Effectiveness of audiovisual interventions in increasing knowledge about sexually transmitted infections: a systematic review

Silva, Emanoelle Fernandes; Mendes, Polyana Norberta; Galvão, Marli Teresinha Gimeniz; Macêdo, Danielle Nedson Rodrigues de; Martins, Breno Dias de Oliveira; Magalhães, Rosilane de Lima Brito

doi:10.1590/1518-8345.7531.4704

person Emanoelle Fernandes Silva

Substantial contributions to the conception or design of the work · or the acquisition, analysis, or interpretation of data for the work · drafting the work or reviewing it critically for important intellectual content · final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved · Data curation · Project supervision and management

schoolUniversidade Federal do Piauí, Teresina, PI, Brazil.schoolScholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil.

0000-0002-4328-6155

person Polyana Norberta Mendes

Substantial contributions to the conception or design of the work · or the acquisition, analysis, or interpretation of data for the work · drafting the work or reviewing it critically for important intellectual content · final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved · Data curation · Project supervision and management

schoolUniversidade Federal do Piauí, Teresina, PI, Brazil.schoolCentro Universitário Santo Agostinho, Teresina, PI, Brazil.

0000-0002-2765-0236

person Marli Teresinha Gimeniz Galvão

Substantial contributions to the conception or design of the work · or the acquisition, analysis, or interpretation of data for the work · drafting the work or reviewing it critically for important intellectual content · final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved · Data curation · Project supervision and management

schoolScholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil.schoolUniversidade Federal do Ceará, Fortaleza, CE, Brazil.

0000-0003-3995-9107

person Danielle Nedson Rodrigues de Macêdo

Substantial contributions to the conception or design of the work · or the acquisition, analysis, or interpretation of data for the work · drafting the work or reviewing it critically for important intellectual content · final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved · Data curation

schoolScholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil.schoolUniversidade Federal do Piauí, Departamento de Enfermagem, Teresina, PI, Brazil.

0000-0002-8804-6323

person Breno Dias de Oliveira Martins

Substantial contributions to the conception or design of the work · or the acquisition, analysis, or interpretation of data for the work · drafting the work or reviewing it critically for important intellectual content · final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved · Data curation

schoolUniversidade Federal do Piauí, Departamento de Enfermagem, Teresina, PI, Brazil.schoolScholarship holder at the Universidade Federal do Piauí (UFPI), Brazil.

0009-0006-7835-7861

person Rosilane de Lima Brito Magalhães

Substantial contributions to the conception or design of the work · or the acquisition, analysis, or interpretation of data for the work · drafting the work or reviewing it critically for important intellectual content · final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved · Data curation · Project supervision and management

schoolUniversidade Federal do Piauí, Teresina, PI, Brazil.

0000-0001-9695-1350

personCorresponding author: Emanoelle Fernandes Silva E-mail:
emanoellefs@gmail.com https://orcid.org/0000-0002-4328-6155

Conflict of interest:

the authors have declared that there is no conflict of interest.

Associate Editor:

Karina Dal Sasso Mendes

Authors, year, and location	Sample/follow-up time	*IG/type of educational technology**	CG ^† /type of technology	Knowledge assessment tool	Key findings
Solomon, DeJong. 1988. USA ( ¹⁶ )	n=175/14 days	Video: “It Just Happens Sometimes” (10 min; n=83) Type/STI ^‡: Educational video/Gonorrhea Content: Characters discussing symptoms, treatment, and prevention, with an emphasis on counseling for diagnosis. Target audience: Black men with gonorrhea.	Group without educational video (n=92).	18-item true/false test.	Knowledge: Average number of correct answers IG* 16.6 (sd ^§ = 1.7), CG ^† 13.3 (sd ^§ = 2.2; 1(239) =13.4, p ^\|\| <0.0001). Attitude: Willingness to notify sexual contacts (p ^\|\| >0.05) between IG* and CG ^† .
Downs, et al. 2004. USA ( ¹⁹ )	n=300/6 months	Video: (1 h; n= not explicit) Type/STI ^‡: Interactive video / STI ^‡ Content: Negotiation behaviors, effective condom use, female reproductive anatomy, and physiological responses to infections. Target audience: Female adolescents.	Reading materials (n=not explicit).	40-item true/false test.	Knowledge: Mean difference between IG* and CG ^† , 5.3 points and 5.1 points, respectively. Significant improvements in knowledge over time (overall: F ^¶ (1,214= 69.09, p ^\|\| <0.001; specific: F ^¶ (1,214)= 58.62, p ^\|\| <0.001).
Merchant, et al. 2009. USA ( ²¹ )	n=574/no follow-up	Video: “Do you know about rapid HIV testing?” (9.5 min; n=270) Type/STI ^‡: Educational video/HIV Content: Definition, transmission, prevention, and testing. Target audience: Adults who visited an urgent care center or emergency room.	Face-to-face session with HIV** testing counselor (n=304).	26-question “Rapid HIV** Pretest Information Comprehension” questionnaire.	Knowledge: Mean difference IG* vs. CG ^† = 0.68 (CI ^†† 95%; 0.18-1.26; p ^\|\| <0.05). The mean scores differed by less than one correctly answered question.
Sánchez, et al. 2010. USA ( ²³ )	n=206/ no follow-up	Vídeo: “Syphilis and Men” (5 min; n=100) Type/STI ^‡: Educational video/Syphilis Content: Transmission, symptoms, treatment, connection between syphilis and HIV**, and risk reduction. Target audience: Men who visited an urgent care center or emergency room.	Standard care without video on syphilis (n=106).	Questionnaire with 10 multiple-choice questions.	Knowledge: IG* scored on average 24.8% higher than CG ^† in the post-intervention test (p ^\|\| < 0.001). IG* scored on average 24.8% higher than CG ^† in the post-intervention test (p ^\|\| < 0.001).
Sánchez, Guilliames, et al. 2010. USA ( ²⁴ )	n=168/no follow-up	Video: “Syphilis and Men” (5 min; n=85) Type/STI ^‡: Educational video/Syphilis Content: Transmission, symptoms, treatment, connection between syphilis and HIV**, and risk reduction. Target audience: Black men who have sex with men.	“Syphilis is Back” Palm Card (n=83).	A questionnaire developed by researchers (10 multiple-choice questions).	Knowledge: IG* 8.9 to 9.8 correct answers, CG ^† 6.9 to 7.9 correct answers. Increase from 19.5% to 20.9% in the post-test score for IG* (p ^\|\| <0.05).
Calderon, et al. 2011. USA ( ²⁵ )	n=200/no follow-up	Video: (4 min, n=100) Type/STI ^‡: Educational video/HIV Content: Covers seven essential elements for a pre-test counseling session for HIV. Target audience: Adolescents.	Face-to-face session with HIV testing counselor** (n=100).	10-question survey created by Carey and Schroder, and questions from the New York State Department of Health.	Knowledge: Mean difference IG* vs. CG ^† = 12.2% (p ^\|\| <0.01); IG* 78.5% correct and CG ^† 66.3% correct. Attitude: Accepting HIV testing*: IG, OR ^‡‡ = 3.6x (CI ^†† 95%:1.8–7.2; p ^\|\| <0.001) compared to CG ^† .
Krawczyk, et al. 2012. Canada ( ³⁶ )	n=200/no follow-up	Video (5 min, n=74) + Educational pamphlet (n=61) Type/STI ^‡: Video + Pamphlet/HPV ^§§ Content: The video features a doctor discussing the incidence, transmission, consequences of the virus, and effectiveness of the vaccine. The pamphlet provides information about HPV ^§§ and the vaccine. Target audience: College students.	Only pamphlet on cancer prevention in general (n=65).	22-item test (evaluation: true, false, and don’t know).	Knowledge: Average correct answers IG* (pamphlet) = 17.46; IG* (video) = 16.70; CG ^† = 12.06 (p ^\|\| <0.001). Attitude: Increase in vaccination intention for IG* (pamphlet) and IG* (video) compared to CG ^† (p ^\|\| < 0.001).
Merchant, et al. 2014. USA ( ²⁷ )	n=150/ no follow-up	Video: (9.5 min, n=75) Type/STI ^‡: Educational video/HIV Content: Definitions, nature, transmission, prevention, testing methods, and interpretation of HIV results. Target audience: Spanish-speaking Latinos.	Oral information from HIV testing counselor** (n=75).	25-item test (Assessment: yes, no, don’t know).	Knowledge: Mean difference IG* vs. CG ^† = IG* 20.4 (95% CI ^††: 19.5-21.3); CG ^† 20.6 (95% CI ^††: 19.7-21.5), indicating similarity (95% CI ^††: -1.4-1.1).
Hadley, et al. 2016. USA ( ²⁸ )	n=170/3 months	DVD + book: “Work It Out Together” (20 min/module; n=83) Type/STI ^‡: Interactive DVD + activity book/HIV** Content: Six modules addressing communication between parents and adolescents, prevention, condom use, negotiating safe sex, skills, and decision-making. Target audience: Adolescents.	General health promotion DVD (n=87).	Knowledge test with 10 items (true, false, uncertain).	Knowledge: Average correct answers IG= 6.71; CG ^† = 6.45. Parents scored higher (t ^\|\|\|\| (158)=2.00, p ^\|\| <0.05). Attitude: IG (parents) greater self-efficacy to engage in preventive behaviors (t ^\|\|\|\| (158)= 2.28, p ^\|\| <0.05). Attitude: IG* (adolescents) greater self-efficacy to use condoms (t ^\|\|\|\| (64)= 2.06, p ^\|\| <0.05).
Ortíz, et al. 2022. Mexico ( ⁶ )	n=33/7 days	Vídeo: “7 cosas que debes saber sobre el VPH ^§§ !” (3 min; n=16) Type/STI ^‡: Educational video/HPV ^§§ Content: Definition, forms of transmission, symptoms, diagnosis, treatment, and prevention. Target audience: Young people over the age of 18.	Group without educational video (n=17).	38-item test (True, False, and Don’t Know).	Knowledge: IG* higher than CG ^† (p ^\|\| =0.020 and p ^\|\| =0.024, respectively). Average correct answers IG*= 30.75 (sd ^§ = 2.32); CG ^† 28.18 (sd ^§ = 3.55).

Authors, year, and location	Sample/follow-up time	*IG/type of educational technology**	CG ^† /type of technology	Knowledge assessment tool	Key findings
Rhodes, Wolitski. 1989. USA ( ¹⁷ )	n=441/6 weeks	Videos: (16-20 min; n= not explicit) Type/STIs ^‡: 4 Informational videos/Aids Content: (1) Aids: Acquired Immune Deficiency Syndrome, 1986, 18 min; (2) Aids: What Everyone Needs to Know, 1986, 18 min; (3) Beyond Fear: The Virus, 1986, 20 min; (4) Sex, Drugs, and Aids, 1986, 16 min. Target audience: University students.	Did not watch any of the videos (n= not explicit).	True and false test with 23 items.	Knowledge: Increase in knowledge in the four videos (p ^§ <0.001), superior to CG ^† in the late post-test (p ^§ <0.01).
Lipson, Brown. 1991. USA ( ¹⁸ )	n=144/1 month	Video: (19-40 min; n=90) Type/STIs ^‡: 3 Informative Videos/Aids Contents: (1) Sex, Drugs, and Aids, 19 min; (2) Aids: Beyond Fear, 40 min; (3) Aids: What You Need to Know, 40 min. Target audience: University students.	The video “Where Did I Come From?” addresses sex education, but not HIV/Aids (n=54).	55-item questionnaire (The most correct answer received a score of 4, and the least correct answer received a score of 0).	Knowledge: Average difference IG* vs. CG ^† = 15.93 points (p ^§ <0.01). Attitude: IG* improvements in attitudes toward preventive behaviors, average difference of 1.33 points compared to CG ^† (p ^§ <0.01).
Torabi, et al. 2000. Russia ( ³³ )	n=1.124/2 weeks	Video: (2 h; n=731) Type/STI ^‡: Informational video/HIV ^\|\| Content: Prevention, using lecture techniques, illustrations, and questions and answers. Target audience: Adolescents.	Usual academic program, excluding education about HIV/Aids (n=393).	51-question test (“yes,” “no,” and “not sure”).	Knowledge: IG* scores were higher than CG ^† scores (F ^¶ =58.73, p§<0.01).
Velásquez. 2005. Peru ( ³⁴ )	n=454/there was no follow-up	CD: “ Planeta Riesgo Xero ” (duration not specified; n=454) Type/STI ^‡: Educational CD/STI ^‡ and HIV ^\|\| Content: Everyday stories of adolescents, game about decision-making, general information, risks, myths, and beliefs. Target audience: Adolescents.	There was no CG.	Questionnaire with 101 questions divided into four sections.	Knowledge: 3x increase in knowledge about HIV ^\|\| and 6x increase in knowledge about Aids ( p ^§ <0.001). Increased likelihood of knowing about gonorrhea (OR=5.4), syphilis (OR=4.8), chlamydia (OR=13.2), genital herpes (OR=3.7), and soft chancre (OR**=2.3, p ^§ <0.001).
Brock, Smith. 2007. USA ( ²⁰ )	n=51/4 to 6 weeks	Video: (25 min; n=51) Type/STI ^‡: Educational video/HIV ^\|\| Content: Shown on a Personal Digital Assistant (PDA), containing information on adherence to antiretroviral medication. Target audience: Infectious disease outpatient clinic patients.	There was no CG.	Instrument with nine questions.	Knowledge: Improvements in knowledge of HIV ^\|\| and treatment ( p ^§ <0.005). Attitude: Increase in self-efficacy for treatment adherence ( p ^§ <0.005).
Camargo, Barbará, Bertoldo. 2008. Brazil ( ³⁵ )	n=141/1 week	Videos: (duration not specified) Type/STI ^‡: Documentary videos/HIV ^\|\| Content: Video 1, scientific approach, development of Aids, prevention, and details of the disease (n=46). Video 2, basic information and testimonials from adolescents living with the virus (n=39). Target audience: Adolescents.	Did not watch any of the videos (n=56).	Scientific knowledge test on Aids.	Knowledge: IG1 showed better knowledge than IG2 and CG ^† (F ^¶ =8.15; p ^§ <0.001).
Mayor. 2010. USA ( ²² )	n=110/8 weeks	Multimedia program: (25-35 min/session; n=110) Type/STI ^‡: Educational program/HCV ^†† Content: Developed in PowerPoint, it addresses susceptibility, protective measures, and the relationship with HIV ^\|\| .	There was no CG.	Self-administered questionnaire with Likert scale.	Knowledge: Understanding that hepatitis C is a viral condition increased from 73.1% to 85.2% (p ^§ =0.03). Understanding that HCV ^†† is predominantly found in blood increased from 92% to 98.2% (p ^§ =0.01).
Mayor. 2013. Puerto Rico ( ³⁷ )	n=88/6 months	Target audience: Patients living with HIV ^\|\| . Multimedia program: (duration not specified; n=88) Type/STI ^‡: Educational program/HCV ^†† Content: Developed in PowerPoint, it addresses susceptibility, protective measures, and the relationship with HIV ^\|\| . Target audience: Drug users with HIV ^\|\| .	There was no CG.	Self-administered questionnaire with Likert scale.	Knowledge: Increased awareness of clinical manifestations, risk behaviors, prevention practices, and synergisms of HIV ^\|\| /HCV ^†† coinfection (p ^§ <0.05). Behavior: Reduction in sharing of syringes and drug preparation equipment from 39.8% to 13.6% (p ^§ <0.001).
Wells, Clark, Sarno. 2014. USA ( ²⁶ )	n=49/ there was no follow-up	Multimedia program: (1.5 hours, n=49) Type/STI ^‡: Interactive program/HIV ^\|\| Content: Computer-based, focused on prevention. Target audience: Men with mild to moderate intellectual disabilities.	There was no CG.	Questionnaire with 44 questions.	Knowledge: Gains in all areas evaluated, with an average effect size of 0.67 (large effect).
Jadranin. 2015. Serbia ( ³⁸ )	n=102/ no follow-up	Film: “HIV/Aids prevention and control in the Serbian Armed Forces” (17 min, n=102) Type/STI ^‡: Educational film/HIV ^\|\| Content: Prevention, transmission, disease progression, and testing. Target audience: Armed forces soldiers.	There was no CG.	23-question multiple-choice questionnaire.	Knowledge: Average difference before and after = 1.91 points, with an increase in score after the intervention (p ^§ <0.001).
Shao. 2016. Online study ( ³⁹ )	n=817/6 weeks	Video: (15 min, n=817) Type/STI ^‡: Informative video/HIV ^\|\| Content: Uses animation to provide information about acute infection and testing methods. Target audience: Internet users.	There was no CG.	Questionnaire with 25 questions + a single question on a 4-point scale.	Knowledge: Average difference before and after the video = English speakers (Post: 19.6 vs. Pre: 16.4; Δ ^‡‡ =3.2; CI ^§§ 95%: 2.8-3.5) and Spanish speakers (Post: 20.7 vs. Pre: 17.3; Δ ^‡‡ =3.4; CI ^§§ 95%: 3.0-3 .8), with English speakers showing less prior knowledge (p ^§ <0.05).
Dewi, Amir, Nauli. 2019. Indonesia ( ²⁹ )	n=144/ no follow-up	Video + brochures: (n=72) Type/STI ^‡: Educational video + brochure/HIV ^\|\| Content: Information to increase understanding and promote preventive behaviors. Target audience: Married women.	Did not receive any of the interventions (n=72).	Questionnaire tested for validity and reliability.	Knowledge: Mean difference between IG* vs. CG ^† = 3.1; IG(12.86) and CG ^† (9.69) (95% CI: 2.60-3.73, p ^§ = 0.000). Attitude: Mean difference of 8.4 for preventive attitude between IG and CG ^† (95% CI: 0.879-6.66, p ^§ =0.000).
Nuramalia, et al. 2020. Indonesia ( ³⁰ )	n=96/4 weeks	ABAT audiovisual media: “I’m Proud I Know” (120 min/session; n=48) Type/ STI ^‡: Educational media/HIV ^\|\| Content: Reproductive health, drugs, lifestyle, HIV ^\|\| and Aids. Target audience: Adolescents.	One session per week (lasting three weeks), covering the same topics (n=48).	Questionnaire with questions on knowledge and prevention practices.	Knowledge: Increase in the “Good” category to 91.6%, while the “Sufficient” category was 8.3%. There were differences in knowledge between IG* and CG (p ^§ < 0.05).
Prihanti. 2020. Indonesia ( ³¹ )	n=41/ no follow-up	Video: (duration not specified; n=41) Type/STI ^‡: Online video/HIV ^\|\| Content: Contains information about the general picture of HIV, risk factors, transmission, and the importance of diagnostic testing. Target audience: Health professionals.	There was no CG.	E-Questionnaire via Google Form with 28 questions.	Knowledge: 97.6% of participants demonstrated good knowledge and only 2.4% demonstrated insufficient knowledge (p ^§ =0.00). Attitude: 85.4% of participants demonstrated positive attitudes and 14.6% demonstrated negative attitudes (p ^§ =0.00).
Ambarwati. 2021. Indonesia ( ³² )	n=43/ no follow-up	Vídeo + slides: (n=43) Type/STI ^‡: Educational video + slides/HIV ^\|\| Content: Developed to improve knowledge and attitudes towards HIV ^\|\| /Aids. Target audience: Adolescents.	There was no CG.	Questionnaire with non-detailed questions.	Knowledge: Increase in knowledge (Z ^\|\|\|\| =-3.819; p ^§ =0.000). Attitude: Increase in attitude after the intervention (Z ^\|\|\|\| =-3.873; p ^§ =0.00).

Certainty of evidence							Number of patients		Effect ^††		Certainty
Number of studies	Study design	Risk of bias	Inconsistency	Indirect evidence	Inaccuracy	Other considerations	Audiovisual resources	Neither one nor the other	Relative *(95% CI)**	Absolute *(95% CI)**
Increased knowledge about STIs
10	RCT ^†	serious ^‡	not serious	not serious	serious ^§	none	886/1815 (48.8%)	929/1815 (51.2%)	not estimable	not estimable	⨁⨁◯◯ Low ^‡§
15	Quasi-experimental studies	extremely serious ^\|\|	not serious	not serious	serious ^§	none	2781/3404 (81.7%)	623/3404 (18.3%)	not estimable	not estimable	⨁◯◯◯ Very low ^§\|\|
Change of attitude
4	RCT ^†	serious ^¶	not serious	not serious	serious ^§	none	327/671 (48.7%)	344/671 (51.3%)	not estimable	not estimable	⨁⨁◯◯ Low ^§¶
5	Quasi-experimental studies	extremely serious**	not serious	not serious	serious ^§	none	297/423 (70.2%)	126/423 (29.8%)	not estimable	not estimable	⨁◯◯◯ Very low ^§ **
Behavior change
1	Quasi-experimental studies	extremely serious**	not serious	not serious	serious ^§	none	88/88 (100.0%)	0/0	not estimable	not estimable	⨁◯◯◯ Very low ^§ **

[1] *IG = Intervention Group; ^†CG = Control Group; ^‡STI = Sexually Transmitted Infections; ^§SD = Standard Deviation; ^||p = Statistical Significance; ^¶F = Analysis of Variance; **HIV = Human Immunodeficiency Virus; ^††CI = Confidence Interval; ^‡‡OR = Odds Ratio; ^§§HPV = Human Papillomavirus; ^||||t = t-statistic (Student’s t-test)

Effectiveness of audiovisual interventions in increasing knowledge about sexually transmitted infections: a systematic review

Highlights: