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Abstract

The objectives of this study were to determine if a video improved HIV/AIDS and HIV testing knowledge among a global sample of Internet users, to discern if this improvement was the same for English and Spanish speakers, and to ascertain if the video was efficacious for those with lower health literacy. A worldwide sample of English- or Spanish-speaking Internet users was solicited. Participants completed a 25-item questionnaire to assess their HIV/AIDS and HIV testing knowledge before and after watching the video. Mean scores on the questionnaire improved after watching the video for both English speakers (after: 19.6 versus before: 16.4; Δ = 3.2; 95% confidence interval [CI]: 2.8-3.5) and Spanish speakers (20.7 versus 17.3; Δ = 3.4; 95% CI: 3.0-3.8). There was no difference in improvement of scores between English and Spanish speakers (Δ = −0.24; 95% CI: −0.79 to 0.31), and this video was equally efficacious for those with lower and higher health literacy skills.

Keywords

HIV acquired immunodeficiency syndrome health literacy video–audio media health education survey Internet World Wide Web global sample Hispanic

Introduction

While information about HIV/AIDS is readily available, there still exists a lack of basic knowledge about it worldwide.¹ The number of young people globally with a comprehensive knowledge of HIV/AIDS is one-third of the United Nations General Assembly Special Session’s target. Other research has demonstrated that HIV/AIDS and HIV testing knowledge is lower among those with low health literacy² and Spanish-speaking Latinos than Latino English speakers in the United States.³ A lack of HIV/AIDS knowledge is associated with greater chances of virus acquisition,^4,5 less testing among those at risk,⁶ and more negative stigma⁷ toward those who are infected. Additionally, with the increased availability of at-home HIV testing options,^8

–11 it is even more important for test recipients to be informed about fundamental HIV testing concepts, such as risky behaviors, importance of testing, and how to interpret their test results correctly.

Use of the Internet has increased dramatically across all demographic groups around the world.¹² By the end of 2014, 44% of the world’s households will have Internet access.¹³ Additionally, with social media and other peer-to-peer content sharing platforms, information spread is faster than ever before.⁹ In the Americas, an estimated two-thirds of the general population will be using the Internet by the end of 2014, and the percentage of users in Africa and Asia is expected to increase dramatically. The Internet’s widespread availability and ease of incorporation into education tools make it a powerful medium for the dissemination of health information.

In previous research, we found that an animated and live-action short video on HIV/AIDS and HIV testing (“What do you know about HIV and HIV testing?”) was as efficacious as comparable information delivered in person by a trained HIV test counselor for 18- to 64-year-olds undergoing rapid HIV testing in both clinical and nonclinical settings in the United States.¹⁴ Further, this video was efficacious for those with high and low health literacy skills and for those who primarily spoke English or Spanish. However, its use has not been tested among a global population. It also has not been examined when HIV testing is not being performed concurrently, during which knowledge acquisition may be less due to a lack of context for this information. If the video is shown to be efficacious among a global Internet audience, it can serve as a means to deliver HIV/AIDS and HIV testing rapidly and potentially reduce the negative consequences of lack of knowledge on this topic, thereby increasing awareness for testing and methods of HIV prevention. The global reach of this video could allow for the quick access of this information by English and Spanish speakers around the world, including those in the more HIV-vulnerable areas of Latin America and Africa with a Spanish- or English-speaking population.

The primary objective of this study was to determine whether the video, as an informational intervention, improved self-perceived and examined knowledge of HIV/AIDS and HIV testing fundamentals among a global sample of Internet users of any age who were not concurrently undergoing HIV testing. The secondary objectives were (1) to assess factors associated with lower baseline knowledge about HIV/AIDS and HIV testing and (2) to examine the moderating effects of demographic characteristics, health literacy, and education level on greater improvement of HIV/AIDS and HIV testing knowledge and self-perceived knowledge through the video. Further, we aimed to identify which topic areas from the video were less understood by study participants before and after watching the video, thereby identifying areas for further improvement of the video and other potential interventions to increase HIV/AIDS and HIV testing knowledge.

Methods

This preintervention/postintervention study involved assessing improvement of self-perceived and objectively examined HIV/AIDS and HIV testing knowledge after watching a video. Participants were recruited online over a 6-week period from July to August 2013. The hospital institutional review board approved the study.

Study Sample

We first created a study Web site that hosted the video, “What do you know about HIV and HIV testing?”, and the accompanying 25-item “HIV/AIDS and HIV testing literacy questionnaire.” The study was advertised in English and Spanish. Study participants were solicited through a broad mix of some of the most frequently accessed¹⁵ social networking sites, commerce sites, blogs, bookmarking Web sites, a general search engine, and a research participant solicitation specific Web site (Supplemental Table 1). Study enrollment was open to anyone who accessed the study Web site, indicated that they comprehended English or Spanish, self-reported that they were not known to be HIV infected, and consented to participate. Those who indicated that they were known to be HIV infected were ineligible to participate.

Study Content and Administration

The video and questionnaire used in this study were developed by the study authors and described in detail previously.¹⁴ The 15-minute animated and live-action video contains Centers for Disease Control and Prevention–recommended elements of HIV/AIDS and HIV testing information¹⁶ as well as information about acute HIV infection and current methods of HIV testing.

The questionnaire’s 5 domains examining HIV/AIDS and HIV testing knowledge were the definition and nature of HIV and AIDS, HIV transmission, HIV prevention, HIV testing methods, and the meaning of HIV test results. Self-perceived knowledge was assessed through a single question (“How well informed do you think you are about HIV/AIDS and HIV testing?”) on a 4-point scale (“not well” [0] to “very well” [3]). Health literacy was assessed using 3 questions from the Rapid Estimate of Adult Literacy in Medicine (REALM) as recommended from previous studies for their ability to accurately stratify people by health literacy skill levels.^17,18 It has been shown that at least one of these screening questions might be able to detect marginal health literacy skills.

Participants answered questions about their demographic characteristics, HIV testing history, the health literacy questions, the self-perceived knowledge question, and then the HIV/AIDS and HIV testing knowledge questionnaire. The testing knowledge questionnaire was used as the objective assessment of knowledge. Next, they watched the video. The study Web site did not allow participants to fast-forward through the video to the postvideo questionnaire and did not allow them to watch the video again. Afterwards, they answered the self-perceived and objective knowledge questions again. After completing the study, all participants were offered the chance to enter a lottery for one of the 4 US$50 Amazon.com gift cards. Participants were shown the correct and incorrect answers to the questionnaire after completing the study.

Data Analysis

A study enrollment flow diagram, in accordance with the Consolidated Standard of Reporting Trials (CONSORT) guidelines¹⁹ and stratified by language spoken, is shown in Figure 1. Demographic characteristics, HIV testing history, and health literacy responses were reported as median and interquartile range for continuous variables and percentages for categorical variables, as appropriate. English- and Spanish-speaking participants were compared according to their demographic characteristics, HIV testing history, and health literacy responses using Student’s t tests for continuous variables and chi-square tests for categorical variables. An α = .05 level of significance was used for these and all other comparisons.

Figure 1.

Study enrollment diagram.

The proportions of “pre” (before watching the video) and “post” (after watching the video) correct and “don’t know” responses to the 25-item HIV/AIDS and HIV testing knowledge questionnaire were summarized by language. Scores on the questionnaire were tabulated (range 0-25 points based on correct responses) for the pre- and postquestionnaires and stratified by language. Overall prevideo mean scores and the 5 domain mean scores along with their 95% confidence intervals (CIs) were calculated. Differences in prevideo scores were calculated by language. Within each language, differences between post- and prescores were calculated for each domain overall and by language along with 95% CIs of their differences. Univariable and multivariable linear regression models were created to examine factors associated with lower overall prevideo scores and greater improvement in scores (postvideo versus prevideo). Demographic characteristics, HIV testing history, health literacy level, and language were used as covariates in these models. An α = .20 level of significance was used to help identify variables from the univariable analyses for inclusion in the multivariable models. Beta (β) coefficients with corresponding 95% CIs were estimated.

Results

Study Enrollment and Participant Characteristics

There were 482 participants who completed the English version of the study (English speakers) and 335 participants who completed the Spanish version (Spanish speakers) (Figure 1). North America and Asia had the highest representation in our sample overall (Supplemental Table 2). India and the United States were the most heavily represented in our English-speaking sample, while Central and South American countries were more represented in our Spanish-speaking sample. English speakers generally had more years of formal education (Table 1). Spanish-speaking participants were more likely to have been previously tested for HIV. There was no difference between the 2 language groups in gender composition, time since last HIV test, self-reported language skills, or age. Based on the comparison of the health literacy results of our groups, English speakers were more confident in completing medical forms. However, Spanish speakers were less likely to self-report needing help with completing the forms. No difference existed among the 2 language groups for perceived difficulty reading and understanding medical forms as measured by REALM.

Table 1.

Demographic Characteristics, HIV Testing History, and Health Literacy.

	English Speakers	Spanish Speakers	P Value
	n = 482	n = 335	P<
Demographic characteristics
Age in years, median (IQR)	28.0 (23.5-36.0) %	28.0 (22.0-36.0) %	.94
Gender (female)	43.4	48.7	.23
Ethnicity/race			.00
White/Hispanic	3.7	46.7
Black/Hispanic	35.0	10.0
White/Non-Hispanic	26.5	7.7
Black/Non-Hispanic	2.8	0.5
Asian	49.9	7.7
Pacific Islander	0.5	0.3
Native American/American Indian	0.4	0.3
Formal education (highest level completed)			.01
Elementary	0.6	0.6
High school	2.7	5.7
General equivalency diploma	9.1	12.2
Some college	26.4	33.4
Completed college	44.4	37.9
Graduate school	16.8	10.2
Self-reported language skills (English or Spanish)
Very well	79.9	84.5	.03
Well	19.1	13.7
Somewhat	0.6	0.9
Not well	0.4	0.9
Self-reported HIV testing history
Have ever been tested for HIV	36.7	53.1	.00
Last HIV test
<6 months	21.5	23.6	.08
>6 months, <1 year	15.3	21.4
>1 year, <2 years	20.9	17.4
>2 years, <5 years	19.8	24.2
>5 years	22.0	13.5
Health literacy assessments
Confidence with completing forms			.00
Not at all	2.9	16.1
A little bit	7.5	14.6
Somewhat	17.2	27.2
Quite a bit	32.8	29.9
Extremely	39.6	12.2
Difficulty reading/understanding forms			.43
Most of the time	3.9	2.7
Some of the time	18.5	16.4
A little of the time	32.4	35.8
None of the time	45.2	45.1
Needing help with forms			.01
Most of the time	6.0	2.4
Some of the time	16.6	16.1
A little of the time	30.9	26.0
None of the time	46.5	55.5

Abbreviation: IQR, interquartile range.

Prevideo Knowledge

For both English speakers and Spanish speakers, prevideo knowledge was lowest in the “testing methods” and “meaning of HIV test results” domains and highest in the “HIV prevention” domain (Table 2). Before watching the video, English speakers had lower overall objective prevideo knowledge and lower self-perception of HIV/AIDS and HIV testing knowledge than Spanish speakers. In the multivariable analysis, lower prevideo scores on the objective knowledge items were more likely among English speakers and those with fewer years of formal education, lower self-reported language skills, lower self-perceived HIV/AIDS and HIV testing knowledge, and lower health literacy (Table 3).

Table 2.

Changes in HIV/AIDS and HIV Testing and Self-Perception of Knowledge.

	English Speakers			Spanish Speakers			Difference in Prevideo Scores, English Spanish	Difference in Post-Prevideo Scores, English Spanish
	Prevideo	Postvideo	Δ Postvideo−Prevideo	Prevideo	Postvideo	Δ Postvideo−Prevideo	Difference in Prevideo Scores, English Spanish	Difference in Post-Prevideo Scores, English Spanish
	n = 482	n = 482	n = 482	n = 335	n = 335	n = 335
	Mean (95% CIs)	Mean (95% CIs)	Δ (95% CIs)	Mean (95% CIs)	Mean (95% CIs)	Δ (95% CIs)	Δ (95% CIs)	Δ (95% CIs)
Questionnaire scores by domains
Definition and nature of HIV/AIDS	3.59 (3.46 to 3.70)	4.18 (4.08 to 4.29)	0.60 (0.50 to 0.70)	3.99 (3.86 to 4.11)	4.59 (4.49 to 4.68)	0.60 (0.48 to 0.72)	−0.40 (−0.58 to −0.22)	0.00 (−0.15 to 0.15)
HIV transmission	3.53 (3.43 to 3.63)	4.33 (4.23 to 4.42)	0.80 (0.70 to 0.90)	3.62 (3.50 to 3.74)	4.51 (4.41 to 4.60)	0.90 (0.76 to 1.02)	−0.08 (−0.25 to −0.07)	−0.09 (−0.26 to 0.08)
HIV prevention	4.00 (3.90 to 4.10)	4.36 (4.26 to 4.45)	0.36 (0.26 to 0.45)	3.84 (3.72 to 3.96)	4.33 (4.23 to 4.43)	0.50 (0.38 to 0.61)	0.16 (0.01 to 0.31)	−0.14 (−0.28 to 0.00)
HIV testing methods	2.56 (2.45 to 2.67)	3.57 (3.46 to 3.68)	1.00 (0.88 to 1.14)	2.92 (2.78 to 3.05)	3.93 (3.81 to 4.04)	1.01 (0.86 to 1.16)	−0.36 (−0.53 to −0.18)	0.00 (−0.20 to 0.20)
Meaning of HIV test results	2.73 (2.63 to 2.83)	3.13 (3.04 to 3.22)	0.40 (0.30 to 0.51)	2.90 (2.78 to 3.02)	3.31 (3.21 to 3.41)	0.40 (0.28 to 0.54)	−0.17 (−0.33 to −0.02)	0.00 (−0.17 to 0.16)
Total score	16.4 (16.00 to 16.79)	19.57 (19.18 to 19.96)	3.16 (2.81 to 3.52)	17.27 (16.82 to 17.72)	20.67 (20.29 to 21.05)	3.40 (2.98 to 3.83)	−0.86 (−1.45 to −0.27)	−0.24 (−0.79 to 0.31)
Self−perception of HIV/AIDS and HIV testing knowledge	2.75 (2.67 to 2.82)	3.39 (3.33 to 3.45)	0.64 (0.56 to 0.72)	2.82 (2.74 to 2.90)	3.52 (3.45 to 3.59)	0.70 (0.61 to 0.79)	−0.07 (−0.18 to 0.04)	−0.06 (−0.18 to 0.06)

Abbreviation: CI, confidence interval.

Table 3.

Factors Associated with Lower Total Prevideo Questionnaire Score and Greater Improvement in Post–Prevideo Questionnaire Total Score.^a

	Univariable		Multivariable
	Prevideo Score	Postvideo–Prevideo Score	Prevideo Score	Postvideo–Prevideo Score
	β (95% CI)	β (95% CI)	β (95% CI)	β (95% CI)
Language
English	0.86 (0.27 to 1.45)	0.24 (−0.31 to 0.80)	0.11 (−0.34 to 0.56)
Age
Years	0.03 (0.00 to 0.05)	0.01 (−0.02 to 0.03)	0.00 (−0.02 to 0.02)	0.01 (−0.02 to 0.03)
Language
Male	0.52 (−0.07 to 1.10)	0.57 (0.03 to 1.11)	0.33 (−0.20 to 0.86)	0.52 (0.00 to 1.05)
Education
Elementary	0.62 (0.34 to 0.90)	−0.43 (−0.69 to −0.16)	0.33 (0.07 to 0.60)
Language proficiency (“How well can you understand English/Spanish?”)
Not well	2.33 (−1.72 to −2.94)	0.48 (−0.10 to 1.07)	1.70 (1.09 to 2.29)
Self-perception of HIV/AIDS and HIV testing knowledge before video
Not informed	1.64 (1.30 to 2.00)	−1.37 (−1.70 to −1.04)	1.26 (0.90 to 1.61)
Self-perception of HIV/AIDS and HIV testing knowledge after video
Not informed	1.49 (1.06 to 1.92)	0.57 (0.16 to 0.97)	0.58 (0.15 to 1.00)
Self-perception of HIV/AIDS and HIV testing knowledge
Before video−after video	−0.56 (−0.90 to −0.21)	1.61 (1.30 to 1.92)		1.58 (1.27 to 1.88)
Confidence with completing forms
Not at all	0.49 (0.25 to 0.72)	−0.24 (−0.46 to −0.02)	0.12 (−0.10 to 0.34)	−0.25 (−0.46 to −0.03)
Difficulty reading/understanding forms
Most of the time	0.82 (0.48 to 1.16)	0.13 (−0.19 to 0.45)	−0.10 (−0.47 to 0.26)
Needing help with forms
Most of the time	1.28 (0.96 to 1.60)	0.05 (−0.25 to 0.36)	1.03 (0.68 to 1.39)
Time (minutes)	0.00 (0.00 to 0.00)	0.00 (0.00 to 0.00)	0.55 (−2.29 to 3.39)
Source from which the study was accessed
Facebook	0.23 (−0.05 to 0.52)	−0.07 (−0.33 to 0.19)

Abbreviations: β, β -coefficient; CI, confidence interval.

^aReference group is noted in row underneath factor name.

Improvement in Knowledge

Self-perceived knowledge and mean scores on the objective knowledge items improved for both English and Spanish speakers (Table 2) after watching the video. This improvement reflected an overall increase in 3 or more correct responses on the objective knowledge items on average. Improvement in self-perceived knowledge and objective knowledge mean scores did not differ by language. Don’t know responses also decreased post versus pre for both language groups (Supplemental Table 3a and b). Participants from both language groups showed the greatest improvement in scores for the HIV testing methods domain and the least improvement in the meaning of HIV test results and HIV prevention domains.

In the multivariable analysis, participants with lower and higher health literacy skills had similar improvement in scores after adjusting for demographic characteristics, language, and HIV testing history (Table 3). Greater improvement in scores was associated with more years of formal education and a larger increase in self-perceived HIV/AIDS and HIV testing knowledge. Age, language, language skills, and education were not significantly associated with improvement in objective knowledge.

Knowledge by Questionnaire Topic

Among English speakers and Spanish speakers, fewer than 70% responded correctly to 4 of the questions in the testing methods and meaning of HIV test results domains prevideo (Supplemental Table 3a and b). Fewer than 50% of English-speaking participants responded correctly to 3 questions, and fewer than 50% of Spanish-speaking participants responded correctly to 2 questions in the HIV testing methods domain prevideo.

Both English and Spanish speakers showed the greatest improvement in the question “Can oral fluids be used for an HIV test?” (HIV testing methods). All other questions showed improvement for both language versions except for Q15 (“If your HIV test result is negative, does this mean that it is impossible for your body to become infected with HIV in the future?”), which showed slightly worse performance postvideo.

Discussion

The video “What do you know about HIV and HIV testing?” improved HIV/AIDS and HIV testing knowledge among a global sample of English- or Spanish-speaking Internet users, and this improvement in knowledge was similar by language. Thus, this video can be an efficacious, informational tool for speakers of either language. Additionally, the video improved self-perceived knowledge for both English- and Spanish-speaking participants. This finding suggests that participants felt more confident about their knowledge of HIV/AIDS and HIV testing after watching the video. In turn, they may be more prepared to seek HIV testing and preventive measures.

This video appears to be equally efficacious for those with low and high health literacy. Because those with lower health literacy are more likely to lack knowledge about HIV and HIV testing,² this video can serve as a tool to provide important information to this population in a readily accessible and inexpensive manner. In addition, improvements in knowledge were made regardless of age or other demographic characteristics, which indicate its value for a wide audience.

Participants showed the greatest improvement after watching the video for the HIV testing methods domain. This domain included topics such as the use of oral fluids for testing and the circumstances for getting tested. This finding is important because the availability of more testing options results in the need for more information about these different testing methods. The question that had the most improvement in performance was “Can oral fluids be used for an HIV test?” Improvements in knowledge about this topic indicate that people can be made aware of the less intrusive oral testing options that can be conducted at home. Participants also showed relatively greater improvement in the question “Is it necessary to wait 1 to 2 weeks to receive the results of a rapid HIV test?” Again, this finding is important because it demonstrates that people can be made aware of opportunities to receive HIV test results sooner through rapid HIV testing. Participants had the lowest improvement in HIV prevention and the meaning of HIV test results. One potential explanation for this is that participants had relatively high baseline knowledge about HIV prevention and therefore there was less room for improvement. However, additional research is needed to determine whether there are other explanations and/or whether our approach to improving knowledge in this area should be reexamined.

In terms of future research and applications of the study findings, a follow-up study of this video could focus on the impact of knowledge improvement and knowledge retention over time. Future research also should involve adapting this video for other languages (eg, Mandarin, Hindi, Swahili, and Shona). Different methods of video dissemination (in classroom settings, waiting rooms, etc) also should be examined. Other research has shown that a youth-friendly HIV video can be effective for conveying information to adolescents²⁰ and that video games may improve HIV knowledge.²¹ We believe that our study and these other studies demonstrate the value, cost-effectiveness, and applications of alternative forms of education beyond formal, in-person presentations. The impact of the video on knowledge retention, impact on HIV risk-taking behaviors, and HIV testing can be evaluated in future research.

Limitations

While we recruited a global sample of participants, ours is not a random sample. Furthermore, much of the sample were from a few countries, and not all English- or Spanish-speaking countries were represented. Thus, we do not claim to be representative of all Internet users around the world, non-Internet users, and all English or Spanish speakers (whether Internet users or not). A very small percentage of people in both language groups indicated lower language proficiency, and most of these individuals were English speakers. This lower language proficiency, along with differences in education backgrounds and HIV testing histories, among English speakers might partially account for the differences in baseline knowledge as compared to Spanish speakers. Similar to many survey-based studies, there was a substantial proportion of participants who did not complete the entire study. We cannot know how well those who left the study would have performed. It is possible that the utility of a video to inform Internet users about HIV/AIDS and HIV testing could be adversely affected if dropout were high when it is used as an information intervention outside of the context of a study. Furthermore, we did not compare the video against other types of information dissemination and did not examine the retention and impact of knowledge over a longer period. We also excluded from our global study sample those who did not speak English or Spanish, so the external validity of this approach to HIV/AIDS and HIV testing knowledge improvement is not yet known for speakers of other languages. Although we obtained some demographic characteristics data as well as health literacy assessments on study participants, we did not inquire about other characteristics (eg, concern about risk for HIV, interest in HIV testing, HIV risk behaviors, and sexual orientation) that might have influenced attention to the information presented in the video and hence performance on the questionnaires. Finally, although we took great care to develop and evaluate our questionnaire prior to its administration, some questions may not have been optimally presented (eg, use of a double negative in Q15), which might have impacted results.

Conclusion

The video “What do you know about HIV and HIV testing?” can improve self-perceived and objectively tested knowledge about HIV/AIDS and HIV testing fundamentals for both English- and Spanish-speaking Internet users. The video appears to be useful for those with low health literacy skills. This video might be especially helpful for those who are interested in Internet-based self-learning, home-based HIV testing, and widespread educational efforts.

Footnotes

Authors’ Note

The preliminary results from this study were presented at the Center for Disease Control and Prevention National Conference on Health Communication, Marketing, and Media in Atlanta, Georgia, on August 20, 2014.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Ms Shao was supported by a summer undergraduate research opportunity from the Lifespan/Tufts/Brown Center for AIDS Research (P30AI042853), which is supported by a grant from the National Institute of Allergy and Infectious Diseases. Mr Guan was supported by a graduate assistantship from the Brown University Department of Emergency Medicine.

Supplemental Material

The online supplemental tables are available at .

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Supplementary Material

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Does a Video Improve Knowledge of HIV/AIDS and HIV Testing among a Global Internet Audience?