Background
Interactive narrative–based digital health interventions hold promise for effectively addressing the complex determinants of vaccine hesitancy and promoting effective communication across a wide range of settings and vaccine types. Synthesizing evidence related to the implementation and evaluation of these interventions could offer valuable perspectives for shaping future strategies in vaccine communication. Prior systematic and scoping reviews have examined narrative-based vaccine communication interventions but not the inclusion of interactivity in such interventions.
Objective
The overall objective of the scoping review is to summarize the evidence on the use of interactive narrative–based digital health interventions for vaccine communication. Specific research questions focus on describing the use of interactive narrative–based digital health interventions (RQ1), describing evaluations of the impact of interactive narrative–based digital health interventions on promoting vaccine uptake (RQ2), and factors associated with their implementation (RQ3).
Methods
A detailed search string will be used to search the following databases for records that are relevant to the review questions: PubMed, Embase, Scopus, Web of Science, CINAHL, and PsycINFO. Two reviewers will independently screen the titles and abstracts of identified records against the predefined eligibility criteria. Subsequently, eligible records will undergo comprehensive full-text screening by 2 independent reviewers to assess their relevance to review questions. A data charting tool will be developed and used to extract relevant information from the included articles. The extracted information will be analyzed following the review questions and presented as a narrative summary. Tabular or graphical representations will be used to display review findings, as relevant.
Results
Public health informationists were consulted to develop the detailed search strategy. The final search string comprised terms related to narrative communication, digital health, and vaccines. The search string was customized to each proposed publication database and implemented on April 18, 2023. A total of 4474 unique records were identified using the search strategy and imported into the Covidence (Veritas Health Innovation Ltd) review management software for title and abstract screening. Title and abstract screening of identified records are ongoing as of December 29, 2023.
Conclusions
To our knowledge, this will be the first scoping review to investigate the features of interactive narrative–based digital health interventions and their role in vaccine communication. The goal of this study is to provide a comprehensive overview of the current research landscape and identify prevailing gaps in knowledge. The findings will provide insights for future research and development of novel applications of interactive narrative–based digital health vaccine communication interventions.
Objectives: The past decade has seen changes in US HIV policy in sub-Saharan Africa in response to a new Administration and far-reaching technical, scientific and programmatic developments. These include dramatically increased access to life-saving anti-retroviral therapy (ART) and related services, the roll-out of voluntary medical male circumcision and growing sensitivity to gender-based violence, including child sexual abuse, and to its role in increasing vulnerability to HIV. The Families Matter! Program (FMP) is an intervention for parents and caregivers of 9- to 12-year-olds that promotes effective parent–child communication about sexuality and sexual risk reduction. FMP was adapted from a US evidence-based intervention in 2003–2004 and is now implemented in eight African countries. In 2012–2013, the FMP curriculum was updated and enhanced to respond to new US Government priorities.
Methods: Enhancements to the curriculum drew on the results of Violence Against Children surveys, on a review of existing literature, on feedback from the field on the existing curriculum and on stories written by young people across Africa for scriptwriting competitions.
Results: We updated FMP with scientific content and stronger linkages to services. We also intensified our focus on structural determinants of risk. This contextualisation of sexual risk-taking within structural constraints led us to place greater emphasis on gendered vulnerability and the diverse pressures children face and to intensify our situation-based pedagogical approach, drawing on the authentic youth-authored narratives.
Conclusion: We describe these changes as an illustration of and source of insight into much-needed programmatic adaptation in response to evolving HIV policy.
BACKGROUND: Young people aged under 25 years make up an increasing proportion of the population in emerging economies such as Kenya, where half of new adult HIV infections are among 15- to 24-year olds. Interventions targeting this age group have the potential to avert HIV infections among an increasingly large at-risk population. Interactive communication technologies offer a promising platform for reaching young people in engaging ways.
OBJECTIVE: Tumaini is a narrative-based smartphone game designed to help young Africans protect themselves from HIV. The objective of this study was to pilot test the game, focusing on the data needed to inform a future randomized controlled efficacy trial, including assessments of study feasibility and safety.
METHODS: The study took place in Kisumu Town, western Kenya, in spring 2017. The game-based intervention was pilot tested for 16 days with a sample of 60 preadolescents aged 11 to 14 years. Participant recruitment was initiated through schools. Participants were randomly assigned to the control or intervention arms of the study. One parent for each of the intervention arm participants was also recruited (n=30). The intervention arm participants were provided with smartphones on which Tumaini was loaded so that they could play the game at home. Youth completed behavioral surveys at baseline, posttest, and 6-week follow-up. The intervention arm participants provided quantitative feedback on their experience of the game-based intervention at posttest. They and their parents further participated in postintervention focus group discussions. Feasibility-related study metrics were collected on recruitment, enrollment, attrition, safety of participants, and return of phones. RESULTS: Recruitment and enrollment of the 60 preadolescents and parents were successfully completed within 18 days. No participants were lost to follow-up: all youth completed all 3 waves of the survey and 27 intervention arm youth and 22 parents and caregivers participated in the focus groups. No safety concerns were reported. All phones were returned after the intervention period; none were damaged or lost. All intervention arm participants initiated gameplay, recording a mean exposure time just under 27 hours.
CONCLUSIONS: Findings indicate that it is feasible and safe to test a smartphone-based HIV prevention intervention for very young adolescents in urban and peri-urban sub-Saharan Africa by initiating recruitment in schools and temporarily providing youth participants with smartphones on which the game is loaded. A randomized controlled trial powered to assess the efficacy of the game-based intervention is being designed to be carried out in the same geographic area as the pilot, using similar methods.
Nearly 32% of women report experiencing physical violence from an intimate partner and more than 8% report being raped by a significant other in their lifetime. Young people’s perceptions that their peers perpetrate relationship violence have been shown to increase the odds of self-reported perpetration. Yet, limited research has been conducted on this relationship as individuals begin to age out of adolescence. The present study sought to examine the link between the perception of peer perpetration of intimate partner violence (IPV) and self-reported IPV perpetration among a sample of predominately young adult (21-35 years) males. This study also explored the discordance between the perception of peer IPV behavior and self-reported perpetration. Data from 101 male peer dyads (n = 202) were taken from a study on the effects of alcohol and bystander intervention in Atlanta, Georgia. Thirty-six percent (n = 73) of men reported perpetrating physical IPV and 67% (n = 135) reported perpetrating sexual IPV in the past 12 months. Nearly 35% (n = 55) of the sample reported that none of their peers had perpetrated physical IPV, which contradicted their friend’s self-report of physical IPV perpetration. Similarly, 68% (n = 115) of the men perceived none of their peers to have perpetrated sexual IPV, which contradicted their friend’s self-report of sexual IPV perpetration. Discordance variables were significantly associated with self-reported perpetration for both physical (χ2 = 152.7, p <.01) and sexual (χ2 = 164.4, p <.01) IPV. These results point to an underestimation of peer IPV perpetration among young adult males. Findings suggest a traditional social norms approach to IPV prevention, which seeks to persuade individuals that negative behaviors are less common than perceived, may not be the best approach given a significant number of men believed their friends were nonviolent when they had perpetrated violence.
Background: There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa. Objective: To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change. Methods: Tumaini (“hope for the future” in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics. Results: Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=.006), and overall survey scores (P<.001) compared with the control arm at T3. The postintervention survey revealed high subjective measures of the game's value, relevance, and appeal. Focus groups identified a wide range of knowledge and skills the participants had gained, including setting goals and planning how to achieve them, which was perceived as a key motivator for avoiding or reducing risk. Conclusions: The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design.
Little is known about how young Africans have made sense of the dramatic ways in which the HIV epidemic has evolved, and how that sense-making varies across countries with different epidemiological and sociocultural profiles. Symbolic representations of HIV and people living with HIV influence prevention, stigma, treatment-seeking, and illness experience. We compared social representations of HIV among young people from Senegal, Burkina Faso, Nigeria (South-East), Kenya, and Swaziland between 1997 and 2014. From a pool of 32,759 HIV-themed creative narratives contributed by 10–24 year-olds to scriptwriting competitions at eight time points (1997, 2000, 2002, 2005, 2008, 2011, 2013, and 2014), we randomly sampled 1937 narratives, stratified by author's sex, age, and rural/urban residence. We quantified components of each narrative and calculated descriptive statistics and adjusted odds ratios, controlling for year, country, and author demographics. From 2005 onwards, representations of death, treatment access, and hopefulness improved significantly. Representations of death reached their lowest point in 2013, while biomedical treatment and hope peaked in 2011 and 2008, respectively, then declined. Narratives increasingly focused on female protagonists. Nigerian texts had significantly higher odds of death and blame, and lower odds of hope. A focus on life post-infection and representations of support for characters living with HIV increased with country HIV prevalence. Narratives by older authors were less blaming and more hopeful, supportive, and prevention-focused. While aggregate social representations in the narratives from 2005 to 2008-11 reflect increased optimism fostered by access to antiretroviral therapy (ART), positive developments are not sustained at this level. Stigmatizing representations persist, particularly in Nigeria. The hope-promoting and stigma-reducing influence of the advent of ART access may have partially run its course by 2011/2013. However, significant temporal and cross-national differences point to opportunities to reframe HIV in more constructive ways and contribute to improved education, communication, and stigma-reduction efforts.
by
Kate Winskell Enger;
Robyn Singleton;
Gaelle Sabben;
Georges Tiendrebeogo;
Chris Obong'o;
Fatim Louise Dia;
Siphiwe Nkambule-Vilakati;
Benjamin Mbakwem;
Robert Stephenson
HIV prevention has evolved dramatically since the 1990s. The ABC trilogy (abstinence, be faithful, use a condom) has expanded to incorporate a range of biomedical prevention strategies, including voluntary medical male circumcision, pre- and post-exposure prophylaxis, and treatment-as-prevention, and to accommodate structural and combination prevention approaches. This study examines how young Africans from five epidemiologically and socio-culturally diverse countries (Swaziland, Kenya, Nigeria, Burkina Faso and Senegal) made sense of the evolving prevention of sexual transmission of HIV between 1997 and 2014. It uses a distinctive data source: 1,343 creative narratives submitted to HIV-themed scriptwriting competitions by young people aged 10-24. The study triangulates between analysis of quantifiable characteristics of the narratives, thematic qualitative analysis, and narrative-based approaches. Over time, HIV prevention themes become less prominent. Condoms are represented less often from 2008, though representations become more favourable. Biomedical prevention is all but absent through 2014. While prevention strategies may be described as effective in narratorial commentary, they are rarely depicted as preventing HIV, but are evoked instead in moralistic cautionary tales or represented as ineffective. Over time, an increasing proportion of protagonists are female. One in five narratives acknowledge structural drivers of HIV, but these are generally either disempowering or condemn characters for failing to prevent HIV in the face of often overwhelming structural challenges. In the context of combination prevention, there is a need to disseminate an empowering cultural narrative that models successful use of HIV prevention strategies despite structural constraints and avoids blaming and stigma.
The sexual abuse of power is a form of sexual coercion in which individuals–typically male–use their positions of authority to obtain sex. We analysed social representations of sexual abuse of power in a sample of 1,446 narratives about HIV written by young Africans between 2005 and 2014. The narratives were prepared at five different points in time (2005, 2008, 2011, 2013 and 2014) by authors aged 10–24 in urban and rural areas of Swaziland, Kenya, South-East Nigeria, Burkina Faso and Senegal. We combined three analytical approaches: descriptive statistics of quantifiable characteristics of the narratives, thematic data analysis and a narrative-based approach. Analysis revealed two underlying cultural scripts describing the sexual abuse of power between (a) teachers and female students, and (b) male employers and domestic workers. Cross-national variation was evident in the emphasis authors placed on socio-contextual inequalities, particularly poverty, and on individual level blame. While a minority of Nigerian and Burkinabe authors depicted female characters creatively exercising agency and avoiding unwanted sex, overall there was little critique of underlying assumptions of male sexual entitlement and female responsibility for controlling male sexuality in the context of unequal control of resources. We outline recommendations for strategies to deconstruct these harmful scripts.
Despite the high prevalence of HIV among men who have sex with men in South Africa, very little is known about their lived realities, including their social and sexual networks. Given the influence of social network structure on sexual risk behaviours, a better understanding of the social contexts of men who have sex with men is essential for informing the design of HIV programming and messaging. This study explored social network connectivity, an understudied network attribute, examining self-reported connectivity between friends, family and sex partners. Data were collected in Cape Town and Port Elizabeth, South Africa, from 78 men who have sex with men who participated in in-depth interviews that included a social network mapping component. Five social network types emerged from the content analysis of these social network maps based on the level of connectivity between family, friends and sex partners, and ranged from disconnected to densely connected networks. The ways in which participants reported sexual risk-taking differed across the five network types, revealing diversity in social network profiles. HIV programming and messaging for this population can greatly benefit from recognising the diversity in lived realities and social connections between men who have sex with men.
Condoms are an essential component of comprehensive efforts to control the HIV epidemic, both for those who know their status and for those who do not. Although young people account for almost half of all new HIV infections, reported condom use among them remains low in many sub-Saharan African countries. In order to inform education and communication efforts to increase condom use, we examined social representations of condoms among young people aged 10–24 in six African countries/regions with diverse HIV prevalence rates: Swaziland, Namibia, Kenya, South-East Nigeria, Burkina Faso, and Senegal. We used a unique data source, namely 11,354 creative ideas contributed from these countries to a continent-wide scriptwriting contest, held from 1st February to 15th April 2005, on the theme of HIV/AIDS. We stratified each country sample by the sex, age (10–14, 15–19, 20–24), and urban/rural location of the author and randomly selected up to 10 narratives for each of the 12 resulting strata, netting a total sample of 586 texts for the six countries. We analyzed the narratives qualitatively using thematic data analysis and narrative-based methodologies. Differences were observed across settings in the prominence accorded to condoms, the assessment of their effectiveness, and certain barriers to and facilitators of their use. Moralization emerged as a key impediment to positive representations of condoms, while humour was an appealing means to normalize them. The social representations in the narratives identify communication needs in and across settings and provide youth-focused ideas and perspectives to inform future intervention efforts.