We conducted an analytical cross-sectional study to evaluate AGYW knowledge about, and experiences with, accessing SRH, and STIs, including HIV services in Mozambique. This analysis represents baseline (phase one) data collection of a larger multi-phase implementation science study that utilized a mixed-method approach, aiming to assess the feasibility and effectiveness of an “adolescent-friendly approach” for improving access to and use of SRH, and STIs, including HIV services by AGYW at selected health facilities. At baseline, we conducted an exit survey with AGYW who had sought SRH services, STI, and including HIV services, within AYFHS at two primary health care level facilities: Zimpeto and June 1st health facilities (Centro de Saúde 1 de Junho) in Maputo City, Mozambique. AGYW primarily sought SRH services related to family planning, maternal health, STI care, HIV testing and counseling, antiretroviral therapy, and health education. These centers were selected due to their historically poor performance in providing AGYW with access to and utilization of SRH and HIV services.

All AGYW, aged 15–24 years, who had accessed SRH and HIV services at either of the two study centers between May 1 and June 9, 2023, were considered eligible to participate in the exit survey. AGYW were selected by convenience and approached for enrollment as they were exiting the health center (provided they had contact with the SRH or HIV services on the day of the interview). Initially, a sample size of 520 AGYW was defined, but during the data collection process, 598 were consented and enrolled. The sample size was calculated using the following formula: n=p(1−p)Z2ε2; n: sample size; p: expected proportion; z: value of the normal distribution for a given confidence level, and ε = size of the confidence interval. Where p = 0.38 (10); z = 1.645; ε=0.05. A 95% confidence interval was used for a 5% significance level. The value of n was doubled, taking into account that data collection would take place in two health centers.

Interviews took place on weekdays, during normal service hours (7:30 a.m. to 3:30 p.m.). The first AGYW to leave the health facility during this time interval was approached and, if accepted, she was interviewed. Only after the interview was finished would subsequent participants be approached for recruitment. This continued until the defined sample was reached. Trained interviewers conducted the interviews using a semi-structured interview guide in a private location. The interviews were conducted in Portuguese.

AGYW were questioned about their sociodemographic data; knowledge of the types of SRH and STIs, including HIV services offered at the facility; types of SRH and, STIs, including HIV services received on the day of the visit; the perceived quality of the SRH and HIV services offered on the day of the visit; and their level of satisfaction with the SRH and HIV services received on the day of the visit (Supplementary File S1). Questions designed to assess AGYW knowledge about the services offered and received, were based off a list of SRH and HIV services outlined in the Guidelines for the Implementation of adolescent and youth-friendly health services of the Mozambican Ministry of Health (16).Questions related to the perceived quality of the services offered were based on World Health Organization (WHO) standard quality assessment questions for AYFHS (20).

A survey tool was developed using REDCap (Research Electronic Data Capture) and uploaded onto a tablet computer. During the interview, interviewers input data directly into the tablet (REDCap v10.6.12, 2023). At the end of each day, data was synchronized and sent to a REDCap server housed at the Faculty of Medicine of University Eduardo Mondlane (UEM) in Maputo. The data were extracted from REDCap into excel format, and then imported into the Statistical Package for the Social Sciences (SPSS) Version 20. Data were cleaned and all lines with missing data for reference variables for analysis were excluded from the analysis. Sociodemographic variables with a variety of different categories were aggregated in order to simplify analysis. The aggregated variables include: Age—Transformed into two age ranges: “15–19 years”, and “20–24 years”; Who do you live with?; the responses “grandmother”, “grandfather” and “grandparents” were combined into a single category called “Grandparents”; the responses of father, mother, parents were aggregated into a single category called Parents; and Religion: All Christian responses of non-Catholic religious affiliation have been aggregated into the Protestant category. To assess the average knowledge of AGYW about the SRH services offered at the two health facilities, participants were asked to answer 10 questions. Questions were given a score of either 0 or 10; 0 if the response was wrong and 10 if it was correct. Therefore, the 10 questions had a minimum total score of 0 (if no question was answered correctly) and a maximum of 100 points (if all questions answered correctly). The same scale was converted into a percentage, and a scale of 0 to 100% was adopted. All the questions were given the same weight.

Descriptive statistics, including absolute and relative frequencies, were used to determine which SRH and HIV services were known to AGYW, which services were utilized (including modern contraceptive methods) and to evaluate AGYW's perceptions of the health facility environment for adolescent care. The One-Way Anova (Analysis of Variance) test was applied to test the equality of the means of knowledge of SRH, and STI, including HIV services in AGYW. The student's t-test was applied to compare the means of AGYW 's knowledge. Level of knowledge of SRH, and STIs, including HIV services, was checked for normality using the Shapiro Walk test. The result showed that it does not follow a normal distribution (p < 0.001). Although it does not follow a normal distribution, the variable shows low variability (mean = 81.29 ± 21.379) and a coefficient of variation (CV) equal to 26%. A 95% confidence interval was used for a 5% significance level, α = 0.05.

The study protocol was reviewed and approved by the Mozambican National Bioethics Committee for Health (Ref: 88/CNBS/23). Administrative approval was granted by the MoH of Mozambique (Note nr: 396/GMS/290/023). All participants provided written informed consent prior to participation in the exit interview. For participants below the age of 18 years, informed consent was first obtained from a parent/guardian and then informed assent from the participant. No identifying information was recorded by the interviewer to ensure anonymity.

A total of 598 AGYW were approached and surveyed. Eight participants were subsequently excluded from the analysis because of missing data. A total of 590 AGYW were included, of which 304 (51.5%) were recruited from the June 1st health facility and 286 (48.5%) from the Zimpeto health facility. Fifty-one percent of AGYW were aged 15–19 years and 49% were aged 20–24 years, with a mean age of 20 years ±2.42. Approximately 70% (n = 419) of respondents listed themselves as a current student, of which the majority (86.8%) had achieved at least some level of secondary education. Of the AGYW interviewed, 79.6% (n = 468) were single, while 20.4% (n = 122) reported being in a marital union. The majority of participants (65.5%) lived with their parents, while 19.3% (n = 114) lived with their husbands. Protestant was the leading religious affiliation (53.5%), followed by Catholic (34.5%), and Muslim (4.9%) (Table 1).

In general, AGYW knowledge of SRH and HIV services was fairly high, with knowledge of each specific service offered ranging between 38% and 97%. The best-known SRH and HIV services were pregnancy prevention counseling (97%); HIV and STI prevention counseling (97%); safe sex counseling (97%); sexuality counseling (96%); HIV and STI diagnostic testing (89%); antenatal care consultations (84%); and gender-based violence (GBV) services (82%). Pregnancy testing services (64%), and abortion services (72%) were moderately known, and the least known service was the postpartum care clinics (38%) (Figure 1).

Average knowledge about SRH and HIV services differed depending on where the AGYW sought healthcare, the participants age, their status of employment, their religion, and who they lived with. AGYW who attend the Zimpeto health facility had a higher average level of knowledge about the SRH and HIV services offered (86.6%; CI: 83.8–89.3), compared with those who attended the June 1st health facility (76.3%; CI: 74.3–78.3) (p < 0.001). AGYW aged 20–24 years had a higher average level of knowledge (83%; CI: 80.7–85.4) when compared to AGYW aged 15–19 years (79.6%; CI: 77.1–82.1) (p = 0.046). AGYW who are actively in school had a higher average level of knowledge about SRH and HIV services (82.4%; CI: 80.2–84.5), compared to adolescents who are out of school (78.7%; CI: 75.8–81.7) (p = 0.048). AGYW who reported a religious affiliation: Protestant (77.9%; CI: 75.5–80.3), Catholic (86.5%; CI: 83.8–89.3), and Muslim (88.9%; CI: 83.2–94.7), had a higher average level of knowledge as compared to those reporting no religious affiliation (75.8%; CI: 67.9–83.8) (p < 0.001). Of note, a significantly higher average level of knowledge was observed among Muslim and Catholic participants, compared to Protestants or non-religious counterparts. Lastly, AGYW who live with their parents had a higher average level of knowledge (84.20% CI: 82.2–86.2) about SRH and HIV services as compared to participants in other living arrangements (p < 0.001) (Table 2).

AGYW reported a variety of SRH and HIV services they sought on the day of their interview. Counseling services were the most commonly reported services, with >90% of participants reporting having received counseling for each of the following: STI and HIV prevention, pregnancy prevention, sexuality, and safer sex practices. Further, 51% of participants attended family planning services and 31% received testing for HIV and/or another STI. Smaller numbers of participants attended other services such as antenatal care or gender-based violence (GBV) counseling (<20% for each service) (Figure 2). Among those participants who attended family planning services on the day of their interview (n = 303), birth control options were received in the following proportions: 33% injectables (Depo-Provera); 30% oral contraceptive pills; 16% male condoms; 12% female condoms; and 10% implant. Participants could receive more than one type of contraceptive.

Overall, more than 90% of participants reported to have received counseling in private spaces and that upon arrival to the service, they were greeted and served according to their needs. At Zimpeto health facility, over 95% of participants reported that services were offered in a dedicated space catering to adolescents. In contrast, only roughly 13% of participants at the June 1st health facility reported a lack of an adolescent dedicated space. In addition, the vast majority of participants (87.8%) at the June 1st health facility reported a lack of separate waiting room for adolescents, compared to Zimpeto health facility, where <10% of participants reported a lack a separate waiting room. Overall, only 4% of AGYW correctly reported that the health facility had a dedicated schedule for when adolescent services were available. Of the other respondents, 54.2% responded that the facility did not have a dedicated schedule and 41.7% responded that they did not know. At both facilities, >25% of AGYW reported no comfortable sitting arrangements at the waiting area.

In terms of service quality, >90% of participants at both facilities ranked the attitude of the provider as “Good”. With regards to service quality, >90% of participants at Zimpeto ranked the services as “Good”, whereas at June 1st, only 79% ranked the services as “Good” and 18% ranked them only as “Acceptable”.

When asked about how satisfied the participant was with regards to whether their needs had been met that day, roughly 95% of AGYW at Zimpeto health facility responded that they were either “satisfied” or “very satisfied”. In contrast, at the June 1st health facility, only about 75% of AGYW reported that they were either “satisfied” or “very satisfied”, with another 20% responding that they were “little satisfied” (see Table 3).

This study has important implications for policy, research, and practice. From a policy perspective, the gap between knowledge of counselling services and awareness of diagnostics, treatment, and clinical care highlights the need for balanced dissemination of comprehensive SRH and STI (including HIV) services for AGYW to improve knowledge and service uptake. For research, findings indicate the need to examine SRH and STI (including HIV) knowledge among AGYW and adolescent boys and young men through community-based surveys with larger, geographically diverse samples. In practice, AYFHS health providers can use these findings to strengthen service dissemination at facility and community levels, enhancing knowledge and uptake of care among adolescents and young people.

Despite the contributions of this study, several limitations should be acknowledged. The sample may not represent all adolescents and young people in the region. Self-reported knowledge may introduce response bias, and the cross-sectional design limits causal inference. The fact that it involved only AGYW with previous contact with SRH and HIV services could be considered a possible bias, as contact with these services would presumably increase one's knowledge about them. However, targeting recruitment to AGYW immediately following their use of these services, was intended to reduce memory bias and to better capture the respondent's opinions as to their experiences in near real-time.

Future research should include larger, more diverse samples, including adolescent boy and young men, and consider longitudinal or mixed-method designs to explore causal links between knowledge and service uptake. Recognizing the financial burden that comes with such methodology, with the increase on the availability of cell phones, especially in urban areas, cell phone surveys can be a better option then health facility-based surveys. Objective measures of knowledge and service use are recommended to reduce bias. Policymakers and practitioners should ensure equitable and comprehensive dissemination of SRH and STI (including HIV) services for adolescents and young people.