307772","identity":"rs-8307772","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}