Using Narrative Transportation Theory to Build Interventions that Reduce Perceived Stigma Among Women Living with HIV/AIDS

INTRODUCTION

HIV significantly impacts women worldwide, driven by both social and physiological factors.¹ Women have a larger mucosal surface exposed during sexual intercourse, increasing their susceptibility.¹ Social factors include sexual violence, economic disadvantage, difficulty in disclosing HIV status, and lack of control over sexual matters.^2,3 In 2022, females made up 53% of the 39 million people living with HIV/AIDS (PLWHA) globally, and 46% of the 1.3 million new infections.⁴ In China, women living with HIV/AIDS (WLWHA) accounted for over 20% of reported cases from 2008 to 2022, with a detection rate of 3.4 per 100,000 nationally, rising to 11.5 per 100,000 in Southwest China.⁵

Most WLWHA experience HIV-related stigma.⁶ It was categorized into four types: enacted, anticipated, perceived, and internalized stigma. Enacted stigma involves overt discrimination, while anticipated stigma is the fear of such discrimination.⁷ Perceived stigma reflects how PLWHA believe they are viewed by others, and internalized stigma occurs when individuals adopt negative societal attitudes.^8,9 These forms of stigma are often cyclical.¹⁰ For instance, WLWHA may encounter enacted stigma when accessing healthcare and reinforcing anticipated stigma, which deepens perceived stigma and eventually leads to internalized stigma. Internalized stigma can make WLWHA less likely to resist discrimination, perpetuating the cycle. Therefore, the potential strategy for reducing HIV-related stigma involves targeting a specific form of stigma to disrupt the perpetuating cycle of stigma.

WLWHAs in China experience heightened levels of perceived stigma, particularly influenced by Chinese cultural norms.^11,12 In China’s collectivist society, there is a strong emphasis on adhering to social norms, especially for women.¹³ Behaviors linked to HIV transmission, like homosexuality, sex work, and drug use, are seen as deviations from the public order and good customs placed on women, leading WLWHA to fear judgment from their social circles and contributing to perceived stigma.¹³ Additionally, Confucian values stress women’s familial responsibilities. When HIV hinders women from fulfilling these roles, they may feel inadequate, further intensifying perceived stigma.¹⁴

Perceived stigma in WLWHA can lead to negative emotions like self-doubt, depression, and anxiety, resulting in fear, concealment, resistance, and even hostility toward society.¹² This reduces their willingness to seek testing or treatment, hindering effective AIDS prevention and care.¹⁵ Additionally, perceived stigma weakens interactions with family, harming both intrafamilial relationships and the broader social network.¹² In America, interventions such as the ROADMAP,¹⁶ Self-Care Symptom Management,¹⁷ and the 90 DAYS film have shown significant reductions in perceived stigma among WLWHA.¹⁸ However, these studies have limitations. For instance, the ROADMAP intervention, designed to reduce high-risk sexual behaviors among older women, primarily included African American participants of lower socioeconomic status.¹⁶ This limits the generalizability of the findings. The Self-Care Symptom Management intervention, though effective, did not include a control group, making it difficult to attribute the results solely to the intervention itself.¹⁷ The 90 DAYS film, aimed at improving HIV disclosure, showed potential in reducing stigma, but it was unclear whether the reduction specifically included perceived stigma, despite it being mentioned as an outcome indicator.¹⁸ These interventions highlight several gaps. Notably, the single-center settings limit the generalizability of the results. Additionally, while video interventions show promise, using actors rather than real patients may reduce empathy and intervention effectiveness. Finally, there remains an urgent need for precise interventions specifically targeting perceived stigma among WLWHA, as no such interventions have been published to date. Within the context of China’s collectivist culture and Confucian values, challenges such as fear of disclosing HIV status, family responsibilities, and a low desire for communication hinder offline participation and the effectiveness of long-term interventions among Chinese WLWHA. Given these cultural factors, online interventions may be more adaptable and effective for this population in China.

This manuscript aims to provide a detailed description of the application of narrative transportation theory in the development of the innovative intervention approach known as Helping Overcome Perceived Stigma (HOPES). This intervention is specifically tailored to reduce perceived stigma among Chinese WLWHA within the context of Chinese culture. It features narrative videos in which WLWHA peer volunteers share their personal experiences with perceived stigma and coping strategies, and is delivered through the LNOB online platform across Eastern, Southern, and Southwest China. This manuscript is presented within the framework of Research and Reporting Methods, emphasizing the methodological innovation and approach of the intervention rather than focusing on original research findings.

Challenges in Reducing Perceived Stigma Among WLWHA

Reducing perceived stigma in WLWHA faces some challenges. Firstly, stigma among WLWHA requires a comprehensive and ongoing approach due to the chronic and infectious nature of AIDS.¹⁹ WLWHA may perceive stigma not only due to the infectious aspect but also because of the chronicity of the condition. This requires sustained care and support. Secondly, perceived stigma may intersect with psychological and psychosocial issues that WLWHA may encounter. These issues include depression, perceived stress, and social isolation.²⁰ For example, WLWHA may perceive stress in seeking social support owing to perceived stigma, thereby experiencing social isolation or depression, and vice versa. Moreover, women frequently adhere to deeply ingrained traditional social and familial roles, particularly evident in contexts like China.²¹ This adherence can result in challenges related to self-identification and a sense of belonging within their HIV/AIDS identity. The above challenges result in less research on reducing perceived stigma among WLWHA.

METHODS

Reducing Perceived Stigma Using HOPES

HOPES is proposed to target perceived stigma among WLWHA in China. Participants were recruited from five designated AIDS diagnosis and treatment hospitals in East China, South China, and Southwest China. Narrative videos were recorded by HIV-infected people as peer volunteers. The similarity in perceived stigma experiences and shared emotional journey increases volunteers’ empathy for participants. This facilitates participants’ immersion in the narrative story, enhancing the narrative transportation effect.²² This protocol has been registered at chicr.org.cn, https://www.chictr.org.cn/ (registration number, ChiCTR2300074982).

Narrative Transportation Theory

Narrative transportation theory, proposed by Green in 2000, is one of a narrative persuasion framework.²³ Narrative transportation was defined as “immersion” in a story, a “unique psychological process that integrates attention, emotion, and imagery.” When people are transported into the story, the real world becomes “hard to touch.” They are completely focused on the story, and they have an almost real mental representation of the scenes described in the story. Experience strong emotional reactions as the plot develops, as if you completely leave the real world and are “lost” in the story world. When people return from the story world to reality, attitudes, beliefs, and even self-concepts change and become consistent with those in the story.²⁴

Narrative transportation changes attitudes and beliefs primarily by reducing negative cognitive reactions, liking and identifying with story characters, creating a near-real sense of presence, and evoking strong emotional responses.

Reduce Negative Cognitive Reactions

The chronological order of the Narrator narrative makes the narrative information appear correct. Gilbert’s (1991) research showed that people would naturally accept propositions that appear to be true.²⁵ Receivers’ mental resources are dedicated to imagining the events in the story. This leaves them with insufficient ability to refute the points in the story and reduces people’s motivation to refute the point.²⁶ Then, the view is likely to be integrated into their belief structure. Stories make people less aware of their persuasive purpose and less likely to inspire resistance.²⁷ When the persuasive message is contrary to people’s values, story evidence is considered more persuasive.²⁸ This thereby weakens resistance.

Prefer and Identify with the Story Characters

Transportation will increase people’s preference and identification with the story characters. This in turn may make individuals tend to imitate and accept the behaviors and attitudes of the story characters, becoming more and more similar to the story characters.²⁹ Role models can have a significant impact on increasing self-efficacy. In narrative persuasion, story characters are the source of information. Identification with the characters in the narrative enhances the persuasiveness of the message conveyed. This change in consciousness is achieved by being transported into the story world. After returning to the real world, people change their attitudes because they merge with the story characters.³⁰

Arouse Strong Emotional Responses

When the receiver’s emotional state matches the narrator’s emotional frame, it is easier to be persuaded.³¹ Transportation can make receivers’ emotions highly consistent with the emotional tone contained in the story.³² This also increases the persuasive effect of the story.

Produce an Almost Real Sense of Presence

Stories can arouse people’s vivid mental images. This has a strong sense of reality and are even more vivid and real than real scenes. Imaginary events can be mistakenly remembered as real, and the properties of this memory are the same as those of real memories.³³ Research by Fazio and Zanna (1981) showed that if individuals directly experienced the attitude object, they could develop strong and lasting attitudes.³⁴ Stories can trigger people’s near-real sense of presence and help people transform attitudes into behaviors at the level of mental simulation.

Hypothesis: Narrative Transportation Theory for Reducing Perceived Stigma Among WLWHA

Based on the narrative transportation theory framework, we hypothesize that (1) H1: Among participants exposed to the video, the higher the level of narrative transportation, the lower the perceived stigma. H2: The higher the level of identification with the video protagonist, the higher the participants’ self-esteem and coping self-efficacy. H3: Narrative transportation and identification with the video protagonist will moderate the relationship between video exposure and reduced anxiety and loneliness and improved resilience, social support, and quality of life.

The Application of the Narrative Persuasion Mechanism from the Narrative Transportation Theory in HOPES

WLWHAs are continuously indoctrinated with the storyline by the peer volunteers in HOPES intervention. In this emotional framework similar to the story, WLWHA can easily reach empathy with the peer and experience strong emotions. They share the same perceived stigma experience and coping strategies with the peer volunteers. According to Gerrig’s definition, WLWHA will actively imagine how the story will develop.³⁵ They will also presuppose how the ending of this story will change if the specific events of the story are altered. WLWHAs apply this active imagination to persuade herself to change her perceptions and beliefs about perceived stigma. That is, when WLWHAs come back to the real world from the story, some of their emotions and cognition are consolidated and retained. Up to this point, peer volunteers complete transporting the beliefs to WLWHA through narrative story. WLWHAs consequently form new attitudes or change the original attitudes.

HOPES is implemented by the self-developed WLWHA video interactive platform. The platform is named “Leaving No One Behind,” reflecting the core commitment of the United Nations 2030 Agenda for Sustainable Development.³⁶ It aims to help WLWHA access equal public health resources, ensuring that no one is left behind on the path to health equality. The narrative video was uploaded to LNOB. This can improve the feasibility of multicenter studies and reduce implementation costs.³⁷ The implementation of HOPES via the LNOB platform among WLWHA is shown in Fig. 1.

Figure 1.

The implementation of HOPES via the LNOB platform among WLWHA.

HOPES Protocol

HOPES intervention mainly consists of eight narrative videos. According to the temporal structure and spatial structure in narrative transportation theory,³⁸ WLWHA peer volunteers narrate around the narrative theme and record it into a video draft. The framework of narrative transportation theory in narrative videos is presented in Fig. 2. The eligibility criteria for WLWHA peer volunteers included being WLWHA, having experienced perceived stigma and possessing coping strategies relevant to the narrative theme, willingness to share their experiences, consenting to video recording, and the ability to clearly express their thoughts and feelings. The video theme comes from one-on-one in-depth interviews. The interviews involved 30 WLWHAs. The temporal structure includes four parts: background introduction, theme introduction, main narrative, and summary (see Table 1). The spatial structure is to construct the important components of the narrative story into the temporal structure so that each component forms a causal relationship. The components of the narrative story include the development of the plot and the characters, the coherent story structure (including temporal and causal coherence), and the emotions of the narrator in the video. Then, the narrative script was written according to the sexual script theory.³⁹ The initial draft of the video was edited based on the narrative script to create a narrative video encompassing three levels: cultural, interpersonal, and intrapersonal.

Figure 2.

Framework of narrative transportation theory in narrative videos.

Table 1.

The Construction of Narrative Videos

Construction	Details
Background introduction	Use a highly refined narration to introduce the age, marital status, number of children, years of HIV infection, and other information of the peer volunteers (picture: Use the daily life pictures of the peer volunteers as video materials, let the patients slowly enter the story of the volunteers with the pictures. The text fades in and out. Background music: fits this theme. Content audio: intercept part of the audio of this section, from slow to fast)
Introduce the theme	Introduce the theme with questions related to the volunteer’s experience. The “theme” is suppressed on the black screen as a transition between the background introduction and the development of the narrative (typewriter effect produces text)
Main narrative	Volunteers narrate (volunteer’s original voice). As the volunteer tells the story, the scene and composition are switched to make the picture richer and more attractive for participants to continue watching (volunteer’s original voice). If volunteers tell certain stories, the authorized materials on the Internet can be used to match the content and present it in the video, so that patients can immerse themselves in the story and empathize with it
Summary	Use pictures, narration, and text to explain the inspiration and thinking brought by the stories of WLWHA companion volunteers to the audience (narration dubbing, music starts, and disappears with the dubbing)

The titles of the eight narrative videos are “Innocent Me,” “Keeping my secret,” “The burden of guilt,” “Indispensable Companion,” “Strength in Adversity,” “The Most Familiar Stranger,” “Through the Wind and Rain,” and “Beautiful Hopes.” Among them, “The burden of guilt,” “Keeping my secret,” and “Beautiful Hopes” belong to the cultural level; “Innocent Me” and “Through the Wind and Rain” belong to the intrapersonal level; and “Indispensable Companion,” “Strength in Adversity,” and “The Most Familiar Strangers” belong to the interpersonal level. We showed the one-to-one correspondence from qualitative research topics to narrative scripts to narrative video topics and the summary of each narrative video in Table 2.

Table 2.

Narrative Video Development: From Qualitative Research Themes to Scripts and Final Production

Theme cluster in qualitative research	Theme in qualitative research	Script level	Theme of narrative video (duration)	Synopsis
Experiences with perceived stigma among WLWHA	Family Role (Wife/Mother/Grandmother/Daughter) Collapse and Disgusted by Family	Cultural script	The burden of guilt (6 min 50 s)	This video narrates the story of the women who, upon discovering their HIV infection, distanced themselves from their family due to fears of transmission. Influenced by the family-oriented ideology in traditional Chinese Confucian culture, they worry that their children will face stigma due to their HIV status
	Resignation in Being Shunned by Others	Intrapersonal script	Innocent Me (7 min 1 s)	This video presents the shock and confusion experienced by the women upon learning of their HIV infection. They struggle to comprehend the cause of their illness, resulting in a profound sense of helplessness and numerous unanswered questions
	Helplessness Due to Social Exclusion
	Grief at Being Devalued
	Resentment for Experiencing Injustice
Coping strategies for perceived stigma among WLWHA	The power of intimate partner support	Interpersonal script	Indispensable Companion (6 min 29 s)	This video narrates the story of the women who actively pursues HIV treatment with the support of their partners. Their partners understand and accept their condition, providing them with strong emotional support
	Social Avoidance	Cultural script	Keeping my secret (6 min 27 s)	This video narrates the story of the women who conceal their HIV medication to avoid detection of their infection. They fear being discovered due to perceived stigma, which is influenced by Chinese cultural norms regarding women
	Concealing the Condition
	Rebuilding self-confidence	Intrapersonal script	Through the Wind and Rain (10 min 1 s)	This video narrates the story of the women who actively pursue HIV treatment. After enduring multiple life-and-death experiences, they develop a strong desire for life and believe that AIDS is not frightening
	Family understanding	Interpersonal script	Strength in Adversity (5 min 29 s)	This video narrates the story of the women who received support from their families, when facing HIV. These supports strengthen their self-confidence and enable them to gain the strength to overcome the disease in adversity
	Support from fellow patients	Interpersonal script	The Most Familiar Strangers (3 min 40 s)	This video narrates the story of the women confronting HIV infection alongside their peers. Despite experiencing the separation of life and death, they firmly believe that God has opened a new window of hope for them
	Spreading hope	Cultural script	Beautiful Hopes (3 min 23 s)	Advocate and promote the Confucian principles of benevolence, righteousness, propriety, wisdom, trustworthiness, filial piety, and harmony as espoused in traditional Chinese Confucian culture. These principles aim to create an inclusive and caring social environment that enhances tolerance and support for women living with HIV

We employed both qualitative and quantitative methods to assess participants’ narrative engagement and evaluate the quality of the videos.

Qualitative Methods

One-on-one in-depth interviews were conducted with participants using open-ended questions to collect detailed feedback from viewers on their experience watching narrative videos. This included which aspects of the narrative video were most attractive, which were less effective, and suggestions for improvement.

Quantitative Methods

A self-designed narrative engagement form was used to quantitatively assess participants’ narrative engagement. The form includes four dimensions: psychological engagement, emotional engagement, cognitive engagement, and behavioral engagement, with a total of 16 items. The Likert 5-point rating method was used, with a rating of 1–5 points from “totally disagree” to “totally agree.”

The eight videos were uploaded to the homepage of the self-developed online platform LNOB (see eFigure 1), and the intervention was implemented through the online platform. Only participants assigned to the intervention group could access LNOB and receive the narrative video intervention. This ensured the independence of the two intervention groups while protecting the confidentiality and privacy of the participants. The HOPES intervention program also included writing reflective notes around the narrative videos, liking videos, commenting on videos, and online discussions. The LNOB video interaction platform records the viewing time, viewing duration, and video interaction of the narrative videos.

The companion volunteers came from Shanghai, Nanning, Kunming, and Dali. Shanghai is a major urban and financial hub with a cosmopolitan population. WLWHA in Shanghai may face perceived stigma shaped by the coexistence of traditional and modern views on HIV. Nanning is the capital of Guangxi, known for its Zhuang minority. WLWHA in Nanning may experience compounded perceived stigma from both HIV status and minority identity. Kunming is the capital of Yunnan Province, with a diverse ethnic population. WLWHA in Kunming may face perceived stigma influenced by ethnic minority status and traditional beliefs about HIV. Dali is a culturally significant city, home to the Bai ethnic minority. WLWHA in Dali may encounter perceived stigma driven by the close-knit community and the cultural emphasis on social harmony. The narrative video adopts testimonial message format. The peer volunteers face the camera (participants) directly. The narrator first introduces the narrative background, including that the peer volunteers are real patients, their experiences of perceived stigma and coping experiences are real, and the theme of the narrative comes from the interviews of 30 WLWHA. Then, the volunteers’ self-narration is introduced with questions related to the volunteers’ experiences. Then, the volunteers officially begin the narrative. Finally, the images, narration, and text are used to explain the inspiration and thinking brought by the volunteers’ stories to the audience.

To ensure full understanding of the content of the narrative video, WLWHAs were required to watch the video at least once a week in the first 12 weeks. However, if they wished, they could watch the video an unlimited number of times. After 12 weeks of intervention, participants in the intervention group could watch the video as they wished. After the 24-week follow-up period, the LNOB login platform was opened to participants in the control group. This was a compensatory measure for the control group.

Implementation of HOPES via the LNOB Platform Among WLWHA

After enrollment of WLWHA in the intervention group, the researcher assisted them in registering as users of LNOB (see Fig. 1). The platform automatically recorded the registration information, which includes demographic information, socioeconomic status, disease information, and responses to relevant questionnaires. These questionnaires assessed perceived stigma, self-esteem, coping self-efficacy, anxiety, loneliness, mental resilience, social support, and quality of life. This information served as the baseline data for the study. The registration account and password served as the sole credentials for logging into the platform. If the account number and password did not match during login, access to the platform was denied. Upon accessing the platform’s homepage, the researcher provided WLWHA with an explanation of the operational procedures and precautions related to functions of various module. These modules included user management, video management, social interaction, match recommendation, and privacy protection (see eFigure 2).

Measures

Perceived stigma was measured using the HIV/AIDS Perceived Stigma Questionnaire (HPSQ), developed by the researcher’s team in China, contains 10 items.⁴⁰ Cronbach’s alpha was 0.811.

Self-esteem was assessed using the Chinese version of the Rosenberg Self-Esteem Scale (RSES), comprising 10 items.⁴¹ This scale demonstrates reliability within the range of 0.78 to 0.89.

Coping self-efficacy was measured using the Chinese version of the Coping Self-Efficacy Scale (CSES),⁴² consisting of 26 items. Cronbach’s alpha for three dimensions was 0.91, 0.91, and 0.80, respectively.

Anxiety level was evaluated using the Chinese version of the Self-Rating Anxiety Scale (SAS),⁴³ comprising 20 items. The SAS indices are calculated by multiplying the total score of each questionnaire by 1.25 and then converting it to a 100-point scale. Cronbach’s alpha coefficient was 0.82.⁴⁴

Loneliness level was measured utilizing the third edition of the Chinese UCLA Loneliness Scale.⁴⁵ It comprises a total of 20 items. The internal consistency Cronbach alpha coefficient was 0.887, and the expert validity was 0.94.

Resilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC), developed by Connor and Davidson in 2003.⁴⁶ It consists of 25 items rated on a 5-point Likert scale. It has a reliability coefficient of 0.87.

Social support was assessed using the Social Support Rating Scale (SSRS) developed by Xiao Shuiyuan.⁴⁷ This scale consists of 10 items rated on a 4-point Likert scale. It has shown a reliability coefficient of 0.92.

Quality of life was measured using the World Health Organization Quality of Life HIV Brief Form (WHOQOL-HIV BREF), developed by the WHO.⁴⁸ It consists of 31 items rated on a 5-point Likert scale. Reliability coefficients for the different domains range from 0.78 to 0.88.

DISCUSSION

HOPES based on the narrative transportation theory is a potential method to reduce perceived stigma. It contributes to assisting WLWHA in establishing and maintaining a safe ecosystem, accessing equitable health resources, and enhancing their quality of life. This study has many strengths, including a multicenter representative dataset, real patient-narrated videos, a context-specific intervention targeting perceived stigma among WLWHA, and online delivery. However, there are several limitations. Although the study used a multicenter approach covering Eastern, Southern, and Southwest China, the generalizability may be limited, and it may not fully represent WLWHA in other regions. Future research should expand the geographic scope to validate the intervention’s effectiveness more broadly. The intervention’s design, based on China’s collectivist culture and Confucian values, may limit its applicability in other cultural contexts, indicating the need for validation in different settings to ensure broader applicability. Additionally, the removal of a camera feature during the LNOB online intervention to protect privacy resulted in lower compliance. Future research should explore ways to enhance this feature without compromising privacy, potentially improving compliance and intervention effectiveness.

Funding

This work was supported by the National Natural Science Foundation of China (grant number 71673057), the Fudan-Fosun Nursing Research Fund (grant number FNF202303), and the China Scholarship Council (grant number 202306100228).

Data Availability:

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations:

Conflict of Interest:

No conflicts of interest have been declared by the authors.