Impact of an educational digital storytelling intervention on HIV risk perception among Nigerian adolescents.

Introduction

College students in Nigeria have a low awareness of the risk of human immunodeficiency virus (HIV). Lammers and van Wijnbergen[1] have noted the low risk perception of unprotected sex in Nigeria, which invariably leads to poor awareness of HIV risk. A 2009 study reported that 74.6% of adolescents in Nigeria were sexually active, 66.4% had multiple partners and only 38.1% always used condoms during sexual intercourse.[2] The low perception of HIV risk has increased the rate of HIV infection in adolescent college students. There is evidence that 77% of college students in Nigeria are at risk of HIV infection.[3] A recent study has confirmed that students (mostly adolescents) in Nigeria and other developing countries are exposed to HIV infection.[4] HIV infections affect adolescents’ education, vocational education, and personal and social lives. Ezegbe et al.[4] have pointed out that HIV infection can prevent adolescents from achieving their needs in every area of life, as adolescents with HIV may experience poor health, malnutrition, low education, lack of affection, insecurity, lack of protection, rejection, depression, discrimination, fear, loneliness, school dropout and suicidal thoughts.

In addition, there are substantial misconceptions about HIV that lead to low HIV risk perception.[3,5-7] In Africa as a whole, the high level of misconceptions about HIV risk frequently undermines HIV prevention efforts.[7] For example, most adolescents obtain HIV information directly from mass media sources; such information is often superficial and does not dispel erroneous beliefs.[8] Thus, HIV information obtained from the mass media can generate irrational beliefs that perpetuate HIV risk in adolescents. Although peer education and social media messaging have been used as strategies to disseminate HIV knowledge,[9,10] an educational digital storytelling intervention (EDSI) could help adolescents to acquire a broad, realistic knowledge of HIV.

Generally, digital storytelling is considered an effective therapeutic technique for treating behavioural problems. For instance, there is evidence that digital storytelling (in oral, pictorial, written and film media forms) is an essential element in learning new behaviours.[11,12] Digital storytelling has also been used as a creative counselling tool.[13,14] A recent study revealed that rational emotive digital storytelling (REDStory) is effective in increasing HIV knowledge and risk perception among students.[4] Similar to REDStory, the EDSI acknowledges that the way people think, feel and behave can make them vulnerable to HIV infection. Hence, effective HIV interventions should consider the cognitive patterns of individuals. There is also evidence that HIV prevention programs that incorporate cognitive and behavioural skills training are more effective.[4,15] Therefore, the EDSI incorporates cognitive restructuring, re-education and sexual communication to help people alter their erroneous thoughts, emotions and behaviours, and gain the skills to reduce risk behaviours. The EDSI is built on the assumption that Nigerian adolescents are vulnerable to HIV infection owing to their daily patterns of thinking, feeling and behaving. To this end, cognitive restructuring and re-education are required to help adolescents overcome HIV risks. Thus, the objective of this study was to investigate the impact of an EDSI on HIV risk perception and knowledge among Nigerian adolescent college students.

Method

Ethical standards

The study procedure complied with the ethical principles of the American Psychological Association, the Declaration of Helsinki and the Faculty of Education, University of Nigeria, Nsukka. The study protocol was approved by the ethics committee of the Department of Art Education, University of Nigeria. The participants provided written informed consent before the beginning of the program.

Participants

We recruited 98 adolescents who attended a federal science college in Akwa Ibom State, Nigeria. We used G*Power 3.1 software (Heinrich-Heine-Universität Düsseldorf, Germany)[16] to determine the appropriateness of the sample size. The G*Power analysis showed that 98 participants were needed for an effect size of 0.60, an alpha of 0.05 and 0.80 power. The inclusion criteria were having access to social media platforms, availability to attend all the study sessions, and willingness to sign the informed consent form.

Measures

We used the 8-item Perceived Risk of HIV Scale (PRHS) generated by Napper, Fisher and Reynolds.[17] The PRHS had a Cronbach’s alpha of 0.77 in the present study, showing good internal reliability. We also used the HIV Knowledge Questionnaire (HIV-KQ-18) designed by Carey and Schroder[18] to measure HIV-related knowledge (Cronbach’s alpha was 0.87 for this scale in the present study, indicating good internal reliability). Other details of this instrument have been described previously.[4]

Intervention

In line with a previous study,[4] the EDSI was structured to cover 16 sessions over 8 weeks and featured a rational emotive psychoeducational audio-visual intervention about HIV. The aim of the EDSI was to help adolescent college students learn from and about other people’s HIV-related lived experiences to increase their HIV risk perception. Other details of the intervention (contents, techniques, principles, assignments, procedures, meetings and skills) have been described previously.[4] The EDSI was delivered by therapists who were experts in the use of digital storytelling and HIV interventions and who had qualifications in educational technology, psychology, social work and counselling.

Procedure

We used a group randomized controlled trial design procedure involving pre-test, post-test and follow-up. We randomly assigned participants into either a treatment group or a no-treatment control group using computer-generated random numbers. The participants in the treatment group received the EDSI whereas the participants in the control group received no intervention. Pre-test, post-test and follow-up data for the two groups were collected and subjected to repeated measures analysis of variance by experts. There were 2 months between the pre-test and post-test. Follow-up occurred 2 months after the post-test day. We observed a dropout of 23 participants (15 from the treatment group and 8 from the no-treatment control group), whose data were excluded from the analysis. Both the participants and the data analysts were blinded, as in our previous study.[4,19]

Results

There were 49 participants in the treatment group (23 males, 26 females; mean age ± standard deviation = 20.43 ± 0.89 years). There were 49 participants in the no-treatment control group (25 males, 24 females; mean age ± standard deviation = 21.67 ± 0.73 years). The pre-test assessment showed no significant difference between the treatment and no-treatment control groups in perceived risk of HIV and HIV knowledge, F(1,75) = .074,  = .001, ΔR2 = .−013; confidence interval (CI) for the treatment group = 30.18 to 32.87; CI for the no-treatment control group = 30.13 to 32.44; and F(1,75) = .126,  = .001, ΔR2 = .−013; CI for the treatment group = 18.53 to 19.40; CI for the control group = 18.67 to 19.46. After the EDSI, we observed a significant increase in HIV risk perception and HIV knowledge among adolescents in the treatment group compared with those in the no-treatment control group, F(1,75) = 717.92, P = .000, = .908, ΔR2 = .907; CI for the treatment group = 11.52 to 12.82; CI for the control group = 29.80 to 32.14 and F(1,75) = 2972.19, P = .000, = .976, ΔR2 = .976; CI for the treatment group = 48.44 to 50.72; CI for the control group = 18.69 to 19.50. The follow-up assessment showed that adolescents who had participated in the EDSI retained an increased HIV risk perception and HIV knowledge compared with adolescents in the no-treatment control group, F(1,75) = 809.32, P = .000, = .917, ΔR2 = .916; CI for the treatment group = 9.20 to 10.79; CI for the control group = 29.76 to 32.13 and F(1,75) = 3048.68, P = .000, = .977, ΔR2 = .977; CI for the treatment group = 48.79 to 51.08; CI for the control group = 18.62 to 19.42.

Discussion

This study investigated the impact of an EDSI on HIV risk perception and knowledge among Nigerian adolescent college students. The pre-test measure showed that adolescents had low HIV risk perception and low HIV knowledge, a finding that supports previous study findings.[1-4] The post-test and follow-up measures indicated that the EDSI was effective in increasing HIV risk perception and knowledge among adolescents who received the intervention compared with those in the control group. The findings support previous evidence that HIV prevention programs that incorporate cognitive and behavioural skills training are more effective.[15] Moreover, the current results support recent findings that a REDStory intervention program was effective in increasing schoolchildren’s perceived risk of HIV.[4] The findings also support previous evidence that digital storytelling is an essential element in learning new behaviours[11,12] and is a useful creative counselling tool.[13,14]

The study findings indicate that educational technologists, counsellors, psychologists and medical professionals should consider the development and implementation of educational digital storytelling to increase HIV risk perception and knowledge in different sectors of society. However, it is important that future researchers address the present study limitations of the small sample size, the lack of qualitative data and the limited participant information collected.

Conclusion

The study objective, which was to investigate the impact of an EDSI on HIV risk perception and knowledge among Nigerian adolescent college students, was achieved. We conclude that the EDSI should be used to help increase adolescents’ HIV risk perception and knowledge and that further research and policy changes are needed to support the full implementation of the EDSI in different sectors of Nigerian society and in other parts of the world. We therefore call for more studies on the use of the EDSI to increase HIV risk perception and knowledge.