Contextual and culturally appropriate video narratives: A potential health promotion tool for young adults
Abstract
Issue Addressed
There is an increasing incidence of diabetes mellitus (DM) among the young adult population worldwide, with a high prevalence of undiagnosed DM in. This study aims to evaluate the preliminary effects of a culturally appropriate DM audio-visual among young adults.
Methods
This study involved two phases; the first to develop and validate the videos followed by the second phase exploring the engagement level among 80 young adults. The variables of interest included the participants' knowledge and their planned action after watching the video.
Results
Most of the participants (60%) were between the age of 21 and 25 years and had a family history of DM. The majority of participants (80.0%) demonstrated good awareness of DM. Slightly more than half of them (58.8%) thought that DM was curable, which contradicts their knowledge measure. Nevertheless, 88.8% of participants were interested to learn more about DM.
Conclusions
The use of a strategic storyboard and creative editing of the promotional video was a potential trigger to raise the young adults' curiosity to find out more about DM.
1 INTRODUCTION
Diabetes mellitus (DM) is a disease caused by abnormal glucose metabolism that can subsequently lead to hyperglycaemic states. Prediabetes, a condition that occurs before DM, puts one at a higher risk of developing type 2 diabetes mellitus (T2DM).1 People with early onset of DM demonstrated more aggressive progression of DM complications compared to those diagnosed above 40 years and above.2 Thus, young-onset DM patients are at a higher risk of mortality and morbidity.
The global prevalence of DM among adults is predicted to continue rising from 8.8% in 2015 to 10.4% in 2040.3 Zimmet et al4 reported that such an upward trend in the prevalence and incidence of T2DM would equally affect young adults aged between 18 and 39 years old. The shift in the risk of DM towards the young adult age group is a worrying trend and warrants urgent attention. In Malaysia, as high as 3.9 million or one in five adults aged over 18 years old have developed diabetes.5 The National Health and Morbidity Survey5 revealed that the prevalence of undiagnosed DM in Malaysia has increased from 4.0% in 2011 to 8.9% in 2019. The diagnosis of DM is often delayed and characterised by complications, especially among the population with poor awareness of the disease.
In line with the increasing prevalence of DM worldwide, Malaysia has witnessed an increasing trend of epidemic. It is pertinent to improve the awareness of DM among Malaysians. People can easily access the internet and acquire relevant information on numerous topics in the form of texts, pictures, or videos given the high usage of electronic devices, such as mobile phones and computers. Research has depicted that the use of short video clips results in efficient processing and retention of memory.6 Likewise, a recent study found that digital mobile health assists to increase awareness and health literacy towards self-care among coronary heart disease patients.7 Social media communication and interaction have also enhanced users' exposure and experience. For instance, health information is now easily accessible to everyone.8 Therefore, health promotional videos have the potential to deliver targeted information that can promote a better understanding of DM and its consequences. This preliminary study aims to develop and explore the potential use of video to trigger a behavior change for the population.
1.1 Ethical considerations
This study received ethical approval from the Monash University Human Research Ethics Committee (MUHREC) (Project ID: 27676). Consent was requested from all the participants at the beginning of the online questionnaire. Anonymity was maintained as the participants were not required to provide their names in the questionnaire. All participants were informed that all the data provided will be confidential and used for research purpose only.
2 METHODS
This study design involved two phases. The first phase entailed video development and validation while the second phase involved awareness of DM and Video Engagement. The video development in the first phase comprised specific processes, beginning with a literature search on DM engagement content and format, followed by the development and pre-validation of the video as described.
2.1 Development of video scripts
The video scripts were developed by three researchers and reviewed by two clinicians and two patient education experts. The script and storyboard were edited before the video shooting process. The scripts were delivered in English. The video included a brief introduction to diabetes, complications of diabetes and some of its risk factors. The script was planned to be short and narrated in 4 minutes and to provide crucial information on DM. The video was presented as a self-reflection story supported by flashback scenes to capture the audience's attention.
2.2 Development of video narrative
This study posits that it is ideal to have peer influence, whereby young adults will act as actors and narrators of the script. The actors narrated the script in English within 4 minutes. The delivery of the speech; including expression and tone was later finetuned based on the feedback of a panel of reviewers. Video narration was conducted at a steady pace with several pauses in between. Special attention was given to ensure the actor's facial expressions demonstrated the appropriate emotions during different scenes. Important information and wording were emphasised with written captions and subtitles to ensure that the video is fully understood. Lastly, the video was edited severally according to the comments on its visual and sound clarity and presentation style.
2.3 The validity and reliability of the video narrative
The Video Validation Questionnaire was developed to obtain participants' personal information and their level of engagement with the video. The Video Engagement Scale (VES) was adapted from Visser et al9 for the reviewers to rate the engagement of the health promotional video.10 The score in VES ranged from “1” (Completely disagree) to “7” (Completely agree). In this study, the scores were further categorised into three groups, namely, “Disagree” (1-3), “Neutral” (4) and “Agree” (5-7).
A purposive sample of 40 experts including 20 healthcare professionals; involving doctors, pharmacists, nurses, educationists and 20 young adults from various background were invited to provide feedback based on their comprehension of the English video narrative via the questionnaire sent to them through email. The video was further improvised based on the written comments collected from Phase 1 reviewers.
2.4 Phase 2: Awareness of DM and Video Engagement
A survey was conducted to assess the level of DM awareness and engagement with the video. Items in the questionnaires utilised by Suleman et al11 and Garcia et al12 were adopted. The aspects of the research instrument included patient demographic information, baseline DM knowledge, source of information on DM and video engagement rating scales. The questionnaire was distributed via Whatsapp using convenience and the snowball sampling method. Young adults between 18 and 40 years old who comprehend the English language and provided informed consent were included in the survey. Meanwhile, those with confirmed DM diagnosis were excluded from the survey.
All participants were required to watch the developed health promotional video before answering all the engagement-related questions. The survey was conducted between August 2021 and September 2021.
2.5 Statistical analysis
All data were analysed using Statistical Package for the Social Sciences (SPSS). Data from the first phase of the Video Engagement Scale were presented using standard deviation and inter-rater reliability. Meanwhile, descriptive statistics including mean, standard deviation (SD), frequency and percentage were employed to summarise the data from the second phase. The reliability of the study was assessed using Cronbach's alpha value.
3 RESULTS
3.1 Phase 1: Video development and validation
Most of the panel reviewers were aged between 21 and 30 years old with a mean age of 31 years old. They were further divided into two groups based on their working backgrounds as either health professionals (48.7%) or nonhealth professionals (51.3%). The reviewers rated the health promotional video using the Video Engagement Scale (L.N.C. Visser et al, 2016) ranging from “1” (Completely disagree) to “7” (Completely agree) (Table 1).
| No | Questions/score | STD EVa | SEMb |
|---|---|---|---|
| 1 | I was fully concentrated when viewing the video | 0.916 | 0.147 |
| 2 | While viewing the video, it was as if I was present at the event depicted in the video | 1.495 | 0.239 |
| 3 | When I was watching the video, my thoughts were only on the video | 1.248 | 0.2 |
| 4 | When the video was completed, I had the feeling I came back into the “real” world | 1.576 | 0.252 |
| 5 | After watching for a while, it seemed as if I had become the “video character” in my thoughts | 1.738 | 0.278 |
| 6 | While viewing, I was emotional when the video character expressed particular emotions. I empathized with the “video character” | 1.47 | 0.235 |
| 7 | The video affected me | 1.415 | 0.228 |
| 8 | When I was viewing the video, I was in the world of the video in my thoughts | 1.519 | 0.243 |
| 9 | While viewing, I felt a particular emotion when the video character felt particular an emotion | 1.468 | 0.235 |
| 10 | I found the video moving | 1.234 | 0.198 |
| 11 | I felt for the video character | 1.215 | 0.194 |
| 12 | While viewing the video, I was hardly aware of the space around me | 1.462 | 0.234 |
| 13 | I had the feeling I felt what the video character went through | 1.582 | 0.253 |
| 14 | In my imagination, it was as if I was the video character | 1.642 | 0.262 |
| 15 | A feeling arose in me because of the video | 1.599 | 0.256 |
- a STD EV, standard deviation.
- b SEM, standard error of measurement.
The results revealed that about three-quarters (74.4%) of the reviewers were affected by the health promotional video. Most of them (82.1%) agreed that “their thoughts were only with the video” when watching the video, indicating the video has successfully captured their attention. The mean value of inter-rater reliability (IRR) was 0.534. Given that the SD of the average rating for each question was less than 2 with a standard error of measurement (SEM) of 0.3, the IRR of less than 0.5 or 50% was acceptable and deemed satisfactory.13
Overall, most of the expert panel and young adults provided positive feedback, such as the script being meaningful and informative (Appendix A) and (Supplementary Video S1). Many useful comments were considered for the video editing before it was used in the second phase. For example, the alcohol demonstrated in the video was changed to soft drinks as it would be more culturally appropriate in the Malaysian context. Moreover, one of the experts suggested that nonpharmacological interventions, such as leading a healthy lifestyle via exercise and modified dietary habits could be added to the video.
Several processes including the development of script guidelines based on learning outcomes and video editing were performed before sending the video to the public for the second phase. A few phases of satisfactory validation were conducted by viewing the video and analysing the panel of experts' comments for further video editing. A comprehensive review of all comments was incorporated to finalise the health promotional video. The calculated VES scores were above average, thus indicating a good link with the perceived realism of the video. Hence, the video was deemed suitable for the pilot test among the general public after the video was edited based on the feedback in the first phase.
3.2 Phase 2: Awareness of DM and video engagement
Table 2 presents the respondents' characteristics of Phase two. A total of 139 participants were recruited via social media between July and August 2021. Nevertheless, only 57.5% of them were eligible according to the predetermined inclusion and exclusion criteria. All the participants consented to the survey before completing the questionnaire. About 55.0% and 45.0% of the respondents were males and females, respectively. In terms of the highest educational level, more than half of the participants (61.3%) had a bachelor's degree or higher qualification. Approximately 57.5% of the participants reported that at least one of their family members had been diagnosed with DM in the past.
| Phase 2 | |
|---|---|
| Characteristics | Number of participants, n (%) |
| Age | |
| 18-20 | 12 (15.00) |
| 21-25 | 47 (58.75) |
| 26-30 | 6 (7.50) |
| 31-35 | 5 (6.25) |
| 36-40 | 10 (12.50) |
| Gender | |
| Male | 44 (55.00) |
| Female | 36 (45.00) |
| Ethnicity | |
| Malay | 13 (16.25) |
| Chinese | 63 (78.75) |
| Indian | 3 (3.75) |
| Iban | 1 (1.25) |
| Highest level of education | |
| Graduate from high school | 4 (5.00) |
| Pre-U/STPM/SUEC/STAM/A-Level | 20 (25.00) |
| Diploma | 7 (8.75) |
| Bachelor | 44 (55.00) |
| Master | 3 (3.75) |
| Doctorate | 1 (1.25) |
| Others (certificate, advanced diploma, professional) | 1 (1.25) |
| Has any family member been diagnosed with diabetes in the past? | |
| Yes | 46 (57.5) |
| No | 34 (42.5) |
The majority of the participants (76.2%) answered all the questions relating to DM knowledge correctly. A total of 72 participants answered the question “Eating too much sugar and other sweet foods is a cause of diabetes” correctly. However, there was a mixed response for the last question (“Diabetes can be cured”) as 41.3% of the participants selected “TRUE,” 41.3% selected “FALSE,” while 17.5% choose “DO NOT KNOW” (Table 3). Further exploration indicated that most participants obtained DM-related information from internet sites (n = 39), family members and friends (n = 37) and social media platforms (n = 31).
| Questions/outcomes | True | False | Don't know | Correct response | Total (n) |
|---|---|---|---|---|---|
| Eating too much sugar and other sweet foods is a cause of diabetes | 72 (90.00) | 8 (10.00) | 0 (0) | 72 (90.00) | 80 |
| Diabetes can cause loss of feeling in my hands, fingers and feet | 63 (78.75) | 3 (3.75) | 14 (17.50) | 63 (78.75) | 80 |
| In untreated diabetes, the amount of sugar in the blood usually increases | 70 (87.50) | 2 (2.50) | 8 (10.00) | 70 (87.50) | 80 |
| Diabetes can damage my kidneys | 67 (83.75) | 5 (6.25) | 8 (10.00) | 67 (83.75) | 80 |
| Diabetes can be cured | 33 (41.25) | 33 (41.25) | 14 (17.50) | 33 (41.25) | 80 |
Table 4 represents the engagement of video. Most of the participants found the video to be useful. Based on questions I and IV, more than half of the participants (86.3%) rated the video as useful. Furthermore, 79.3% of the participants could relate to the video and attempted some of the depicted lifestyle advice. The engagement scores were divided into three categories with a score of 1-2 indicating that the participants disagreed with the purpose of the video, a score of 3 was categorised as being neutral, whereas a score ranging from 4 to 5 was categorised as agreeing with the purpose of the video.
| Participants' engagement score, n (%) | |||||||
|---|---|---|---|---|---|---|---|
| No. | Questions/score | Completely disagree | Completely agree | Total, n | |||
| 1 | 2 | 3 | 4 | 5 | |||
| I | I found the information on the video useful | 0 (0) | 1 (1.25) | 10 (12.5) | 36 (45) | 33 (41.25) | 80 |
| II | I learnt something new about heart disease | 1 (1.25) | 4 (5) | 34 (42.5) | 28 (35) | 13 (16.25) | 80 |
| III | I would watch the video again if I could. | 6 (7.5) | 3 (3.75) | 23 (28.75) | 25 (31.25) | 23 (28.75) | 80 |
| IV | I want to apply the advice from the video to my current lifestyle. | 1 (1.25) | 1 (1.25) | 14 (17.5) | 31 (38.75) | 33 (41.25) | 80 |
The baseline DM knowledge was computed based on the total sum of DM knowledge obtained from the questions answered correctly. The scores were further categorised as “Excellent” (>4/5 correct) or “Poor” (<4/5 correct). A total score of four engagement scores was categorised as “Good” (>16/20) or “Poor” (<16/20). The Action Score indicating the participant's willingness to know more about DM in the future was categorised as “Yes” or “No.”
3.3 Reliability of validated tools
The Cronbach's alpha value was .604, which suggests that the survey had sufficient inter-relatedness between each dataset and that the items or questions in the questionnaire were reliable. The Cronbach value of 0.6 and above was considered acceptable based on the number of statements and the behavioural-related nature of the items in the questionnaire. Meanwhile, the Chi-Square analysis reflected no significant association (P > .05) between the total engagement score, baseline DM knowledge and activity score.
4 DISCUSSION
This study was designed to develop and explore the potential of a contextualised and culturally-appropriate health promotional video to trigger a short-term DM awareness among young adults. The basic awareness of DM and its association with pre-planned behavioural outcomes following the engagement with an audio-visual as a trigger factor among young adults were also investigated. The participants' feedback assisted the researcher to elucidate a common baseline knowledge of DM. The narrative script used simple layman's language to accommodate the varying levels of health literacy among the Malaysian population. These data contribute an additional knowledge of preliminary understanding of the antecedents and consequences of digital multimedia or social media on Malaysian young adults' health behaviour. User experiences in health information enable us to understand the potential strength of sharing video contents.14
The Internet has increasingly become a convenient and accessible tool for the general public to obtain information. Thus, online videos have become an alternative for digital contents for individuals growing up in the digital age and most likely to influence individual's awareness and behaviour.15 Good construction of the video script and content, use of appropriate language and audio, the inclusion of cooperative actors and application of an appropriate video presentation style are vital components in a video recording to attract the attention of the audience.16-18 Likewise, in the present developed video, flashback scenes with subtitles, audio and a special focus on certain health belief concepts were incorporated to provide a more relatable context for the audience.
The survey findings revealed that most of the participants (86%) posited that the video was acceptable for this population age range and helped to trigger a short-term awareness of DM. However, its sustainability and impact in health information is yet to be explored. This finding is consistent with the report by Kageyama et al19 in which a video-based educational program depicted that video-based interventions impact positively and are beneficial, especially for a specific group of population. Video interventions that incorporate various health experts' opinions can improve diabetic-related knowledge, thereby improving the health status of targeted populations.20 In 2020, about 88.7% of the Malaysian population were Internet users. Internet usage is expected to increase annually,21 especially with the accelerated growth of different digital technologies during the COVID-19 pandemic. Thus, the role of audio-visual interventions is pertinent in digital-health promotional efforts.
5 LIMITATIONS
The effect of the health promotional video among young adults was not achievable in this study due to several limitations, such as an inadequate sample size and a relatively short intervention period. Whilst ethnic and gender derivation is recorded in the survey statistics, there were inadequate sample distribution to discuss on these differences related to multi-demographic video engagement. Thus, an effective understanding of the value of mediatised information was not achievable. Nevertheless, the positive responses indicated a potential trigger for antecedent and consequences in behavioural change. There is no substantial evidence to conclude that the video was not beneficial as some participants remained neutral in their responses. Hence, either the questions were not optimally phrased or personalised for the present study context. Nonetheless, only 11.3% of the participants claimed that they would not rewatch the video in the future, that indicates the video managed to grab the attention of most participants. For future studies, outcomes such as the self-efficacy level and motivational outcomes could be applied to elucidate the effect of interventional videos on DM awareness. Several editing in Malay and Tamil languages should be considered in the future. Nevertheless, the present video narrative development and the pre-validation process would serve as a useful foundation for follow-up behavioural research plans in the management of chronic illnesses, especially in the community setting.
6 CONCLUSION
In summary, this study demonstrated the importance of purposeful and culturally appropriate video development as an effort to increase awareness of DM among young adults. The feasibility and acceptability of this intervention of intervention were reflected in the steps taken to ensure video validation. Furthermore, the findings highlighted the vast potential of video interventions in health promotional activities that should be further explored in future research.
ACKNOWLEDGEMENT
The authors would like to acknowledge all the participants for spending their valuable time on the interviews and reviews. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.
CONFLICT OF INTEREST
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
ETHICAL STATEMENT
This study received ethical approval from the Monash University Human Research Ethics Committee (MUHREC) (Project ID: 27676).
Appendix A
| Main theme: Engagement and comprehension | |
|---|---|
| Health professional 1 | “Well done on producing an excellent quality video. The message was well delivered. I really appreciate all your effort in producing this video. Just a slight comment from me” |
| Health professional 4 | “Spot on! It's important to highlight T2DM among youth and promote an early healthy lifestyle. Prevention is better than cure. Your message is well delivered. Kudos to all of you” |
| Health professional 6 | “The video presented was so detailed on the awareness of the disease and complication one might face even at a younger age” |
| Young adult 2 | “Overall, I think the video was well designed and the story was very straightforward. Although I'm uncertain as to who the video was targeted to so I'm still impartial as I relatively have a well-balanced lifestyle” |
| Main theme: Generalisability | |
| Young adult 1 | “The video was very clear and direct in portraying the factors that would lead to diabetes. It was very realistic as many people have a similar lifestyle, hence they could relate to it very well” |
| Main theme: Informational and evocative | |
| Health professional 2 | “I think this is a really good video to raise awareness of Type II Diabetes among young people. I think this is really very good and targets a group that we frequently ignore: young adults. Well done” |
| Health professional 3 | “Congratulations for choosing this topic to create awareness among the public, especially the young generation! Several cases of diabetes in the young that were undiagnosed” |
| Young adult 3 | “It was indeed a good and inspiring video, especially the ending video. It did serve as a good reminder for me to take care of my diet and lifestyle” |
| Young adult 5 | “Cinematic shots of an awareness video are revolutionary” |
| Main theme: Feedback and improvement | |
| Health professional 1 | “The symptoms shown by the patient are more of a ‘heart attack’ rather than a ‘stroke’. He was holding on to his chest, which presents more like a chest pain typical from a heart attack” |
| Health professional 3 | “In this video, risk factors were highlighted including sedentary lifestyle, poor dietary habits, obesity and so on. Nevertheless, in terms of complications, only stroke was highlighted. You can take this opportunity to highlight other possible important complications, such as Myocardial Infarction, End stage renal failure, Blindness due to Diabetic Retinopathy, Diabetic Foot and Erectile dysfunction. All of these will have an impact on their future (work, social, financial, relationship etc), especially in the younger generation. They don't see this! You can add on what they should start doing (healthy lifestyle, exercise, change the dietary habit)” |
| Health professional 5 | “In the first part of the video; the drinking part seems to imply alcoholic drinks only with the bottle as background. The most problematic are the nonalcoholic drinks; so, having blank cans or the 1.5 L plastic bottles included would be good. A lot of young people still do not know the health impact of drinking ‘soft’ drinks” |
| Young adult 5 | “I would also like to point out the issue of the depicted symptoms of stroke, as what I saw is a MI rather than stroke, which could potentially lead to misunderstanding for audiences” |
- Note: Extraction of written feedback from health professionals and young adults.
Biographies
Tay Cheng En is currently a graduate from Bachelor of Pharmacy (Hons), Monash University Malaysia. He is currently working as a provisionally licensed pharmacist at Hospital Ampang. His research interests are in health communication and health information technologies. He can be contacted at [email protected]
Yeow Zhen Yee is currently a graduate from Bachelor of Pharmacy (Hons), Monash University Malaysia. He is currently working as a pharmacist assistant at Alpro Pharmacy. His research interests are in Medical Ethics and Alternative Pain Management. He can be contacted at [email protected]
Wesley Chung Sheng Zhi is currently a graduate from Bachelor of Pharmacy (Hons), Monash University Malaysia. He is currently working as a provisionally licensed pharmacist at Sarawak General Hospital. His research interests are in patient centered care and health information technology. He can be contacted at [email protected]
Shazwani Shaharuddin is a lecturer at the School of Pharmacy Monash University Malaysia. She is an experienced academician and researcher with a history of working in varied health and education settings for almost 10 years. She has published her work and presented at national and international conferences. She is interested in noncommunicable disease studies and in developing mobile health apps. She can be contacted at [email protected]
Jamuna Rani Appalasamy is a lecturer at the School of Pharmacy Monash University Malaysia. Jamuna has been actively involved in clinical pharmacy teaching and learning activities, module development and coordination and student placement facilitation. She collaborates with many local and international researchers and industries with a keen interest in personalised solutions involving digital technology advancement for the aging workforce and geriatric community. She can be contacted at [email protected]
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
