As the number of HIV-infected persons continues to increase in resource-limited settings, there is need for effective health education strategies.1 The rationale for an educational intervention in HIV-infected individuals is to improve their knowledge about different aspects of the disease such as opportunistic infections and antiretroviral treatment and to promote behavioral change to prevent the transmission to other individuals. Health education talks or lectures have been the most common methods used to promote these messages.2 Little is known however about their effectiveness in encouraging behavioral change. Effective health education should involve an open dialogue about positive and healthy lifestyle, sex, relationships, risk behavior, risk settings, and cultural practices.3Therefore, there is an urgent need to devise innovative health education approaches that may enhance knowledge that leads to positive behavioral change.
Educational games have been designed as a communication tool that bridges the gap between awareness and behavior change.4,5 Educational games have been shown to both attract and hold players' attention on topics that might generate less interest in lecture-style teaching sessions.6,7 A new educational game called “Make a Positive Start Today!” was developed in Uganda to provide a platform to engage people living with HIV infection in open dialogue about important HIV and sexually transmitted infections (STIs)–related topics.8
The objective of our study was to assess the effect of the board game on knowledge of HIV and STIs in HIV-infected patients attending the Infectious Diseases Institute, Kampala, Uganda. We also assessed the acceptability of the board game by facilitators and players.
The “Make a Positive Start Today!” Board Game
“Make a Positive Start Today!” board game has been developed by Caspar and Carew Edutainment International Uganda (Fig. 1). The game is intended to increase people living with HIV's participation and attention, to generate knowledge on HIV, STIs, and antiretroviral treatment, and to enhance prevention behavior. The game also explores myths and beliefs about HIV/AIDS and STIs by providing a platform to engage participants. In short, it is an entertainment education tool.6
This tool consists of a board game and an accompanying handbook, both written in English. The board game illustrates a route with different “stations”. Each station contains HIV and STI information or questions for discussion. Each player spins an arrow mounted on the board and then moves his game piece the number of stations the arrow shows. The ideal number of players for a game session is 6.
The handbook answers the main questions triggered by the game in straightforward language appropriate for HIV-positive persons. Currently, both the board game and handbook are available only in English, but plans are underway to have them translated into local languages.
Study Area Setting and Population
The study was conducted at the Infectious Disease Institute (IDI), Kampala, which is an HIV and AIDS care and research center of excellence based within Makerere University College of Health Sciences at the Mulago National Referral Hospital. The IDI adult clinic offers specialized outpatient care. Currently, more than 26,000 patients have been registered of which more than 10,000 have been started on antiretroviral treatment .The clinic is open 5 days a week with a minimum of 300 patients seen daily by medical officers and nurses. The provider patient ratio is 1:30, which results in long waiting times.9,10 Waiting areas are normally used by health educators, some of whom are HIV-positive volunteers, to give health talks about HIV, STIs, opportunistic infections, contraception, family planning, and antiretroviral treatment.
Patients were eligible to be enrolled in our study if they were (1) ≥18 years old; (2) English literate; (3) registered at IDI for less than 3 months; (4) antiretroviral treatment naive. These last 2 criteria were chosen to exclude patients who had participated several times to health talks in our clinic waiting areas or to detailed antiretroviral treatment information given by the clinic counselors.
This was a randomized controlled trial. From the clinic database, we generated a list of eligible patients based on the above criteria; we then consecutively contacted them through a phone call and invited them to come to the clinic and join the study until we reached the desired sample size. Study participants were randomly assigned using a randomization list to play the board game (intervention arm) or receive a standardized health talk [standard of care (SOC) arm]. A total of 12 participants were randomized on every study day, with 6 participants allocated to each study arm.
The content of the health talk was designed to deliver the same information contained in the board game and its manual. Both the board game and health talk groups took a standard 20–30 minutes period of health education; 15 minutes were given for participants to ask questions and receive answers to exhaust all the information that might not have been fully covered in the health education or the game session. Both the game and the health talks were facilitated and conducted by trained HIV-positive volunteers, 2 per each arm; the facilitators alternated treatment arm daily.
Participants' knowledge on HIV and STIs in both groups was assessed before (pretest assessment) and after the educational activity (posttest assessment) through an interviewer-administered structured questionnaire using a multiple choice format; this tool was pretested on 40 patients to assess the flow and clarity of the questions and possible answers by the respondent. The assessment tool consisted of 20 questions regarding all the topics covered by the health talk and the board game and required deep understanding of the information acquired to give the correct answer (Appendix 1); 1 point was assigned for each correct answer for a maximum score of 20 if all questions were answered correctly. The possible answer “I do not know” was categorized as a wrong answer. Knowledge uptake was calculated as the difference between posttest and pretest assessments.
The Principal Investigator received all answered questionnaires from the pretest and posttest and reviewed them for completeness, and another independent study staff transcribed the answer given by the participants on data fax forms and faxed the information in the data fax database.
Fifty percent of participants from both study arms were selected using simple random sampling and asked another set of questions to evaluate their experiences with the health education method. Key informant interviews were also held with facilitators to evaluate their experiences regarding usability of both methods of health education.
To calculate the sample size, we used the formula given by Smith and Morrow, 11 and we hypothesized a 10% difference in knowledge uptake between the 2 groups. Mean pretest and posttest scores and confidence intervals were obtained for both groups. We compared the pretest and posttest scores for both arms using a paired t test; we then compared the knowledge uptake (mean differences between the pre and post test) using a t test. Data were analyzed using STATA version 10.0.
For the qualitative questionnaire, proportions were compared using χ2 test, although 2 samples Wilcoxon rank-sum test were done to compare the study participants' median rating.
The investigators obtained clearance from Makerere University School of Public Health Higher Degrees Research and ethics committee.
Baseline Characteristics of Study Participants
Three hundred eighty-two participants were eligible for the study; 189 were consecutively contacted by phone, of which, 4 turned to be English illiterate and 5 did not answer the phone call. One hundred eighty participants were enrolled in the study. Ninety participants were randomized to the intervention arm and 90 to the SOC arm.
The baseline characteristics of the participants are showed in Table 1: overall, the participants in the 2 arms were similar in all of the sociodemographic characteristics including age, gender, education level, employment status, marital status, and religion, the time they had been into care in the clinic, and exposure to prior HIV education. In particular, the knowledge on different HIV and STI aspects measured at baseline through the pretest questionnaire was similar in the 2 groups (mean: 10.3 vs. 10.7, P = 0.53).
Table 2 shows the mean score in the pretest and posttest in the 2 study arms. In both groups, there was a significant knowledge uptake with a difference in the pretest and posttest score of 4.69 (confidence interval: 3.94 to 5.43) (P < 0.001) and 1.53 (confidence interval: 0.92 to 2.13) (P = 0.007) points in the intervention arm and in the SOC arm, respectively. However, the score in the posttest was significantly higher in the intervention group as compared with the SOC group (15 vs. 12.236, P < 0.001) due to the higher knowledge uptake in the intervention group; the mean difference in knowledge uptake between the 2 groups was 3.16 points (P < 0.001).
Qualitative Evaluation of the Intervention
A total of 85 participants were interviewed; 41 participants in the intervention arm and 44 in the SOC arm. All the participants in the intervention group liked the design of the game (Table 3). Ninety percent (37 of 41) found the game easy to use as compared with only 52% of the participants in the SOC arm who found the educational talk easy to follow (P < 0.001). A higher proportion of participants in the intervention arm found that the information passed through the educational tool was clear, as compared with participants in the SOC arm (95% vs. 58%, P < 0.001).
Study participants were also asked to rate the 2 methods of health education on a scale of 1–5, 1 being strongly disagree and 5 strongly agree. Generally, more participants in the intervention group felt that they understood all the information for a given method, that the tool encouraged them to express their views, and that they recommend this method to be used to educate other HIV persons (Table 4).
Facilitators' Qualitative Assessment
All facilitators liked the design of both methods, found them easy to use, and found the instructions clear and easy to follow. When asked to choose the method they preferred, all of them preferred “Make a Positive Start Today!” board game over the SOC.
Three of the 4 facilitators strongly agreed that using the board game as an educational tool resulted in better understanding of the information, gave participants the chance to express their views, and were likely to recommend the board game to educate people living with HIV over the standard of care.
In this randomized controlled trial, we evaluated the use of an educational game and health talks, which are currently the standard of care to deliver knowledge about HIV, STIs, and antiretroviral treatment to HIV-positive patients.
The patients' characteristics and the level of baseline knowledge at study enrollment were comparable in the 2 arms. Both interventions resulted in a significant increase in knowledge. However, in the arm that was educated using the board game, the knowledge uptake was significantly higher than in the group that educated using the health talk. When qualitatively assessed, the board game as a method of health education resulted into more positive experiences by both participants and facilitators as compared with the health talk.
A major limitation to this study was that it assessed short-term acquisition of knowledge which may not be sufficient to sustain long-term behavior change.6 Second, the study was conducted only among English literate patients, yet the majority of patients (60%) at the IDI are not English literate, thus limiting generalizability to non–English-speaking populations. English knowledge in the Ugandan setting is a proxy for socioeconomic, cultural, and perception differences, which justifies further testing of the effect of “Make a Positive Start Today!” board game in other cultural populations in the country after translation into relevant local languages.
Additionally, the clinical setting of our participants may not be reflective of the knowledge of HIV-positive people living in rural communities. Because IDI is a referral center for advanced HIV care and treatment, the clinic receives patients from various Ugandan communities with different sociodemographic backgrounds. We also recognize also that using a game to educate patients requires more human resources as compared with giving health talks, as the game can only be played by a maximum of 6 players and needs at least 1 facilitator although a health talk can potentially reach simultaneously a bigger audience. Because many big HIV programs in Sub Saharan Africa enroll HIV-positive or community volunteers to support clinic staff, this game could be used in such busy programs with long waiting lines and volunteers available to facilitate patients playing the game.
In conclusion “Make a Positive Start Today!” educational board game improved the knowledge uptake in HIV-positive English literate patients. This educational method was preferred by both study participants and peer educators compared with traditional health talks. Entertainment education using educational games represents a potentially viable approach to enhancing knowledge uptake in HIV-positive patients.
We recommend that the “Make a Positive Start Today!” board should be translated into other native languages and tested in different populations; further studies are also needed to investigate the long-term knowledge retention and the impact on behavioral change.
We thank the study participants and facilitators who volunteered to participate in this study. We also thank Dr Edith Nakku Joloba, Dr Danstan Bagenda, Dr Fredrick Makumbi, Dr Noah Kiwanuka, and Dr Roy Mayega.