Sexual behaviour among Kenyan adolescents enrolled in an efficacy trial of a smartphone game to prevent HIV: a cross-sectional analysis of baseline data.

Sexual behaviour of adolescents is contextual, with various determinants affecting sexual activity and age of sexual debut. Insight into sexual activity among young adolescents has the potential to influence appropriate sexual and reproductive health interventions. For this analysis, adolescents were recruited as part of the Tumaini smartphone game efficacy trial. Data collection included a self-administered behavioural survey and blood test for HIV and HSV-2. Descriptive statistics were calculated for demographics and measures of sexual behaviour and behavioural intent based on gender and sexual experience, with associations assessed using chi-square tests, t-tests and Wilcoxon rank sum tests as appropriate. We enrolled 996 adolescents, mean age 14 years and 2.2% HSV-2 positivity. Overall, 15% of the adolescents were sexually experienced, this being associated with lower socio-economic status (p = 0.01), household food insecurity (p = 0.008), a living situation without both parents (p < 0.01), substance use (p = 0.02), no adult conversation about future goals (p = 0.003), conversations about condoms (p = 0.01), with some gender disparity within these factors. Among those sexually experienced, 21.7% reported unwilling sex; 17.5% had engaged in transactional sex; 57.8% had willing first sex, of whom 60.9% reported no condom use. Among those abstaining, female adolescents were less likely to contemplate condom use at first sex (p = 0.006). Our findings determine that young sexually active adolescents are likely engaging in unprotected sex and having unwilling sexual experiences. Socio-economic status, living situation and parental monitoring remain significant factors associated with sexual experience among young adolescents. In this context, early adolescence is an opportunity to provide age- and developmentally appropriate education about safer sex practices.Trial registration: ClinicalTrials.gov identifier: NCT04437667.

Interactive Narrative-Based Digital Health Interventions for Vaccine Communication: Protocol for a Scoping Review.

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. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51137.

The Efficacy of a Smartphone Game to Prevent HIV Among Young Africans: Protocol for a Randomized Controlled Trial in the Context of COVID-19.

BACKGROUND: Adolescents contribute slightly less than one-third of all new HIV infections in sub-Saharan Africa. There is a need for more effective intervention approaches to help young adolescents safely navigate through adolescence and into adulthood. We are assessing the efficacy of Tumaini, a smartphone game designed to prevent HIV among young Africans. Against the background of COVID-19, meaningful alteration of the research protocol was necessary to ensure successful implementation and retention of the study participants in ongoing research. OBJECTIVE: The objective of our protocol is to determine (1) if Tumaini delays sexual debut and increases condom use at first sex and (2) whether it influences behavioral mediators of early and unprotected sex. METHODS: Participants were recruited from Kisumu County in Western Kenya. This study is a 2-arm, individual-randomized controlled trial that enrolled 1004 adolescents aged between 12 years and 15 years. The intervention arm participants are playing Tumaini, while the control arm is provided with Brainilis, a commercially available control game. The study period will last 45 months. At baseline, participants in both arms completed a baseline survey and biological testing for HIV and herpes simplex virus, type 2 (HSV-2); participants will have annual game play periods in years 1-3. They will also complete a total of 12 follow-up surveys. At endline, repeat biological testing will be conducted. Protocol adaptations were necessitated by the COVID-19 pandemic and implemented in accordance with local public health guidelines. RESULTS: Participants were enrolled between October 2020 and November 2020. We plan to complete study procedures in September 2024. The enrolled participant sample was 50.1% (499/996) female and had a mean age of 14.0 (SD 0.6) years. CONCLUSIONS: This ongoing research demonstrates that, with appropriate revisions to planned protocol activities guided by the need to maintain study integrity, protect both study participants and staff, and adhere to institutional review board and local health authority guidelines, human subject research is possible in the context of a global pandemic. If the trial demonstrates efficacy, Tumaini would provide an alternative, remote means of delivering age-appropriate education to adolescents on safer sex, HIV prevention, and effective life skills on a highly scalable, low-cost, and culturally adaptable platform. TRIAL REGISTRATION: ClinicalTrials.gov NCT04437667; https://clinicaltrials.gov/ct2/show/NCT04437667. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35117.

Social Representations Theory and Young Africans' Creative Narratives about HIV/AIDS, 1997-2014.

Research on social representations (SRs) has often focused more on categorical than narrative-based representations. However, narratives are considered to play a key role in the organization of social representations. This paper describes an empirical study of some 2,000 creative narratives about HIV written by young Africans from five countries between 1997 and 2014 and examines the theoretical, methodological and applied relevance of SRT for this study and the implications of the study for the intersection between narrative and SRT. The study is unusual within the SR paradigm: it is temporal and cross-national; addresses a subject whose science has evolved over time; and uses creative narratives as its data source. A narrative perspective foregrounds holistic understandings of SRs as systems of thought. Creative narratives fit well within an SR framework. Our triangulating methodologies foreground categorical or narrative dimensions depending on the objectives of specific sub-studies. Central Core Theory provides a framework to articulate stability and change within narrative representations. In creative narrative, objectification also happens at the level of plot and characters, such that dominant cultural narratives can be viewed as a form of hegemonic SR. We link with health communication and embrace more critical streams within SR research.

Making sense of fidelity: young Africans' cross-national and longitudinal representations of fidelity and infidelity in their HIV-related creative narratives, 1997-2014.

Mutual fidelity and partner reduction have been identified as key behavioural strategies to prevent HIV transmission in sub-Saharan Africa, particularly following recognition of the role that multiple concurrent sexual partnerships play in driving generalised HIV epidemics. We analysed social representations of fidelity and infidelity in a sample of 1,343 narratives about HIV written by young Africans between 1997 and 2014. The narratives were written at four different time points (1997, 2005, 2008, 2014) by authors aged 10-24 in urban and rural areas of Senegal, Burkina Faso, South-east Nigeria, Kenya and Eswatini. We combined three analytical approaches: descriptive statistics of quantifiable characteristics of the narratives, thematic data analysis and a narrative-based approach. In the sample, fidelity is often promoted as the ideal by narrators, peers and romantic partners, in line with broader discourses around HIV prevention, romantic relationships, familial obligations, and religious and moral imperatives. However, mutual fidelity is rarely modelled in the narratives and representations of combining methods to prevent HIV from entering relationships via infidelity are uncommon. Representations of fidelity reflect loss-framed fear arousal techniques that perpetuate HIV-related stigma. Narrative-based approaches that facilitate skills-building, critical reflection and address stigma can better address fidelity and partner reduction.

Social behaviors and HIV risk factors among men in Chad and Cameroon.

INTRODUCTION: the neighboring Republics of Chad and Cameroon have respectively one of the lowest and highest HIV prevalence rates in central Africa at 1.3% and 4.5%, respectively. We conducted a comparative description of social behaviors and HIV risk factors among heterosexual men and explored the baseline of the first UNAIDS target (by 2020, 90% of people living with HIV will know their status) in the two countries. METHODS: this was a retrospective cross-sectional study using Demographic and Health Survey data. We fitted a separate multilevel logistic model for each country. In total, 5248 men were interviewed in Chad and 7191 men in Cameroon. RESULTS: Cameroonian men have a higher level of education, higher HIV testing rate, and are more knowledgeable about HIV than Chadian men. However, Chadian men have a lower number of lifetime sexual partners (2 interquartile range (IQR), 1-4) compared to Cameroonian men (6 IQR 3-15) and 86.96% of Chadian versus 57.30% of Cameroonian men reported fidelity to their domestic partners in the last twelve months. CONCLUSION: there is a crucial need to encourage HIV screening and testing among Chadian men, especially in rural areas. Testing also needs to be increased in Cameroon to meet the first UNAIDS target. Government and partners in Cameroon could support more research and campaigns that aim at reducing multiple sexual partnerships among the communities in Cameroon.

Conceptualizing Consent: Cross-national and Temporal Representations of Sexual Consent in Young Africans' Creative Narratives on HIV.

Sexual violence, comprising all non-consensual sexual acts, is an important driver of HIV infection in sub-Saharan Africa. Definitions of sexual violence rely on understandings of sexual consent, understood as a feeling of willingness that is communicated via shared indicators of consent. In this paper, through analysis of young authors' narrative-based social representations, we sought to provide insight into young Africans' sense-making around sexual consent in order to develop a conceptual framework that can guide future methodological and conceptual work. We analyzed representations of sexual consent in a sample of 291 creative narratives about HIV written for a scriptwriting competition by young Nigerians, Kenyans and Swazis in 2005, 2008, and 2014. We combined thematic data analysis and narrative-based approaches. Narratives represented consent as a feeling of wanting or being willing to have sex, or an intention to have sex, communicated via character actions, conversations, or circumstances. Some narratives depicted characters not wanting but consenting to sex to avoid negative repercussions. Representations of sexual consent were fairly consistent across contexts and over time, although certain representations were more prominent in some country/year samples than others. Results are translated into a conceptual framework that can guide future prevention efforts to reframe sexual consent.

Peer Influence on IPV by Young Adult Males: Investigating the Case for a Social Norms Approach.

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.

The spectrum of sexual transaction: representations in young Africans' HIV-themed creative narratives.

Sexual transaction, or any exchange of financial or material goods for sex, contributes to the disproportionate HIV burden among young women aged 15-24 years in sub-Saharan Africa. We analysed representations of sexual transactions in a sample of 363 narratives about HIV written by young Africans. The narratives were written at 4 time points (1997, 2005, 2008, 2014) by authors aged 10-24 years in urban and rural areas of Senegal, Burkina Faso, South-east Nigeria, Kenya and Eswatini, formerly Swaziland. We combined three analytical approaches: descriptive statistics of quantifiable characteristics of the narratives, thematic data analysis and a narrative-based approach. Representations reflect sexual transaction as a spectrum, with commercial sex work and sexual transactions that include romance at opposite ends. Narratives represent female characters increasingly motivated by a desire for social status symbols and by romantic love over time. Condemnation and stigmatisation of sexual transactions motivated by materialism remain similar across countries. In order to mitigate young women's disproportionate risk of HIV there is a need to combine efforts to address the economic marginalisation and gender inequality that drive sexual transactions with activities to promote skills and reflection and influence harmful norms, potentially drawing on companionate ideologies.

Temporal and cross-national comparisons of young Africans' HIV-related narratives from five countries, 1997-2014.

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.

Social representations of the prevention of heterosexual transmission of HIV among young Africans from five countries, 1997-2014.

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.

Interactive Narrative in a Mobile Health Behavioral Intervention (Tumaini): Theoretical Grounding and Structure of a Smartphone Game to Prevent HIV Among Young Africans.

The increasing availability of smartphones, including in low-income countries, offers an unprecedented opportunity to reach individuals with innovative health promotion interventions. Electronic games delivered via smartphone offer promising avenues for sexual health promotion and HIV prevention, especially for young people. By giving players real agency in a virtual and safe environment, well-designed games can provide a level of experiential learning unparalleled by many other behavioral interventions. The design of effective games for health relies on multidisciplinary insight and expertise. However, relatively few studies discuss the theoretical understanding underlying their intervention. Making explicit the theoretical grounding of a game-based intervention allows articulation of assumptions and strategies, anticipation of outcomes, and evaluation of impacts (including intermediate effects), thereby increasing understanding of pathways to change, with a view to contributing to the development of more effective games. It also helps strengthen the credibility and improve the accountability of games for health. We present the multidisciplinary theoretical framework-integrating intervention design, mediators, and behavioral outcomes-and the structure of an HIV prevention game for young African adolescents that has shown promise in a randomized pilot study in Western Kenya. The central component of Tumaini (hope for the future in Kiswahili) is an interactive role-playing narrative in which the player makes choices for characters that determine how their paths unfold. In addition, a series of mini-games reinforce skills, and the "My Story" component links the game world to the player's own life and goals, and a reward system motivates continued play. With its "choose-your-own-adventure" format, Tumaini is intended to be replayed so that players can experience the consequences resulting from different choices made in the role-playing narrative. Grounded in theories of narrative and applied communication and in social behavioral theories, especially Social Cognitive Theory, Tumaini is designed to help young adolescents acquire the information, skills, and motivation they need to avoid and reduce sexual risks. We close by situating Tumaini within discussion of the theory and practice of using interactive narrative in health promotion, with a view to furthering theoretical elaboration.

A Smartphone Game to Prevent HIV Among Young Africans (Tumaini): Assessing Intervention and Study Acceptability Among Adolescents and Their Parents in a Randomized Controlled Trial.

BACKGROUND: Young people aged 15 to 24 years account for one-third of new adult HIV infections. Controlling the HIV epidemic requires effective interventions targeted toward young people and their needs. Smartphone games offer a promising avenue for reaching this population with evidence-based HIV prevention interventions. It is crucial to the effectiveness of these interventions that they be acceptable and intrinsically motivating to adolescents as well as acceptable to their parents. OBJECTIVE: Tumaini is a narrative-based smartphone game designed to help prevent HIV among young Africans aged 11 to 14 years by delaying first sex and increasing condom use at first sex. Following a 16-day feasibility study of Tumaini, we assessed the acceptability (1) of the intervention, where acceptability was operationalized as appeal, relevance, value, usability, and understandability, and (2) of this study and a planned future randomized controlled efficacy trial. METHODS: During the randomized feasibility study (n=60) of Tumaini in western Kenya in spring 2017, 30 participants used the intervention on a study-provided smartphone. The app automatically logged participant interaction with the game in time-stamped log files. All 30 participants completed an Audio Computer-Assisted Self-Interview-based game experience survey, and 27 took part in 4 focus group discussions (FGDs) about the game's appeal, relevance, value, usability, and understandability. Their parents (n=22) also participated in 4 FGDs about the acceptability of the intervention, of this study, and of a planned efficacy trial. Survey data were analyzed using SAS software (SAS Institute Inc); FGD transcripts were coded and analyzed in MAXQDA 12 (Verbi GmbH); and gameplay log files were analyzed using Microsoft Excel. RESULTS: Adolescent participants' survey responses indicated that Tumaini scored well with players on all indicators of acceptability (appeal, relevance, value, usability, and understandability). Focus group analyses aligned with these findings and emphasized a high degree of player engagement with the game, which was supported by log file analysis. Adolescent participants were eager for additional content, and parents were receptive to a longer study involving biomarkers, based on their positive experiences with this study. There is scope to improve communication with parents about their role in the intervention. As the game was tested in beta version, there is also scope to fine-tune some of the game mechanics to increase usability. CONCLUSIONS: This study shows the strong acceptability of an interactive smartphone-based game both to adolescents and their parents in western Kenya and that of the study methods used to pilot-test the intervention. It also suggests that longitudinal efficacy studies of this type of intervention, including those using biomarkers, have the potential to be acceptable among parents. TRIAL REGISTRATION: ClinicalTrials.gov NCT03054051; https://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW).

A Smartphone Game to Prevent HIV Among Young Africans: Protocol for a Randomized Pilot Study of a Mobile Intervention.

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. TRIAL REGISTRATION: ClinicalTrials.gov NCT03054051; https://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/6wjwpX8Bg.). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11209.

Young Africans' social representations of sexual abuse of power in their HIV-related creative narratives, 2005-2014: cultural scripts and applied possibilities.

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.

Transforming narratives into educational tools: the collaborative development of a transformative learning tool based on Nicaraguan adolescents' creative writing about intimate partner violence.

The use of narrative has become increasingly popular in the public health, community development, and education fields. Via emotionally engaging plotlines with authentic, captivating characters, stories provide an opportunity for participants to be carried away imaginatively into the characters' world while connecting the story with their own lived experiences. Stories have been highlighted as valuable tools in transformative learning. However, little published literature exists demonstrating applications of stories in group-based transformative learning curricula. This paper describes the creation of a narrative-based transformative learning tool based on an analysis of Nicaraguan adolescents' meaning-making around intimate partner violence (IPV) in their creative narratives. In collaboration with a Nicaraguan organization, US researchers analyzed a sample of narratives ( n = 55; 16 male-authored, 39 female-authored) on IPV submitted to a 2014 scriptwriting competition by adolescents aged 15-19. The data were particularly timely in that they responded to a new law protecting victims of gender-based violence, Law 779, and contradicted social-conservative claims that the Law 779 destroys family unity. We incorporated results from this analysis into the creation of the transformative learning tool, separated into thematic sections. The tool's sections (which comprise one story and three corresponding activities) aim to facilitate critical reflection, interpersonal dialogue, and self- and collective efficacy for social action around the following themes derived from the analysis: IPV and social support; IPV and romantic love; masculinity; warning signs of IPV; and sexual abuse. As a collaboration between a public health research team based at a US university and a Nicaraguan community-based organization, it demonstrates the potential in the age of increasingly smooth electronic communication for novel community-university partnerships to facilitate the development of narrative-based tools to support transformative learning.

A Smartphone Game to Prevent HIV among Young Kenyans: Household Dynamics of Gameplay in a Feasibility Study.

OBJECTIVE: mHealth interventions often favour individual-level effects. This is particularly problematic in contexts where social support and shifts in social norms are critical to sustained behaviour change. Mobile digital games represent a promising health education strategy for youth, including in low-resource settings. We sought to better understand the interpersonal and social interactions that can be elicited by digital games for health. DESIGN: We piloted Tumaini, a smartphone game rooted in interactive narrative designed to prevent HIV among young Africans (aged 11-14), in a randomised controlled feasibility study and analysed reports of the household dynamics surrounding gameplay. Following a 16-day intervention period, phone gameplay log files were downloaded and intervention arm participants (n=30) completed a gameplay experience survey; eight focus group discussions were held, four with intervention arm participants (n=27), four with their parents (n=22). SETTING: This study took place in Kisumu, Kenya, in Spring 2017. METHOD: Descriptive statistics were computed from survey responses and log files. Focus group transcripts were labelled, analysed thematically, and compared demographically using MaxQDA software. RESULTS: Data from log files, survey and focus groups indicate that the game generated considerable interaction and dialogue with parents, siblings, and friends, and served as a catalyst for children to act as advocates for healthful decisions about sex, both within the family and beyond. The game showed a high level of acceptability with parents. CONCLUSION: Serious digital games using a smartphone platform can generate considerable household interaction. Games can model and facilitate these exchanges, maximising multi-level effects. An additional app for parents could reinforce these effects.

A Smartphone Game-Based Intervention (Tumaini) to Prevent HIV Among Young Africans: Pilot Randomized Controlled Trial.

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. TRIAL REGISTRATION: ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW).

Social representations of mother-to-child transmission of HIV and its prevention in narratives by young Africans from five countries, 1997-2014: Implications for communication.

International recommendations related to the prevention of mother-to-child transmission (PMTCT) of HIV have evolved rapidly over time; recommendations have also varied contextually in line with local constraints and national policies. This study examines how young Africans made sense of mother-to-child transmission (MTCT) and PMTCT and related barriers and facilitators between 1997 and 2014 in the context of these complex and changing recommendations. It uses a distinctive data source: 1343 creative narratives submitted to HIV-themed scriptwriting competitions by young people aged 10-24 from 5 African countries (Senegal, Burkina Faso, Nigeria, Kenya, and Swaziland) between 1997 and 2014. The study triangulates between analysis of quantifiable characteristics of the narratives, thematic qualitative analysis, and narrative-based approaches. MTCT occurs in 8% of the narratives (108), while it is prevented in 5% (65). Narratives differ according to whether they depict MTCT or PMTCT (or, rarely, both), evolve over time, and show cross-national thematic variation. In the aggregate, representations shift in line with increased access to testing and antiretroviral medications, with PMTCT narratives becoming more frequent and MTCT narratives becoming more hopeful as diagnosis becomes the gateway to ART access. However, storylines of intergenerational tragedy in which MTCT is depicted as inevitable persist through 2014. Alongside cross-national differences in theme and tone, narratives from higher prevalence Swaziland and Kenya situate MTCT/PMTCT more centrally within descriptions of life with HIV. Findings illustrate the need to improve communication about PMTCT, reframing negative cultural narratives to reflect the full promise of developments of the past decade and a half.

Enabling Analysis of Big, Thick, Long, and Wide Data: Data Management for the Analysis of a Large Longitudinal and Cross-National Narrative Data Set.

Distinctive longitudinal narrative data, collected during a critical 18-year period in the history of the HIV epidemic, offer a unique opportunity to examine how young Africans are making sense of evolving developments in HIV prevention and treatment. More than 200,000 young people from across sub-Saharan Africa took part in HIV-themed scriptwriting contests held at eight discrete time points between 1997 and 2014, creating more than 75,000 narratives. This article describes the data reduction and management strategies developed for our cross-national and longitudinal study of these qualitative data. The study aims to inform HIV communication practice by identifying cultural meanings and contextual factors that inform sexual behaviors and social practices, and also to help increase understanding of processes of sociocultural change. We describe our sampling strategies and our triangulating methodologies, combining in-depth narrative analysis, thematic qualitative analysis, and quantitative analysis, which are designed to enable systematic comparison without sacrificing ethnographic richness.