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In the era of potent antiretroviral therapy, a high level of condomless anal intercourse continues to drive increases in HIV incidence in recent years among men who have sex with men. Effective behavior change strategies for promoting HIV-preventive behaviors are warranted. Narrative persuasion is a novel health communication approach that has demonstrated its persuasive advantages in overcoming resistance to counterattitudinal messages. The efficacy of narrative persuasion in promoting health behavior changes has been well documented, but critical research gaps exist for its application to HIV prevention.
In this study, we aimed to (1) capitalize on narrative persuasion to design a web-based multisession intervention for reducing condomless anal intercourse among men who have sex with men in Hong Kong (the HeHe Talks Project) by following a systematic development process; and (2) describe the main components of the narrative intervention that potentially determine its persuasiveness.
Persuasive themes and subtopics related to reducing condomless anal intercourse were initially proposed based on epidemiological evidence. The biographic narrative interview method was used to elicit firsthand experiential stories from a maximum variation sample of local men who have sex with men with diverse backgrounds and experiences related to HIV prevention; different types of role models were established accordingly. Framework analysis was used to aggregate the original quotations from narrators into collective narratives under 6 intervention themes. A dedicated website was finally developed for intervention delivery.
A series of video-based intervention messages in biographic narrative format (firsthand experiential stories shared by men who have sex with men) combined with topic-equivalent argumentative messages were produced and programmed into 6 intervention sessions. The 6-week intervention program can be automatically delivered and monitored online.
We systematically created a web-based HIV prevention intervention derived from peer-generated stories. Strategies used to enhance the efficacy of the narrative intervention have been discussed within basic communication components. This paper describes the methods and experiences of the rigorous development of a narrative communication intervention for HIV prevention, which enables replication of the intervention in the future.
Although a steadily decreasing trend has been observed for the global HIV burden, the epidemic has continued to expand among men who have sex with men [
Although health communication is widely acknowledged as an important tool for HIV prevention [
Over the past decade, narrative persuasion has been recognized as a promising avenue for health communication [
Narrative persuasion is grounded in both the Extended Elaboration Likelihood Model [
Remarkably, the incorporation of argumentative support further bolsters narrative persuasion [
Existing empirical evidence supports the efficacy of narrative interventions in promoting health behaviors relative to argumentation or null controls [
Several studies [
Web-based technology has been recognized as a powerful tool to efficiently reach target populations and deliver behavioral interventions to enhance responses to the ongoing HIV epidemic among men who have sex with men [
In this study, we developed a web-based narrative intervention for HIV prevention among men who have sex with men in Hong Kong (the HeHe Talks Project) to deliver a series of video-based persuasive messages to reduce condomless anal intercourse. Biographic narratives (firsthand experiential stories shared by local men who have sex with men peers) were combined with topic-equivalent argumentative messages.
Informed consent was obtained from all participants involved in this project. Ethical approval was obtained from Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee (reference number 2014.274-T). A roadmap of the development procedure is presented in
Procedure for developing the narrative intervention program (HeHe Talks).
We conducted a review of modifiable and significant predictors of HIV/STI infection and condomless anal intercourse among local men who have sex with men in publications and government documents to inform topic selection. Factors were categorized into cognitive (eg, risk perceptions), interpersonal (eg, sex partnership), contextual (eg, substance use), and sexual practice–specific (eg, group sex). In addition, it has been suggested that HIV testing behavior should be addressed simultaneously, given its significant relationship with condomless anal intercourse among Chinese men who have sex with men [
Qualitative evidence was obtained by conducting a focus group discussion with 5 Hong Kong men who have sex with men (age: range 28-38 years). The focus group was led by a public health researcher and a health psychologist and was used to assess knowledge, views, and information needs regarding HIV prevention and condomless anal intercourse. Most interviewees had university-level educations and above (4/5) and had full-time jobs (4/5); 2 interviewees reported consistent condom use for anal sex, and 1 had engaged in substance use–facilitated anal sex in the previous 6 months.
This focus group informed refinement of the intervention topics. For example, the participants emphasized the phenomenon of “complacency about HIV” among local men who have sex with men (ie, that strong belief about antiretroviral therapy efficacy contributed to low-risk perceptions and high motivation to engage in condomless anal intercourse). Proposed intervention topics were sent to several HIV specialists; we further revised the topics based on their feedback. For example, they suggested focusing on drug use other than alcohol consumption to address reducing substance use–facilitated condomless anal intercourse; accordingly, the subtopic
The Sabido entertainment-education strategy [
Criteria for all narrators were (1) men who have sex with men; (2) age ≥18 years; (3) Hong Kong residents; (4) able to speak Cantonese fluently; and (5) of sufficient mental and physical capability to take part in a 2-hour interview. Criteria for HIV-positive narrators were (1) confirmed or high probability of having acquired HIV by sexual transmission; (2) encountered negative experiences due to living with HIV; (3) once or currently undergoing antiretroviral treatment; and (4) having engaged in any condomless anal intercourse with male sex partners prior to the diagnosis. Criteria for HIV-negative narrators were (1) having undergone at least 1 HIV test in the previous year, with the most recent test having yielded a negative result; (2) consistently used condoms with male sex partners (in every sexual encounter in the previous year); and (3) having positive perceptions about condom use for HIV prevention. Prospective narrators were nominated and approached by the research team and a collaborating nongovernmental organization (AIDS Concern). A survey was administered to establish their eligibility and to create a profile for each individual, with background information (eg, age and sexual partnership) and specific experiences related to HIV prevention (eg, contracting HIV/STI infections, engaging in condomless anal intercourse).
Biographic-Narrative Interpretive Method [
Interviewers first briefed the narrator on interview procedures and established rapport. Individual interviews started with a single question that was thematically or temporally focused, to elicit narratives of personal experiences, such as life after being diagnosed as HIV positive or an occasion of safe sex practices at a gay venue. Narrators were free to tell their story in the manner of their choosing (to provoke the narration within their own system of relevancy), and interviewers merely provided nondirectional facilitative support. Keyword notes were also taken to document the topics of interest arising in the original narrative, which helped inform follow-up questions for additional narrative to enrich the overarching story. After narrative-seeking questions, interviewers asked additional questions about topics that had not been raised or for purposes other than narrative extraction (eg, to make a persuasive appeal to the audience).
Videorecordings of the interviews were transcribed. Framework analysis was conducted to develop themed narrative messages using NVivo (version 11, QSR International) in 5 steps [
The videorecordings of the original narratives were segmented and re-organized to create 6 videos for the themes derived from the framework analysis. A background profile was presented for each narrator at first appearance in the videos; persuasive appeals from 1 or 2 narrators were used as epilogues. Videos were sent to the narrators to get their approval. Three male speakers (a nongovernmental organization staff and 2 research assistants) were invited to deliver scripted, videorecorded argumentative messages for each theme. Supplementary material, such as openings, subtitles, images, and background music, were added, and the finalized videos were programmed into 6 intervention sessions. Each included 2 videos with narrative (15-20 minutes) and argumentative (8-10 minutes) messages and a postvideo quiz set to enhance participants’ dedication to intervention content. The narrative videos were longer than the topic-equivalent argumentative videos due to the inherent natures of storytelling (ie, portraying a series of events) and argumentation (ie, listing facts and evidence). A dedicated website was developed to deliver intervention sessions automatically, and a content management system was established for real-time monitoring of engagement in the program.
A total of 36 men who have sex with men were screened, and 9 men were selected as narrators (
Narrators had varying sexual practices (
Background characteristics of the 9 narrators.
Narrator |
Age (years) | Employment | Years as membera | HIVb status | History of other STIsc (type) | Type of HIV testing venues visited |
A (negative) | 24 | Unemployed | Not disclosed | Positive | Yes (syphilis) | Community organization |
B (negative) | 24 | Unemployed | >10 | Positive | No | Public social hygiene clinic |
C (transitional) | 30 | Full-time | >10 | Negative | Yes (urethritis, pubic lice) | Public social hygiene clinic; community organization |
D (positive) | 38 | Full-time | >10 | Negative | No | Community organization; private clinic |
E (transitional) | 26 | Full-time | >5 | Negative | No | Public social hygiene clinic; community organization |
F (transitional) | 36 | Full-time | >10 | Negative | Yes (syphilis) | Community organizations |
G (positive) | 30 | Full-time; |
>10 | Negative | No | Public social hygiene clinic; community organization |
H (transitional) | 32 | Full-time | >10 | Negative | No | Community organization |
I (positive) | 22 | Student | >5 | Negative | No | Community organization |
aPeriod between self-identification as homosexual or bisexual and involvement in the local community of men who have sex with men.
bHIV: human immunodeficiency virus.
cSTIs: sexually transmitted infections.
Characteristics of the 9 narrators related to sexual practices (ie, anal intercourse with male sex partners prior to diagnosis or in the past year).
Narrator |
Sexual partnership | Sexual role | Consistent condom usea | Casual funb (venue) | Chem-sexc (drug typed) |
A (negative) | Not recorded | Not recorded | No | No | No |
B (negative) | Not recorded | Not recorded | No | Yes (gay sauna; private party) | Yes (meth, g water, foxy, rush poppers) |
C (transitional) | Regular; casual | Top; bottom | Yes (recent) | Yes (gay sauna; private party) | Yes (rush poppers) |
D (positive) | Regular | Top | Yes (lifetime) | No | No |
E (transitional) | Casual | Top; bottom | Yes (recent) | Yes (gay sauna) | Yes (meth, g water, foxy) |
F (transitional) | Casual | Bottom | Yes (recent) | Yes (gay sauna) | Yes (meth, foxy, ecstasy) |
G (positive) | Regular | Top | Yes (lifetime) | No | Yes (rush poppers) |
H (transitional) | Regular; casual | Top; bottom | Yes (recent) | Yes (gay sauna) | No |
I (positive) | Casual | Top; bottom | Yes (lifetime) | Yes (gay sauna) | No |
aThe response
bThis refers to engaging in anal intercourse with casual sex partners at any local public venues.
cThis refers to taking illicit drugs during or prior to anal intercourse.
dMeth, g water, foxy (ie, foxy methoxy), rush poppers, and ecstasy as slang for methamphetamine; gamma hydroxybutyrate/gamma butyrolactone; 5-methoxy-N,N-diisopropyltryptamine; inhalant alkyl nitrites; and 3,4-methylenedioxy-methamphetamine, respectively, were reported.
There are 6 intervention sessions in total (
An overview of topics in the narrative messages for each intervention session.
Themes and subtopics of narrative messages | Message sources (narrator and role model type) | ||
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1. HIV diagnosis | A (negative) and B (negative) | |
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2. Life impact of living with HIV | A (negative) and B (negative) | |
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3. Problems encountered during HIV treatment | A (negative) and B (negative) | |
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4. Co-infection with other sexually transmitted diseases | A (negative) | |
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1. Active communication about condom use and assessment of partner(s)’ HIV risk | D (positive), C (transitional), and E (transitional) | |
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2. Assertive responses to unwanted condomless sex | A (negative), D (positive), G (positive), C (transitional), and E (transitional) | |
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3. Barriers to condom use when in an emotional relationship | D (positive), G (positive), C (transitional), and E (transitional) | |
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1. Risk of condomless sex with casual partners and norm about condom use at gay saunas | B (negative), D (positive), I (positive), C (transitional), E (transitional), and F (transitional) | |
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2. Unintentional condomless sex encountered during casual fun | B (negative), D, I (positive), C (transitional), E (transitional), and F (transitional) | |
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3. Contextual risk of group sex parties | B (negative), D (positive), C (transitional), and H (transitional) | |
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1. Impact of drug abuse on sexual practices | B (negative), E (transitional), F (transitional), and H (transitional) | |
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2. Impact of drug abuse on other health outcomes | B (negative), D (positive), C (transitional), E (transitional), and F (transitional) | |
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3. Exposure to drugs when seeking sex | B (negative), D (positive), G (positive), I (positive), C (transitional), E (transitional), and F (transitional) | |
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4. Drug addiction | B (negative), E (transitional), and F (transitional) | |
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1. Protective efficacy of condom use | D (positive), G (positive), I (positive), and E (transitional) | |
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2. Correct condom use | D (positive), I (positive), C (transitional), and E (transitional) | |
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3. Consistent condom use | D (positive), G (positive), C (transitional), F (transitional), and G (transitional) | |
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1. Local HIV testing services | D (positive), G (positive), C (transitional), E (transitional), and H (transitional) | |
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2. Regular HIV testing | A (negative), G (positive), I (positive), C (transitional), and H (transitional) |
The topic-equivalent argumentative messages are delivered after narratives. For example, for the subtopic
If the sexual partner is HIV-positive, one could get infected through only a “single” episode of unprotected sexual encounter, ...research studies demonstrated that there was no significant difference in HIV risk between men who have sex with men who “inconsistently use condoms” and those who “have never ever used condoms.”
After videos, a quiz question is asked. For example, “According to the video messages, what type of immune cell was primarily attacked by HIV?” One correct response options (“CD4 cell”) and 2 false response options (“CD3 cell” and “CD8 cell”) are provided. Feedback and reinforcement are not given after the quiz, although users can return to the video during and after the quiz.
The program website can deliver the intervention automatically in a standardized manner: the 6 intervention sessions can be released sequentially on a weekly basis, and each session is accessible upon completion of the preceding session. Users can be assigned a unique password-protected account to access intervention content within a 6-week period, and activities are automatically recorded (eg, the dates and time of completing an intervention video). The program can also send out reminders when a new session is released, or users fail to engage in any activity for 2 to 3 weeks.
We developed a theory-based and evidence-based narrative communication intervention for HIV prevention among men who have sex with men. The communication strategies used by this intervention program to enhance the potential narrative efficacy can be systematically discussed within the 4 basic components of health communication: message, source, recipient, and channel [
Narratives took the form of firsthand experiential stories, in contrast to commonly used fictional stories [
Collective narratives were extracted from a maximum variation sample of local men who have sex with men peers in this study to improve the comprehensiveness of persuasive content [
The targeted recipients are Chinese men who have sex with men, a highly marginalized community where members are strongly connected to each other [
The intervention comprises web-based videos. Video-based narratives have demonstrated strengths in building affection, facilitating identification with characters, and message elaboration, thereby promoting behavior changes [
In response to the call for innovative health communication approaches for HIV prevention, this paper describes the scientific rationale and rigorous procedure of applying narrative persuasion to promote HIV-preventive behaviors among men who have sex with men. This web-based narrative communication intervention can be easily replicated in other contexts and can be incorporated into comprehensive HIV prevention services.
A summary of factors of HIV/STI infection and related behaviors among men who have sex with men in Hong Kong.
human immunodeficiency virus
sexually transmitted infections
This study was funded by the University Grants Committee of Hong Kong 2015-2016 General Research Fund (reference 14612615). We would like to express our heartfelt gratitude to all the narrators and participants in this project.
None declared.