INTRODUCTION

Human papillomaviruses (HPVs) are a group of more than 200 viruses that are associated with both benign and malignant lesions ¹. These viruses are transmitted through oral, vaginal, or anal intercourse with an infected person, and it is thus considered a sexually transmitted infection, which is generally asymptomatic but over time can develop into some type of cancer ².

It is estimated that 90% of people worldwide will be infected with HPV during their lifetime. In 2017 alone, there was a prevalence of 16.1% in Latin America and the Caribbean ³. In 2020, a total of 4,584 accumulated cases were reported in Mexico ⁴, with young people over 18 years of age showing the highest incidence ⁵. These young people are characterized by exhibiting risky sexual practices, such as unprotected sex, multiple sexual partners, and drug use during sexual intercourse ^6,7, a situation that tends to increase due to, among other things, the lack of knowledge that young people have about the infection.

Related studies, on the one hand, report a lack of HPV knowledge regarding basic aspects, symptomatology, associated diseases, prevention, diagnosis, and treatment ⁸. This situation puts young people at higher risk of becoming infected, regardless of their educational level and sex ^9,10.

On the other hand, a systematic literature review has shown that online interventions through audiovisual media, such as instructional videos, have a significant effect on knowledge related to the prevention of sexually transmitted infections (STIs), such as HPV ^{(11, 12)}. However, other studies still report limited information about the real impact related to the use of videos as a means to improve knowledge related to STIs, which makes clear the need for interventions with rigorous methodologies and valid instruments in order to ensure reliable results that can be standardized and compared over time ^{(13, 14)}.

Considering the above, it is important to evaluate the effectiveness of the educational video: “7 things you should know about HPV!”, based on Fisher and Fisher's information, motivation, and behavioral skills model (IMB) ¹⁵. The video has been designed and validated for a young Mexican population following the theoretical precept that acceptance of preventive behavior is the result of increased knowledge, motivation, and skills related to prevention; in addition, learning processes can be changed through elements of persuasive communication ¹⁶. These are theoretical aspects that, in practice, have provided evidence of a positive change in the sexual health behaviors of people ¹⁷.

Thus, the objective of the present study was to evaluate the effect of the educational video: “7 things you should know about HPV!”, based on Fisher and Fisher's information, motivation, and behavioral skills model, on young Mexicans over 18 years of age.

METHODOLOGY

The design of the study was a randomized, single-blind intervention clinical trial with randomization to a control group and an experimental group under a model of repeated measurements ¹⁸.

The sample consisted of young people over 18 years of age of both sexes that were users of social networks and were interested in participating in the study. Participants that were studying or had graduated from a degree in health science were excluded due to the possible bias that their academic background could have on their knowledge of HPV. We also excluded those who did not complete the required measurements (pre-test, post-test, and follow-up seven days after watching the video), as well as those who requested and received more information about the infection during the study; this was after having answered the questionnaire or watched the video. The sample was calculated using the statistical package n´Query Advisor version 4.0 ¹⁹ for an independent-samples Student's t-test, with a confidence level of .05, a statistical power of .80, and an effect size of .30; obtaining an n=16 participants per group. However, it was rounded to n=20 per group in order to dampen the attrition of the research subjects.

The empirical indicator used was the HPV knowledge questionnaire from Xolocotzi, Marín, Gómez, Valenzuela ²⁰, which consists of 38 items with three response options (True, False, and Don't know) and is divided into four dimensions: the first one evaluates the causal agent through three items (1, 2, 3), the second one assesses the risk factors with twelve items (4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15), the third one evaluates the signs and symptoms with five items (16, 17, 18, 19, and 20), and the fourth one addresses prevention, diagnosis, and treatment with 18 items (21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38). For a better interpretation of the data, percentiles were used to obtain the cut-off points of the instrument: Percentile 1 (P1₂₅) = no knowledge, Percentile 2 (P2₅₀) = insufficient knowledge, Percentile 3 (P3₇₅) = fair knowledge, and Percentile 4 (P4₁₀₀) = adequate knowledge. The instrument has a Cronbach's Alpha of .833 in the Mexican population ²¹. A reliability of .706 was obtained for the present study.

The recruitment was carried out during the months of June and July 2021 by four young people (2 men and 2 women) belonging to youth associations of Puebla City and Chiapas, who were trained to invite other young people to participate in the study through the application of WhatsApp. Once the sample was formed, the participants were numbered and then assigned to the control and experimental groups using a computer program of random numbers. Subsequently, the participants were individually sent a Google Forms link (unique and exclusive for each group) that contained the informed consent, the HPV knowledge questionnaire, and a logical algorithm to control the duplicity and impersonation of participants, which consisted in the identification of their email address, IP, and date and time of the survey. In addition, the researchers kept an internal record in Excel format that contained: date sent, participant's name, phone number, and identification of the group to which they were randomized.

The intervention for the experimental group consisted in viewing the video: “7 things you should know about HPV!” through Google Forms, which contained a private link to a YouTube account with the platform's own online security protocols activated and records of the audience retention time, traffic source, geographic area, and number and date of viewing.

The video is characterized by being a validated tool in the Mexican context and shows two young people (a man and a woman) who answer in a clear and simple way seven questions about HPV, ending with a series of recommendations to prevent the infection and promote responsible sexuality, in a time of approximately three minutes ¹⁶. This audiovisual resource was developed based on the assumptions of Fisher and Fisher's information, motivation, and behavioral skills model ¹⁵ as well as the elements of persuasive communication ²², which is characterized by attempting to produce a positive change in people's health behaviors through: 1.- an attractive source and characters similar to the receiver, 2.- an organization of clear and rational messages, 3.- a direct visual-auditory communication channel, and 4.- a relaxed and pleasant context for the receivers ¹⁶. These aspects have allowed to change some ideas and inspire healthy sexual behaviors in previous studies. ^{(17, 23)}

The statistical analysis was performed using the statistical package for social sciences SPSS version 24 for Windows. A Kolmogorov-Smirnov normality test with Lilliefors correction was applied to know the distribution of the variables. Group means were compared with an independent-samples Student's t-test. In addition, a repeated measures general linear model with a significance level of <.05 was used to compare the pre-test, post-test, and follow-up (seven days after viewing the video) measurements.

Finally, the present study adhered to the provisions of the Mexican general health law regarding research on human subjects ²⁴. The study was approved and registered by the Academic Committee for Research and Postgraduate Studies of the Faculty of Nursing of the Benemérita Universidad Autónoma de Puebla (SIEP/033-A/2020). In addition, the informed consent of all the participants was obtained after having explained the purpose and procedures of the study, always ensuring their anonymity and confidentiality in the study.

RESULTS

A total of 102 young people entered the study, 62 of which were excluded; thus, 40 were randomized (20 to the experimental group and 20 to the control group). There were four losses in the experimental group and three in the control group because they did not respond to the follow-up survey. The progression of the intervention design is shown in Figure 1.

Figure 1.  Desing process 

The characteristics of the participants were similar in both groups (Tables 1 and 2); most of them had started their sexually active life (f=30). There was also a high frequency of young people who reported having two or more partners (f=17), who used contraceptive methods during sexual intercourse (f=25).

Table 1.  Characteristics of the participants 

Note: the data represent the absolute frequencies of each group; EG: Experimental Group; CG: Control Group; p: statistical significance per group and state; the values of X² are the results of the comparison between states.

Table 2.  Age of the participants 

Note: 𝑋 : mean; SD: standard deviation; LL: lower limit; UL: Upper limit; EG: Experimental Group; CG: Control Group.

Regarding the level of HPV knowledge, both groups had mainly fair knowledge at the beginning of the intervention (pre-test) (Experimental Group: 68.8%; f= 11; vs Control Group: 76.5%; f=13).

For the comparison between groups, an independent-samples Student's t-test was performed after previously verifying the distribution of the data (KS=.143; p=.086) and the homoscedasticity of the variance (p>.05), finding no statistically significant differences in the values of the pre-test. This demonstrates that the groups were initially equivalent. In contrast, in the post-test and the follow-up, there was a difference in the experimental group after viewing the video (Table 3).

Table 3.  Independent-samples Student's t-test 

Note: The arithmetic means are shown ( standard deviation; CI= 95% confidence intervals; df= 31.

The repeated measures general linear model, with the covariates of state or province, sex, onset of sexual activity, number of sexual partners, and use of contraceptive methods, confirmed the statistically significant difference in the post-test and follow-up measurements between the experimental and control groups. This result shows the effect of viewing the video on HPV knowledge across time (Wilks Lambda, (= 4.965; F= (.707)= 4.965; p=.016) (Graph 1).

Graph 1.  

DISCUSSION

The present study shows the effect of the educational video: “7 things you should know about HPV!”, based on Fisher and Fisher's information, motivation, and behavioral skills model ¹⁵, on young people over 18 years of age. This theoretical perspective affirms that the adoption of preventive behavior is a consequence of increased knowledge.

The results of the intervention are in agreement with Nuramalia ¹¹ and Garzón-Orjuela et al. ¹², since an immediate positive effect can be observed as well as during the course of seven days after viewing the video, with a tendency to continue to increase. This could indicate that the effect could not only remain in a cognitive phase but also in an emotive-emotional phase, which probably drives the individuals to seek more information related to the acquisition of behavioral skills aimed at preventing HPV. This may confirm that cognitive learning processes can be modified through elements of persuasive communication ¹⁶.

The results of the level of HPV knowledge agree with that reported by Rico et al. ⁸, since there was a fair level of knowledge at the beginning of the study in both groups. This could be explained by the lack of awareness about the infection, which combined with an asymptomatic manifestation that can persist over the course of several years, could result in a low perception of risk and severity of HPV among the young population.

The findings on risky sexual practices agree with that reported by Carrión, Bravo, Izquierdo & Marrero ⁶, as well as what Méndez, Villegas, Guzmán & Santos mention ⁷, since there was a higher percentage of young people who had more than two sexual partners. This situation is a constant among the target population, which is likely due to the level of maturity and the search for new experiences; the latter being factors that could potentiate the low perception of risk and severity of the infection.

Finally, the results of the present study may be limited because it was conducted in a small sample of young Mexicans, where the level of concentration at which the participants viewed the video is unknown. However, this was compensated with the use of a valid and reliable instrument, as well as of mechanisms that prevented the impersonation and duplicity of participants. Thus, we suggest to continue to carry out interventions using videos validated in the Mexican context and with the theoretical perspective of the IMB model, which could be complemented with counseling and/or nursing consultation in order to increase the effect of the intervention.

CONCLUSIONS

The video “7 things you should know about HPV!”, based on Fisher and Fisher's information, motivation, and behavioral skills model and using elements of persuasive communication, favored HPV knowledge in a group of young Mexicans over 18 years of age, immediately and seven days after watching the audiovisual resource.