Merlin Greuel

Background: Low influenza vaccination rates in China pose a serious public health threat. The vaccination prevents infection, but widespread vaccine hesitancy remains a significant barrier. Short, animated storytelling videos may help by conveying health messages in an engaging, culturally neutral format that transcends literacy barriers. Objective: We aim to investigate whether scalable, short, animated storytelling videos, using different storytelling techniques—humor, analogy, and emotion—could reduce influenza vaccine hesitancy among Chinese adults. Methods: In this single-blind, parallel-group, randomized controlled trial, we recruited adults in China through quota sampling. Participants were randomly assigned to 1 of 3 short, animated storytelling video intervention groups, each using a different storytelling technique (humor, analogy, or emotion) or a control group in a 1:1:1:1 ratio. After watching the video or being assigned to the control group, participants completed the questionnaire. Influenza vaccine hesitancy was compared between each intervention group and the control group, respectively, as well as between different intervention groups, with P values adjusted for multiple comparisons. Results: A total of 12,000 participants met the inclusion criteria. Participants in any scalable animated storytelling video group showed lower hesitancy than controls (mean difference −0.41, 95% CI −0.60 to −0.23; P<.001). Specifically, both intervention groups with humor (video A) and analogy (video B) storytelling techniques resulted in significantly lower hesitancy compared to the control group, with mean differences of −0.44 (99.17% CI −0.75 to −0.13; P<.001) for video A and −0.55 (99.17% CI −0.86 to −0.24; P<.001) for video B. However, the intervention group with emotion video (video C) did not show significant effects compared to the control group, nor were there significant differences compared with the other 2 intervention groups. In subgroup analyses, video A effectively reduced vaccine hesitancy among urban residents and participants from southern and southwestern China. Video B was effective within participants aged 40‐49 years, both sexes, both urban and rural residents, those with a college education or higher, households with an income of CN ¥90,000‐180,000 (the 2021 official exchange rate of CN ¥1=US $0.155 was used for reference, based on World Bank data), and participants from the southwestern region and the western economic belt. Conclusions: Our study showed that storytelling videos, especially with humor and analogy, reduced hesitancy among Chinese adults. Our results highlight the importance of selecting appropriate narrative strategies for health communication, particularly for vaccine hesitancy across various demographic and regional contexts. Given the scalability, low cost, and high accessibility of short, animated storytelling videos, integrating them into national health campaigns could enhance vaccine uptake and mitigate hesitancy in underserved populations. Future research should explore the long-term impacts of these interventions on vaccine uptake and their adaptability to other preventive health measures.

Background: Stigma toward people with addiction is a well-documented phenomenon that dramatically impacts help-seeking, treatment, and recovery. Interventions aimed at reducing stigma toward those with addiction must overcome the frequent mischaracterization of addiction as a failure of judgment rather than a chronic, treatable illness. Previous research has demonstrated that social contact with people recovering from addiction can promote empathy and reduce stigma, but social contact is difficult to scale. Short, animated storytelling (SAS) is a novel health communication approach that scales easily because it can leapfrog barriers associated with language, culture, literacy, and education levels. Objective: This study will investigate the effect of a cross-culturally accessible SAS video intervention aimed at reducing stigma and increasing empathy toward people with addiction. We also seek to gain insight into the mechanisms of action of this SAS intervention by measuring the contribution of sound design to their effect. Methods: We will conduct a randomized controlled trial with 13,500 adult participants from the United States, the United Kingdom, and South Africa, recruited online via Prolific Academic and randomized into 3 arms, per country. The 2 intervention arms will receive a wordless, social contact–based SAS video, one arm with a soundtrack and one without. The third arm will receive an educational video about addiction. Validated questionnaires will be used to assess our primary outcome, addiction stigma, and secondary outcomes, optimism, warmth toward the subject, and hopefulness, at baseline, immediately post exposure, and 2 weeks later. Ethics clearance was obtained on August 15, 2024, from the Stanford University institutional review board (protocol 76457). Results: This trial was funded in January 2025 by the Heidelberg Institute of Global Health, the Faculty of Medicine at Heidelberg University, in Germany. As of March 2025, no data have been collected. The estimated start date for this trial is May 15, 2025. We expect to complete data collection by July 1, 2025, and expect results to be published in the spring of 2026. Conclusions: Here, we present the protocol for an online, multicountry, randomized controlled trial. This trial is designed to measure the effect of an innovative approach to global health communication (wordless, short, and animated storytelling) on addiction stigma in 3 global regions. These findings will inform the design of future scalable, digital health storytelling interventions for global audiences while exploring the capacity of SAS to shift public health attitudes and perceptions. Furthermore, if effective, the intervention described here could be disseminated broadly via social media and other online platforms. Trial Registration: ClinicalTrials.gov NCT06705205; https://clinicaltrials.gov/study/NCT06705205 International Registered Report Identifier (IRRID): PRR1-10.2196/73382

BACKGROUND Stigma toward people with addiction is a well-documented phenomenon that dramatically impacts help-seeking, treatment, and recovery. Interventions aimed at reducing stigma toward those with addiction must overcome the frequent mischaracterization of addiction as a failure of judgment rather than a chronic, treatable illness. Previous research has demonstrated that social contact with people recovering from addiction can promote empathy and reduce stigma, but social contact is difficult to scale. Short, animated storytelling (SAS) is a novel health communication approach that scales easily because it can leapfrog barriers associated with language, culture, literacy, and education levels. OBJECTIVE This study will investigate the effect of a cross-culturally accessible SAS video intervention aimed at reducing stigma and increasing empathy toward people with addiction. We also seek to gain insight into the mechanisms of action of this SAS intervention by measuring the contribution of sound design to their effect. METHODS We will conduct a randomized controlled trial with 13,500 adult participants from the United States, the United Kingdom, and South Africa, recruited online via Prolific Academic and randomized into 3 arms, per country. The 2 intervention arms will receive a wordless, social contact–based SAS video, one arm with a soundtrack and one without. The third arm will receive an educational video about addiction. Validated questionnaires will be used to assess our primary outcome, addiction stigma, and secondary outcomes, optimism, warmth toward the subject, and hopefulness, at baseline, immediately post exposure, and 2 weeks later. Ethics clearance was obtained on August 15, 2024, from the Stanford University institutional review board (protocol 76457). RESULTS This trial was funded in January 2025 by the Heidelberg Institute of Global Health, the Faculty of Medicine at Heidelberg University, in Germany. As of March 2025, no data have been collected. The estimated start date for this trial is May 15, 2025. We expect to complete data collection by July 1, 2025, and expect results to be published in the spring of 2026. CONCLUSIONS Here, we present the protocol for an online, multicountry, randomized controlled trial. This trial is designed to measure the effect of an innovative approach to global health communication (wordless, short, and animated storytelling) on addiction stigma in 3 global regions. These findings will inform the design of future scalable, digital health storytelling interventions for global audiences while exploring the capacity of SAS to shift public health attitudes and perceptions. Furthermore, if effective, the intervention described here could be disseminated broadly via social media and other online platforms. CLINICALTRIAL ClinicalTrials.gov NCT06705205; https://clinicaltrials.gov/study/NCT06705205 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/73382

Background: Parents play a pivotal role in supporting transgender and gender diverse (TGD) youth. Yet only 35% of TGD youth describe their home as a gender-affirming place. Lack of parental support contributes to recent findings that TGD youth are approximately three times more likely to attempt suicide than their cisgender peers. In contrast, parents’ affirmation of their children’s gender identity significantly improves their mental health outcomes, by reducing anxiety, depression, and suicidality. Objective: Addressing the urgent need for effective, scalable interventions, this study evaluates a novel digital approach: short, animated storytelling videos. We hypothesized that our 2.5-minute video intervention would reduce antitransgender stigma, or transphobia, and improve attitudes toward gender diverse children among US parents. Methods: We recruited 1267 US parents, through the Prolific Academic (Prolific) online research platform, and randomized them into video intervention or control groups. We measured transphobia using the Transgender Stigma Scale, and attitudes toward transgender children using the gender thermometer, before and after watching the video. We compared outcomes between the two groups using 2 × 3 ANOVA. Both groups were invited to return 30 days later for follow-up assessment, before being offered posttrial access to the intervention video, which portrayed an authentic conversation between a mother and her transgender child. Results: Single exposure to a short, animated story video significantly reduced transphobia and improved attitudes toward transgender children among US parents, immediately post intervention. We observed a significant group-by-time interaction in mean Transgender Stigma Scale scores (F_2,1=3.7, P=.02) and significant between-group changes when comparing the video and control groups from baseline to post intervention (F₁=27.4, P<.001). Effect sizes (Cohen d) indicated small to moderate immediate changes in response to the 2.5-minute video, though the effect was no longer observed at the 30-day follow-up. Gender thermometer scores revealed significant immediate improvements in the attitudes of participants in the video intervention arm, and this improvement was sustained at the 30-day time point. Conclusions: Short, animated storytelling is a novel digital approach with the potential to boost support and affirmation of transgender children, by offering authentic insights into the lived experiences of TGD youth. Repeated exposures to such interventions may be necessary to sustain improvements over time. Future studies could test a series of short, animated storytelling videos featuring the lived experiences of several TGD youth. Evaluating the effect of such a series could contribute to the fields of digital health communication and transgender health. Digital approaches, such as short, animated storytelling videos, that support empathy and acceptance of TGD youth could foster a more inclusive society in which every child can thrive.

Background: Stigma toward transgender children and adolescents negatively impacts their health and educational outcomes. Contact with members of stigmatized groups can dismantle stereotypes and reduce stigma by facilitating exposure to the unique cognitive and emotional perspectives of individuals within the group. Recent evidence suggests that video-based contact interventions can be as effective as face-to-face encounters, but challenges lie in protecting the identities of transgender youth, since many of them live in stealth. Objective: This study aims to evaluate the impact of an animated online course, rooted in authentic, personal narratives, on course participants’ stigma toward transgender youth. Methods: The online course was offered free of charge on Coursera and contained 19 teaching videos (3-7 minutes each), intermittent practice quizzes, and discussion prompts. Using real voice recordings of transgender children and their caregivers, the videos were designed to elicit empathy and transmit knowledge. All videos conveying the narratives of transgender youth were animated to protect their identities. A total of 447 course participants, distributed around the globe, completed pre- and postcourse surveys. While the course primarily targeted parents and caregivers of transgender youth, it was open to anyone with a Coursera account. The survey was based on the Transgender Attitudes and Beliefs Scale but modified to reflect the context of parents and caregivers. Using a 5-point Likert scale, it contained 5 questions that captured participants’ levels of transgender stigma. Results of the pre- and postcourse surveys were then compared. Results: The results were obtained in January 2023. Baseline levels of stigma were relatively low (18/25 across all questions, with 25 representing the lowest possible levels of stigma) and decreased further after completion of the course (to 19/25 across all questions, P<.001). A multivariate ordinal probit regression showed that, depending on the question, participants were 7%-34% more likely to endorse statements that indicated the lowest levels of stigma after completing the course. The course was equally effective across all demographics represented in our participant population. Conclusions: Our findings document a significant reduction in stigma toward transgender youth in participants who chose to enroll in the first animated, open online gender health course, rooted in the authentic narratives of transgender youth. Stigma levels decreased significantly after taking the course, even among participants whose baseline levels of stigma were low. Future interventions should include participants with more variable baseline levels of stigma, ideally in the setting of a randomized controlled trial. Despite its limitations, this evaluation adds to the existing evidence that digital, contact-based antistigma interventions, animated to protect the identity of the narrators, can effectively reduce stigma toward transgender youth.

BACKGROUND Stigma toward transgender children and adolescents negatively impacts their health and educational outcomes. Contact with members of stigmatized groups can dismantle stereotypes and reduce stigma by facilitating exposure to the unique cognitive and emotional perspectives of individuals within the group. Recent evidence suggests that video-based contact interventions can be as effective as face-to-face encounters, but challenges lie in protecting the identities of transgender youth, since many of them live in stealth. OBJECTIVE This study aims to evaluate the impact of an animated online course, rooted in authentic, personal narratives, on course participants’ stigma toward transgender youth. METHODS The online course was offered free of charge on Coursera and contained 19 teaching videos (3-7 minutes each), intermittent practice quizzes, and discussion prompts. Using real voice recordings of transgender children and their caregivers, the videos were designed to elicit empathy and transmit knowledge. All videos conveying the narratives of transgender youth were animated to protect their identities. A total of 447 course participants, distributed around the globe, completed pre- and postcourse surveys. While the course primarily targeted parents and caregivers of transgender youth, it was open to anyone with a Coursera account. The survey was based on the Transgender Attitudes and Beliefs Scale but modified to reflect the context of parents and caregivers. Using a 5-point Likert scale, it contained 5 questions that captured participants’ levels of transgender stigma. Results of the pre- and postcourse surveys were then compared. RESULTS The results were obtained in January 2023. Baseline levels of stigma were relatively low (18/25 across all questions, with 25 representing the lowest possible levels of stigma) and decreased further after completion of the course (to 19/25 across all questions, P<.001). A multivariate ordinal probit regression showed that, depending on the question, participants were 7%-34% more likely to endorse statements that indicated the lowest levels of stigma after completing the course. The course was equally effective across all demographics represented in our participant population. CONCLUSIONS Our findings document a significant reduction in stigma toward transgender youth in participants who chose to enroll in the first animated, open online gender health course, rooted in the authentic narratives of transgender youth. Stigma levels decreased significantly after taking the course, even among participants whose baseline levels of stigma were low. Future interventions should include participants with more variable baseline levels of stigma, ideally in the setting of a randomized controlled trial. Despite its limitations, this evaluation adds to the existing evidence that digital, contact-based antistigma interventions, animated to protect the identity of the narrators, can effectively reduce stigma toward transgender youth.

Background: Community health workers (CHWs) have become essential to the promotion of healthy behaviors, yet their work is complicated by challenges both within and beyond their control. These challenges include resistance to the change of existing behaviors, disbelief of health messages, limited community health literacy, insufficient CHW communication skills and knowledge, lack of community interest and respect for CHWs, and CHWs’ lack of adequate supplies. The rising penetration of “smart” technology (eg, smartphones and tablets) in low- and middle-income countries facilitates the use of portable electronic devices in the field. Objective: This scoping review examines to what extent mobile health in the form of smart devices may enhance the delivery of public health messages in CHW-client interactions, thereby addressing the aforementioned challenges and inducing client behavior change. Methods: We conducted a structured search of the PubMed and LILACS databases using subject heading terms in 4 categories: technology user, technology device, use of technology, and outcome. Eligibility criteria included publication since January 2007, CHWs delivering a health message aided by a smart device, and face-to-face communication between CHWs and clients. Eligible studies were analyzed qualitatively using a modified version of the Partners in Health conceptual framework. Results: We identified 12 eligible studies, 10 (83%) of which used qualitative or mixed methods approaches. We found that smart devices mitigate challenges encountered by CHWs by improving their knowledge, motivation, and creativity (eg, through self-made videos); their status within the community; and the credibility of their health messages. The technology stimulated interest in both CHWs and clients—and sometimes even in bystanders and neighbors. Media content produced locally or reflecting local customs was strongly embraced. Yet, the effect of smart devices on the quality of CHW-client interactions was inconclusive. Interactions suffered as CHWs were tempted to replace educational conversations with clients by passively watching video content. Furthermore, a series of technical difficulties experienced especially by older and less educated CHWs compromised some of the advantages brought about by mobile devices. Adequate CHW training ameliorated these difficulties. Only 1 study (8%) considered client health behavior change as an end point, thus revealing a major research gap. Conclusions: Smart mobile devices may augment CHWs’ field performance and enhance face-to-face interactions with clients, yet they also generate new challenges. The available evidence is scarce, mostly qualitative, and focused on a limited range of health outcomes. Future research should include larger-scale interventions across a wide range of health outcomes and feature client health behavior change as an end point.

BACKGROUND Community health workers (CHWs) have become essential to the promotion of healthy behaviors, yet their work is complicated by challenges both within and beyond their control. These challenges include resistance to the change of existing behaviors, disbelief of health messages, limited community health literacy, insufficient CHW communication skills and knowledge, lack of community interest and respect for CHWs, and CHWs’ lack of adequate supplies. The rising penetration of “smart” technology (eg, smartphones and tablets) in low- and middle-income countries facilitates the use of portable electronic devices in the field. OBJECTIVE This scoping review examines to what extent mobile health in the form of smart devices may enhance the delivery of public health messages in CHW-client interactions, thereby addressing the aforementioned challenges and inducing client behavior change. METHODS We conducted a structured search of the PubMed and LILACS databases using subject heading terms in 4 categories: technology user, technology device, use of technology, and outcome. Eligibility criteria included publication since January 2007, CHWs delivering a health message aided by a smart device, and face-to-face communication between CHWs and clients. Eligible studies were analyzed qualitatively using a modified version of the Partners in Health conceptual framework. RESULTS We identified 12 eligible studies, 10 (83%) of which used qualitative or mixed methods approaches. We found that smart devices mitigate challenges encountered by CHWs by improving their knowledge, motivation, and creativity (eg, through self-made videos); their status within the community; and the credibility of their health messages. The technology stimulated interest in both CHWs and clients—and sometimes even in bystanders and neighbors. Media content produced locally or reflecting local customs was strongly embraced. Yet, the effect of smart devices on the quality of CHW-client interactions was inconclusive. Interactions suffered as CHWs were tempted to replace educational conversations with clients by passively watching video content. Furthermore, a series of technical difficulties experienced especially by older and less educated CHWs compromised some of the advantages brought about by mobile devices. Adequate CHW training ameliorated these difficulties. Only 1 study (8%) considered client health behavior change as an end point, thus revealing a major research gap. CONCLUSIONS Smart mobile devices may augment CHWs’ field performance and enhance face-to-face interactions with clients, yet they also generate new challenges. The available evidence is scarce, mostly qualitative, and focused on a limited range of health outcomes. Future research should include larger-scale interventions across a wide range of health outcomes and feature client health behavior change as an end point.