Paper

ARTICLE

Paradigm shifts in sexual health: Quantitative analysis of story and fact-based health education interventions Roula Kteily-Hawa1,2, Shriya Hari3 , Jaspreet Kaur Soor3, Josephine Pui-Hing Wong 4,5, Vijaya Chikermane3 , Lori A . Chambers 6, and Mandana Vahabi4 1 Faculty of Education and Social Work, Thompson Rivers University, Kamloops, BC 2 Ontario HIV Treatment Network, Toronto, ON 3 Alliance for South Asian AIDS Prevention, Toronto, ON 4 Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON 5 Dalla Lana School of Public Health, University of Toronto, Toronto, ON 6 School of Social Work, McMaster University, Hamilton, ON

There is a pressing need for sex education interventions that combat stigma and increase HIV knowledge and comfort in talking about sex among Canadian South Asians. A community-based research study in the Greater Toronto Area in Ontario, Canada assessed (1) the impact of fact-based versus story-based interventions on two outcomes: knowledge of HIV/STIs and HIV-related stigma; and (2) the potential of parasocial contact to reduce HIV-related stigma. This is a peer-facilitated, mixed method interven­ tion involving a partnership between the Alliance for South Asian AIDS Prevention (ASAAP), an organization serving South Asian and Middle Eastern people living with and affected by HIV, knowledge users, and a team of academic researchers. Eight South Asian women peer leaders were trained to help carry out the interventions. A convenience sample of 78, ages 18–60 were recruited. Participants were randomly allocated to traditional fact sheets (n = 40), and stories (n = 38). Analysis of Covariance (ANCOVA) was conducted to investigate the differences in the two outcome variables (HIV/STI knowledge and stigma) between the two study groups after the intervention controlling for differences in measures before the intervention. Adjusted mean for the HIV/STI knowl­ edge after the intervention was significantly higher in the story-sharing group (M = 8.02, SE = .28) vs fact-based group (M = 7.13, SE = .27), F(1, 75) = 5.10, p = .027, with the small effect size, partial Π 2 = .06. Similarly, a signifi cant difference was found in the mean post-intervention stigma scores between the story-sharing group and the fact-based group, F(1, 41) = 5.03, p = .030, with moderate effect size, partial Π 2 = .11. Specifically, the mean stigma scores in the story-sharing group (M = 45.75, SE = 2.72) were signifi cantly lower than the fact-based group (M = 54.80, SE = 2.85). Story-based interventions facilitated through parasocial contact with peer leaders off er powerful potential across populations and showed promise by increasing HIV/STI knowledge, reducing HIV-related stigma, and fostering capacity building, agency and empowerment. KEYWORDS: Canadian South Asian women, community-based research, fact-based sex education intervention, HIV/STI stigma, story-based sex education intervention, vicarious/parasocial contact

Interventions in sexual health have largely focused on behaviour 2006). While globally, the number of people contracting HIV change but gaps remain in designing interventions that promote has remained static since 2010 (UNAIDS, 2016), it is growing knowledge change and stigma reduction (Brown, Macintyre, & in Ontario and the GTA ( Government of Canada, 2015; Ontario Trujillo, 2003; Hogben, Ford, Becasen, & Brown, 2015; Lyles et al., HIV Treatment Network, 2015), especially amongst South Asian

ACKNOWLEDGEMENTS: We are grateful to all the women who participated in this research. We would like to acknowledge our eight women peer leaders, Abeera Khan, Anjum Sultana, Hadia Akhtar, Mahnoor Shahid, Nora Dikho, Ratna Chaudhary, Roopali Rokade, and Sreya Banerjea, for their important contributions in the successful implementation of this research. CORRESPONDENCE concerning this article should be addressed to Dr. Roula Kteily-Hawa, Faculty of Education and Social Work, Thompson Rivers University, 805 TRU Way, Kamloops, BC V2C 0C8, Canada. E-mail: [email protected]; [email protected]

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Roula Kteily-Hawa et al.

immigrant women. The term “South Asian”1 refers to an extremely diverse group of people whose origins can be traced to the region of South Asia (Statistics Canada, 2006). In 2011, South Asian women represented 3.5% of newly diagnosed HIV cases in Ontario, Canada (Sullivan et al., 2011), a province that includes the Greater Toronto Area (GTA) where South Asians constitute the largest (12%) vis­ ible minority group (National Household Survey, 2011). By 2015, this number had doubled to 7% (Ontario HIV Treatment Network, 2015). Since the early ‘90s, the epidemiology of HIV among South Asian populations in the GTA has been increasingly attributed to heterosexual contact; by 2004, the proportion of HIV infections due to heterosexual exposure to HIV (> 40%) surpassed those attribut­ ed to the MSM exposure category (<  35%) (Liu & Remis, 2007). Furthermore, Raju (2010 ) reports that despite increases in HIV in­ fections among South Asian women in the GTA, this group remains under-reached through prevention campaigns. Factors such as gender norms and expectations, silence on sex within South Asian communities, managing cultural value conflict, power dynamics in intimate and sexual relationships, lack of knowledge on prevention practices, and stigma towards STIs all influence South Asian wom­ en’s vulnerabilities to HIV infection (Raju, 2010). Research studies conducted in the GTA indicated that a high degree of stigma ex­ isted within South Asian communities in Toronto and that South Asian women living with HIV were particularly stigmatized (Hawa, Underhill, Logie, & Loutfy, 2017; Vlassoff & Ali, 2011). In the con­ text of HIV/AIDS, ignorance about its transmission, effects on the body, and a lack of knowledge about treatments and prophylactics for it fuels fear-based stigma (Alonzo & Reynolds, 1995; Herek & Capitanio, 1997; Holzemer et al., 2007).

HIV/AIDS stigma has been shown to impede dissemination of knowledge of HIV transmission and prevention, reinforcing myths and misconceptions about HIV. This in turn discourages preventive behaviours like condom-use, connecting to HIV/AIDS support services, and seeking HIV testing (Berkley-Patton, Goggin, Liston, Bradley-Ewing, & Neville, 2009; Brown et al., 2003; Finn & Sarangi, 2009; Holzemer et al., 2007; O’Leary et al., 2007). Stigma has also contributed to the social isolation and interpersonal violence ex­ perienced by people living with HIV/AIDS (PHA) (Brown et al., 2003; Carr & Gramling, 2004). There is therefore a pressing need for interventions that combat stigma and increase HIV knowledge and comfort in talking about sex among South Asians in Canada (Hawa et al., 2017; Kteily-Hawa & Chikermane, 2017; Kteily-Hawa, Islam, & Loutfy, 2019; Vlassoff & Ali, 2011).

DIDACTIC VERSUS POPULAR EDUCATION APPROACHES: PARASOCIAL CONTACT Didactic, fact-based approaches continue to be the dominant form of HIV prevention and sexual health education in North America and are associated with increased HIV/AIDS knowledge and

reduced risk in transmission and stigma (Brown et al., 2003; Dufl o, Dupas, Kremer, & Sinei, 2006; McCann & Sharkey, 1998). However, less is known about how fact-based education affects changes in at­ titudes and values toward sexuality and HIV-related issues.

In recent years, story-based and story-sharing education models have also become increasingly popular as an HIV/AIDS education approach in South Asia (Catalani, Castaneda, & Spielberg, 2013; Finn & Sarangi, 2009; Singhal & Rogers, 1999) and elsewhere (Nelson, Cordova, Walters, & Szecsy, 2016; Zeelen, Wijbenga, Vintges, & de Jong, 2010). Yet, despite the prevalence of popular education models (entertainment-education [E-E] models) disseminating HIV/AIDS health information (including storytelling and digital stories) in Asia and other developing countries (Berkley-Patton et al., 2009; Brown et al., 2003; Lapinski & Nwulu, 2008; Panford, Nyaney, Amoah, & Aidoo, 2001), there is a lack of research assessing the impact of sto­ ry-based interventions and story-sharing as eff ective sexual health promotion models for South Asians in North American contexts.

Popular (liberatory) education models stress a dialectic or dia­ logical relationship between the educator and the learner (Freire, 2007). Research has shown that popular education approach­ es decrease HIV/AIDS stigma, increase HIV/AIDS knowledge, and influence HIV preventive attitudes (Herek, 1986; Lapinski & Nwulu, 2008). Hinyard and Kreuter (2007 ) pointed to the power of stories in engaging people through values and interests, not­ ing that the cultural context of stories enabled information reten­ tion (see also Corby, Enguidanos, & Kay,1996). Some researchers (Bandura, 2002; Singhal & Rogers, 1999) have pointed out that culturally-relevant stories, especially stories shared by people or peers that participants identify with, can strengthen the eff ects of the popular education approach because peers function as role models and ‘share information in a non-threatening manner by fostering identification with story characters and experiences, en­ gaging recipients with storyline messages’ (Berkley-Patton et al., 2009, p.  200). Schiappa, Gregg, and Hewes (2005 ) suggested the parasocial contact hypothesis as a means of reducing stigma, argu­ ing that vicarious contact through media, video, and textual rep­ resentations, including peer educators, decreased stigma among populations receiving educational and informational materials.

As previously indicated, liberatory education helps people’s ‘understanding [of ] how systemic inequities are created and function and how they can be dismantled [including stigmati­ zation]’ (Wiggins & Pérez, 2016, p.1). However, to advocate ef­ fectively for its use, more studies are needed to develop a deeper understanding of popular education’s potential as a health pro­ motion tool (Wiggins, 2011). In that spirit, Palacios et al. (2015 ) demonstrated the merits of using stories and storytelling for in­ terventions and data collection (especially for HIV education). This study aspired to do the same by exposing participants to either a fact-based or a story-based intervention and by explor­ ing the use of parasocial contact as a way for reducing stigma.

1 The region of South Asia includes the principal countries of Bangladesh, Bhutan, India, the Maldives, Myanmar, Nepal, Pakistan, and Sri Lanka (Statistics Canada, 2006). It also refers to people who identify themselves as South Asian though their country of last permanent resi­ dence is not in South Asia. This includes South Asians from places such as Africa (especially East and South Africa), the Caribbean (Guyana, Trinidad, and Jamaica), South America, and the Pacific (Fiji), and European countries who trace their origin to the Indian subcontinent and continue to describe themselves as South Asians.

46 The Canadian Journal of Human Sexuality, 29(1), 2020, 45–56 • https://doi.org/10.3138/cjhs.2018-0037

Story-based interventions: Promoting sexual health

Study Objectives We undertook a community-based research study to compare (1) the effectiveness of story-based versus fact-based interven­ tions for HIV prevention among South Asian women in the GTA. In particular, we assessed the impact of story-based ver­ sus fact-based interventions on two outcomes: (a) knowledge of HIV/STIs; and (b) HIV-related stigma. Our other intent was to (2) explore the potential of parasocial contact as a way of reduc­ ing stigma towards and improving empowerment opportunities for women living with HIV.

METHODS This peer-facilitated, mixed-method, pilot study was a commu­ nity based research (CBR) project involving a partnership be­ tween the Alliance for South Asian AIDS Prevention (ASAAP), an organization serving South Asian and Middle Eastern people living with and affected by HIV, knowledge users, and a team of academic researchers. This intervention study was guided by the principles of health promotion, collective empowerment and capacity building (see Rubin et al. 2016 ).

Peer Leader Training Using a capacity building approach, the research team recruited eight women peer leaders from South Asian GTA communities to help carry out the interventions. Described in detail elsewhere (Kteily-Hawa, Hari, Wong et al., 2019), peer leaders received training on CBR, including research design, participant recruit­ ment, ethics and consent processes, HIV, STIs, and sexual rela­ tionships. They also learned about participant support, commu­ nity referrals, communication skills, and the social determinants of health and HIV. Peer leaders were trained to deliver both styles of interventions: story-based and fact-based. The training was based on a manual developed by members of ASAAP’s research team (Kteily-Hawa & Hari, 2015). Research ethics approval was obtained from Ryerson University in Toronto, Ontario.

Participants A convenience sample of 78 South Asian women of ages 18–60 were recruited through various GTA sites serving South Asian women and communities (including community centres and community health centres) using word of mouth, the snowball sampling technique, and flyers and e-flyers distributed to com­ munity partners and networks. To be eligible for this study, par­ ticipants needed to identify as South Asian women, be profi cient in English, be 18 years or older, and give informed consent.

Intervention The study design entailed two peer-facilitated intervention mod­ els. Th e first intervention was a conventional factual informa­ tion model that used Toronto Public Health’s fact sheets on HIV (2013a ), HPV (2014 ), and Chlamydia (2013b ). The second inter­ vention used culturally-relevant stories addressing biomedical information comparable to Toronto Public Health’s fact sheet, in­ cluding information regarding risks, transmission, and treatment

of HIV/STIs (See Appendix 1 for sample stories). Stories, by their nature, provide a social and culturally relevant context for infor­ mation delivery; furthermore, two of the stories were produced by South Asian women living with HIV as part of an anthology thereby providing vicarious contact with PHA, and three others were developed through the Women’s Sexual Health platform at ASAAP, Brownkiss. Participants were recruited through several organizations across the GTA. Using a coin toss, women were randomly allocated to either the fact-based intervention (n = 40) or the story-based intervention (n  =  38). To account for facili­ tator effects, all peer leaders delivered both styles of interven­ tions at diff erent sites, and peer leaders rotated their roles (Lead Facilitator, Support Facilitator, Field Note Taker). Also, all peer leaders have undergone the same training and a training manual was developed by the first and second author with support and input from the rest of the research team to standardize the pro­ cesses involved in the interventions (Kteily-Hawa & Hari, 2015).

This study used a mixed-method design involving surveys and focus groups. Upon obtaining written consent, partici­ pants were invited to complete a demographics survey and a pre-intervention sexual health questionnaire. Then, the peer leaders delivered a 45-minute intervention (factual information or story). This session involved handing out the stories or fact sheets, and allowing participants to read the information pre­ sented to them. After the intervention, participants were invited to fill out the same sexual health survey again to assess short- term changes in their sexual health knowledge and to detect changes in HIV/AIDS stigma, attitudes, and perceptions of HIV transmission risk. Longer-term effects were not explored in this preliminary study due to limited resources.

After the participants completed the post-survey, the peer leaders facilitated an audio-recorded group discussion to further explore participants’ perceptions, understandings, and engage­ ment with the intervention material (fact sheets or stories) (see Wong et al., 2018). At the end of the focus groups, each partic­ ipant was given a resource list of community agencies that pro­ vide health services and social support. The total intervention lasted approximately three hours. This paper focuses on the quantitative analysis of the pre-post questionnaires.

Measures The peer leader administered questionnaire contained three sec­ tions: (1) sociodemographic measures; (2) HIV/STI knowledge; and (3) HIV-related stigma.

Sociodemographic measures Questions pertaining to place of birth, educational level, employ­ ment status and self-identified sexual orientation were included.

Outcome measures HIV/STI knowledge Before and after the fact-based or story-based intervention, par­ ticipants answered nine pre/post fill in the blank, true/false and multiple choice type questions to gauge their level of HIV and STI knowledge (e.g., the routes of HIV infection, the risk of HIV

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Roula Kteily-Hawa et al.

infection with condom breakage). Scores ranged from 0 to 9 based on the number of correct answers. A higher score refl ected higher HIV/STI knowledge. There was a total of nine questions in the knowledge questionnaire. Examples of knowledge items included in the questionnaire are “Check all that apply: HIV: is a virus that attacks the immune system; has a cure; is a bacte­ ria that destroys the liver; and is the same as AIDS. HIV can be passed through: hugging or shaking hands; kissing; sharing food; sex with a condom; sex without a condom; sharing needles.”

HIV-related stigma Participants answered a 21-item questionnaire (5-point Likert scale, 1  =  strongly disagree and 5  =  strongly agree) about their stigma levels, and attitude toward and perception of HIV trans­ mission risk. Statements in the questionnaire included fear of transmission through casual contact, blame and judgment, gen­ der norms, and enacted stigma. Some examples from the stigma questionnaire include: “Q#3 It is shameful for a woman to have lots of sex with different people. Q#9 Men can’t be expected to practise safer sex. Q#12 It is safe for me to work with someone who is living with HIV; and Q#19 I would support someone in my family living with HIV.” After recoding seven items in the questionnaire (#10, #12, #13, #15, #16, #19, #21) for directional consistency, the 21 items were summed to derive a total score, with a greater score indicating a higher level of stigma endorsed by a participant. This portion of the questionnaire was construct­ ed using existing sexual health promotion program evaluations for South Asians in the GTA. It also incorporated recommen­ dations from ASAAP’s PHA support program, and the USAID’s Stigma And Discrimination Indicators Working Group and the Tanzania Stigma Indicator produced through USAID (USAID & Population Council, 2008), used in assessing HIV stigma in North India (Nebhinani, Mattoo,  & Wanchu, 2012). Th e ques­ tionnaire had a Cronbach’s alpha of 0.77 for the pre-intervention and 0.84 for the post-intervention (an acceptable reliability).

TABLE 1. Participant Demographics and Chi-Square Analysis

Data Analysis Data were analyzed using SPSS Statistics 22.0 Version. Descriptive statistics (frequency, means, and standard deviation) were com­ puted to depict demographics and to illustrate the questionnaire’s response distribution. Inferential statistics included a mixed factorial analysis of variance (ANOVA) to examine the mean difference in the HIV/STI knowledge and HIV stigma as func­ tions of time (pre-test and post-test questionnaires) and group (story-based and fact-based). In case of signifi cant interaction between the group and time variables in mixed ANOVA, further analysis of covariance (ANCOVA) was planned to investigate the differences in the two outcome variables (HIV/STI knowledge and stigma) between the two study groups after the interven­ tion controlling for the differences in these measures before the intervention.

RESULTS Table 1 shares the demographic profile of the sample. Most (93.59%) of the women were not born in Canada. Th e Majority (70.5%) had completed an undergraduate/graduate professional degree. Of all the women, 38.2% were employed fulltime (in­ cluding keeping house) and 50% were non-fulltime employed. The Majority (88.2%) identified as heterosexual/straight, with a minority (11.8%) identifying as non-heterosexual/straight.

Table 1 also shows the Chi-square values gauging inter-group similarities among the group (story-based and fact-based) de­ mographic profi les. There were no signifi cant diff erences be­ tween the two groups in regards to birth in Canada, highest level of education, employment status and sexual orientation.

A mixed factorial analysis of variance (ANOVA) was con­ ducted to examine the mean differences in the two outcome variables (HIV/STI knowledge and stigma) as functions of time effect (pre versus post intervention) and group eff ect (sto­ ry-based versus fact-based group). With regard to HIV/STI

Variables Total (nb=b79) Missing Data Chi-square Value n (%) n (%)

Birth in Canada nb=b78 1 (1.3) 1.76

Yes 5 (6.4) b b No 73 (93.6) b b

Highest Level of Education 78 (98.7) 1 (1.3) 2.54

High school diploma or less or equivalent 23 (29.4) b b With an undergraduate/graduate degree b 55 (70.5) b b

Employment Status 76 (96.2) 3 (3.8) 0.53

Non-full-time employed 38 (50.0) b b Full-time employed (includes full-time home makers) 29 (38.2) b b Retired and others 9 (11.8) b b

Sexual Orientation 68 (86.1) 11 (13.9) 0.57

Heterosexual/Straight 60 (88.2) b b Non-heterosexual/Bisexual 8 (11.8) b b

* pb<b0.05. ** pb<b0.01. *** pb<b0.001.

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Story-based interventions: Promoting sexual health

knowledge, the within-subject effect is signifi cant (F  =  81.70, Figure 1 suggests that while the story-based group began at p < 0.001). Signifi cant increases in HIV/STI knowledge are ob- a lower knowledge level, the story-based group’s magnitude of served in both groups following intervention. Further, the sig- increase in knowledge level is greater than that in the fact-based nificant time*group interaction term (F  =  8.98, p  <  0.01) sug- group. gests that the changes in participants’ HIV/STI knowledge are As for change in stigma, the within-subject effect is not sig­ unequal between both groups and need further inspection (see nificant (F  =  0.002, p  >  0.05) but the time*group interaction is Table 2). significant (F = 9.45, p < 0.001), suggesting that the changes in

TABLE 2. Within-Measures Mixed Factor Design of the Outcome Variables

Fact-Based Group Story-Based Group Within-subject Interaction Outcome Variables Pre-Intervention Post-Intervention Pre-Intervention Post-Intervention effect (F value) (time*group)

Mean (SD) Mean (SD) b Mean (SD) Mean (SD) b

HIV/STI Knowledge 6.35 (2.73) 7.58 (2.72) 5.10 (2.06) 7.55 (2.15) 81.07*** 8.98** Stigma 46.67 (9.59) 56.05 (17.25) 53.69 (13.05) 44.61 (7.89) 0.002 9.45***

* pb<b0.05. ** pb<b0.01. *** pb<b0.001.

FIGURE 1. Estimated marginal means for HIV knowledge against time (pre-test and post-test questionnaires) for the groups (story-based and fact-based)

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Roula Kteily-Hawa et al.

FIGURE 2 . Estimated marginal means for HIV stigma against time (pre-test and post-test questionnaires) for the groups (story-based and fact- based)

stigma between two intervention groups are not parallel and re­ quire further inspection (see Table 2).

As illustrated in Figure 2, stigma levels reduced in the story-based group after the intervention while increasing in the fact-based group. This result may reflect the distinct nature and effects of the two intervention models. Since mixed ANOVA showed a significant interaction between group and time and the groups had different scores at the baseline, ANCOVA analyses were conducted to investigate the differences in the two outcome variables (HIV/STI knowledge and stigma) between the two study groups after the intervention controlling for the diff erences in these measures before the intervention. The adjusted mean for the HIV/STI knowledge after the intervention was signifi cantly higher in the story-sharing group ( M =  8.02, SE =  .28) as com­ pared to the fact-based group ( M = 7.13, SE = .27), F (1, 75) = 5.10, p = .027, with the small effect size, partial Π 2 = .06. Similarly, a signifi cant difference was found in the mean post intervention

stigma scores between the story-sharing group and the fact-based group, F(1, 41) = 5.03, p = .030, with moderate effect size, partial Π2 = .11. Specifically, the mean stigma scores in the story-sharing group ( M =  45.75, SE =  2.72) were significantly lower as com­ pared to the fact-based group ( M = 54.80, SE = 2.85).

DISCUSSION

Story-Based Versus Fact-Based Sexual Health Education (Objective 1) The stories in this study portray sexual health as a component of health, and by extension, the lives of these women. Stories there­ fore contributed to the short-term gains in HIV/STI knowledge, comfort around talking about sex, and stigma reduction, mea­ sured through the post-survey questionnaire (see Table 2). Indeed, the data indicated that the mean for the HIV/STI knowledge

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Story-based interventions: Promoting sexual health

after the intervention was significantly higher in the story-sharing group as compared to the fact-based group. Through the lack of culturally-specific messaging, fact-based interventions may con­ tribute to heightening stigmatizing attitudes towards PHA, and may generate apathy towards the relevancy of sexual health infor­ mation in South Asian communities.

HIV/STI Knowledge: Implications The story-based intervention improved retention of factual in­ formation and the mean for HIV/STI knowledge was signifi ­ cantly higher in the story-sharing group as compared to the fact-based group. The question of cultural relevancy is perti­ nent: culturally-relevant contexts clearly explicating South Asian women’s sexual health vulnerabilities, needs, gaps, and modes of resilience, perhaps allow South Asian women to understand sexual health information as relevant to their lives. Th ese results deserve further examination in future studies because narrative structure has been proposed as a delivery mechanism for factual information. Negrette (2003 ), discovered that narratives allowed participants to retain information better and for a longer dura­ tion of time compared to purely factual information. Similarly, Mutonyi’s (2015 ) qualitative work established that youth are more engaged and retain more scientific knowledge about HIV when the educative material is delivered in a narrative-based, culturally-relevant format.

Stigma: Implications Similarly, our results show a signifi cant difference in the mean post intervention stigma scores between the story-sharing group and the fact-based group. Our stigma-change results also echoed other study findings. O’Leary et al. (2007 ) found signifi cant diff er­ ences in HIV/AIDS stigma indicators between participants who watched an HIV-specific plot in a popular day-time soap opera in Botswana, and those who did not, with the former indicating more empathy for PHA. Catalani et al. (2013 ) discovered that even a brief intervention with a simple graphic video was useful in eliciting positive short term changes in stigma among diverse populations in South India. Lapinski and Nwulu (2008 ) found that after exposure to a locally-written fi lm, male-identifi ed Nigerian participants held less stigmatizing views of PHA. In contrast, they also found that women explicitly reported a significant increase in mandatory disclosure of HIV, due to contextual messaging in the fi lm. Th eir findings suggest that the content of a narrative-based intervention is not enough to modulate stigma, the context further mediates the relevancy of how people parse information.

Contact And Parasocial Contact (Objective 2) To continue with the context theme, the story-based interven­ tions were facilitated by South Asian women in a peer role capac­ ity, helping them establish a culturally-relevant and comfortable rapport with the participants. The selected stories incorporated a mix of Canadian English and South Asian English linguistic norms, aiding the establishment of a culturally-familiar space that facilitated meaning-making and learning for participants.

Results intimate that the participants appeared to resonate more with the narratives than the fact sheets, probably due to the re­ latable format of the written materials (Bandura, 2002; Hopfer, 2012; Hopfer & Clippard, 2010).

Additionally, the peer-facilitated process followed the tenets of socio-cultural theory of learning whereby group members make meaning through available cultural tools, norms, and sym­ bols (Bruner, 1986; Rogoff , 2003; Vygotsky, 1978). Reading sto­ ries demanded participants to contextually engage with the char­ acters they were reading about (including a snapshot into their lives and every-day concerns). It was anticipated that partici­ pants identify with the characters in the stories, their struggles as well as their resilience. By providing more context than factu­ al information, narrative power can generate empathy through persuasion and subtly challenge stigmatizing counterarguments (Slater & Rouner, 2002).

Regarding the contact and parasocial contact hypothesis (Allport, 1954; Schiappa et al., 2005), our results indicated that stories (narratives) from peers alone are signifi cantly correlat­ ed to decreasing stigma, increasing HIV/AIDS knowledge, and increasing comfort talking about sex (see Table 2 & Figures 1 and 2 ). These results bode well for reducing stigma toward wom­ en living with HIV and increasing female agency in sexual deci­ sion making (per Romero et al., 2006).

In terms of HIV/AIDS intervention strategies, Brown et al. (2003 ) conducted a meta-analysis wherein they grouped stories and narrative-based strategies under ‘information-based ap­ proaches.’ Most approaches were found to be didactic in nature with factual information about HIV risk and transmission, and the harmful effects of HIV-stigma on PHA. They also found that information-based approaches on their own did not result in long-term changes in attitudes or knowledge in the general pop­ ulation. However, direct, contact-based approaches with PHA had longer term impact.

LIMITATIONS This pilot study faced budgetary constraints and could not af­ ford language interpretation at the focus groups. Participants in this study were fluent in English, however accommodating South Asian languages and materials is the next relevant step in reaching women not fluent in English. A related issue is the longer time for some interventions due to participants’ comfort and reading speed with English, possibly resulting in partici­ pant fatigue. Although this does not take away from the study results, future research design should consider allotting more than three hours per intervention. Being a one-time interven­ tion with pre-post surveys, the long-term impact and behaviour change could not be evaluated, something that would require a longitudinal study. Future researchers should also explore the combined effects of narrative-based and fact-based sexual health intervention measures (not part of this pilot study due to limit­ ed resources and funding). The scalability of the study measures of stigma, HIV/STI knowledge, and comfort with sexual health, also vary widely across different studies, contexts and popula­ tions. Future researchers should partner with local AIDS Service

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Roula Kteily-Hawa et al.

Organizations in Toronto and develop a scalability standard to better represent the contexts of various people affected by, living with, or at risk of HIV in the GTA.

CONCLUSIONS The use of narrative-based education stories draws on culturally- appropriate means of knowledge transfer within South Asian communities. This strategy created vicarious or parasocial contact (Schiappa et al., 2005) that increased HIV knowledge, and decreased stigma while minimizing the risk of PHA re-stigmatization. Th is study showed that publications like More Th an Fiction (Aditi et al., 2015), with accounts written by South Asian POZ women in addition to fictitious accounts developed as a narrative-based sexual health intervention resource, have the potential to trans­ port the participants into the narrative’s world, promoting factu­ al information retention while simultaneously empathizing with the wider context of a PHA’s life (Green, 2004).

Stories are a means of generating vicarious contact without the risk of re-stigmatizing individuals who may not be ready to share their stories through POZ Speaker Bureaus, which rely on direct contact between PHA and non-PHA. Education models using vicarious (parasocial) contact through ano­ nymized narrative-based approaches offer powerful potential and scope for marginalized voices to be heard, empathized with, and respected. They also have the potential to eff ect be­ haviour change. More work needs to be done to fully explicate the potential of narratives in popular education health promo­ tion through vicarious contact, as well as their potential as a flexible tool over authorship, HIV disclosure, empowerment, and voice. This dual potential in education and empowerment offers exciting possibilities for narrative-based methods to meet a multiplicity of health promotion and health empower­ ment demands.

This pilot study used a community based participatory re­ search design. Narrative-based sexual health promotion in­ terventions are more ethical within a community-based and community-led format, with the partnership of local AIDS Service Organizations and input from primary stakeholders (e.g., people living with, affected by, or at risk of HIV/AIDS, and AIDS Service Organization staff providing direct client service). The ethical nature of these results make them valuable when de­ veloping materials in various South Asian languages, including combining expository texts and factual material more explicitly into stories.

Finally, all populations are located in a cultural context; therefore, narrative-based methodologies of HIV/AIDS educa­ tion have potential across many populations. Culture-centric approaches with peer-facilitated narratives show promise in ad­ dressing people’s needs by increasing HIV/STI knowledge, in­ creasing comfort about sexual health, and most signifi cantly in reducing HIV stigma.

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APPENDIX 1: SAMPLE STORIES USED IN THE STORY- BASED PACAKGE

Chlamydia—Getting Tested and Treated I’m sitting in a sterile, uncomfortable room in my hospital gown waiting impatiently for the nurse to return. I wish I was any­ where else; I know that this exam is necessary but that doesn’t make it any less uncomfortable.

My name is Saba. I came in for my routine checkup about three weeks ago. I try and do this every time I have a new part­ ner. We’d been dating a few months and I was in some serious honeymoon phase. Th e first few times we were really good about condoms and I’m on the pill too so I wasn’t worried. But the last time we got so caught up in the moment and he insisted he would pull out.Yes, the withdrawal method of safe sex- HA! Not a method to be trusted.

During the routine check-up, I had a simple swipe test and I got my results that same day. I felt so angry and upset that I had an STI—a sexually transmitted infection: chlamydia. I felt like it was stupid of me and I should have known better, but really I know that’s not the case. I started thinking about whether Imran knew all along and just didn’t tell me or whether he didn’t know at all.

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I knew I had to tell him and that he should get tested too. I’d heard that sometimes you would feel a burning sensation when urinating but I hadn’t had any symptoms and I knew there was a real chance that he hadn’t had any either. Having an STI and not having any symptoms—what’s that about? How are we supposed to know to go to the clinic or get tested? I guess it’s just about knowing if you’re at risk—and having a little fun without a con­ dom put me at risk.

They gave me a single dose of Azithromycin and I had to make sure I didn’t have sex for a week, so the antibiotic had a chance to clear the infection completely. I’m here today to make sure the medication worked and the chlamydia has been com­ pletely cleared out of my system. I know that this course of treat­ ment has been successful for many in the past so I’m hopeful that it’ll work.

Practising safer sex or always being careful is so much harder than it sounds. Imran and I aren’t even together anymore, he was not happy about my news. In fact, he insisted that I’d been with other guys and put him at risk, he even called me names that I don’t want to remember. Needless to say, I was not impressed.

Layla’s Story I was diagnosed HIV positive a few years ago. I don’t really re­ member how I felt when the doctor told me that I had HIV. I’ve heard people say that HIV positive people shouldn’t even be on this earth but I was never bothered by their ignorance. I’m a hu­ man being and I deserve to be loved, valued, and heard.

After I found out about my status, I reached out to the HIV community and made some new friends. I was happy to know that there were others like me and that we could support one another through our challenges. It makes me a little upset when I see things on T.V about HIV but then again they’re trying to help people so they don’t end up like me. I guess that’s kind of good because some­ times it feels like nobody gets me. I know most people are trying to help me, but sometimes I just wanna be able to live a life without this illness on my shoulders...you know have a normal life and live with my kids, but I will never regret who I am and what I have. It’s made me who I am and I guess that’s what’s important. Honestly, I really don’t like the meds they give me. If I could think of one word to describe them, it’s nasty. But, my mom makes me laugh about having to take them or at least she tries to make me laugh.

I had to start ARVs shortly after I was diagnosed because my CD4 count was very low and I was not feeling too great. I start­ ed taking the meds after a month and I continue to take them every day. Well, I never thought this would happen to me, but it did happen, and there’s nothing I can do about it except live a positive life. My prayer is for God to keep protecting me all the days of my life.

The only problem I am facing is telling my story to others. I’m so scared that people will judge me and not want to be around me if they find out that I am HIV positive ‘cuz every time I bring up the issue of HIV just to get people’s views, they say HIV pos­ itive individuals would most likely die from depression. I don’t believe them, but it’s hard to challenge them sometimes. I can only live my life one day at a time.

Now let me tell you how I got HIV. I was married for many years and had children. My children are my pride and joy, and they have helped and supported me through the years. Only a few years ago, my husband was admitted to the hospital because he was having a seizure. When the doctors did tests on him, they found out that he had AIDS. As soon as I sat down to help me recover from the news of my husband, the doctor told me that I should go for an HIV test. I think the blood must have drained from my face because he said, “You look very pale.” Well, what did he expect me to feel after such news?

He had just told me to go for an HIV test, no information, no discussion! I sat there in silence while he wrote out instructions on a piece of paper for the hospital to do an HIV blood test on me. I remember looking at it and seeing the word HIV written on it. We got the test results back, and my children were nega­ tive, but my test came back positive. I cannot describe how I was feeling. I thought I was going to die but I knew I had to be strong for my kids. I shut down all my feelings of sadness when I was around them.

When I told my children I was HIV positive they did not know what to do. They were scared to go near me and they were scared to even touch me. We did not know one thing about HIV until doctors told us and we got counselling. I was devastated that I had HIV but I could not do anything but take care of my­ self and try to live my life without my kids fearing me. When I went on medication for HIV I felt weird taking the pills and I didn’t like how I felt aft er I took them. I felt weak and helpless. I had to quit my job because HIV made me sick, but I could not afford to live in my apartment or support my children. Aft er quitting my job, I went on social assistance to help with all the bills and daily living expenses.

When I found out HIV and AIDS were two diff erent things I wondered if my husband was going to have to go on pills too. But in his case it was too late for him. He could not take pills or anything. After months being in the hospital, his vital organs started to shut down and collapse. We knew this was going to be the last time we’d see him alive. I was in tears and heartbroken that I was going to lose my husband, but my children were even more devastated. They were going to lose their loving father.

After we all said our goodbyes, we had a funeral for him. We didn’t know if it was a good idea to keep the casket open at his fu­ neral for everyone to see him but we kept it open so people could say goodbye to this amazing man. Now you all must be wonder­ ing by now, how did my husband catch AIDS? I have been won­ dering the same and till today I do not know how my husband contracted the HIV virus that eventually led him to AIDS. I do not blame him for anything but I do wonder everyday what hap­ pened. I miss my husband a lot and I wish he were here today to see his children grow into young adulthood.

It was a difficult time for me, though one of the fi rst things that gave me the strength to carry on was the fact my children did not have HIV and that they still were and are in my life. Th ey have been a great source of strength for me. Either I could choose to be bitter and blame the world for infecting me with HIV, or I could make the most of whatever life I had left. I chose the latter and to this day, I appreciate each day that I am alive. I do

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what pleases me, within limits of course, and make absolutely no apologies for it!

It is now 2014, and it is going to be 6 years that I am living with this illness. I am in control of it. It has no control over me. I remain happy and content with a positive attitude. Today my children are not afraid to be with me or touch me because we have all taken counselling and therapy to understand more about HIV and they know how to protect themselves from getting HIV. I have gone through a wave of emotions and feelings and it’s been one hell of a ride! I am so thankful for the support I have from my friends and family and the support I can give back to them.

I would hope anyone that’s reading this will understand that it will feel at first like your life has ended when you get an HIV diagnosis. You might wonder how you will function but believe me something like this makes you put life into perspective and you discover just how precious the time you have. What life deals us is what makes us stronger. Believe in yourselves and make the best of what you’ve got. I won’t lie and say I don’t have my down days, but I also have some really great days. Truthfully, not a day goes by without my status and the memory of my husband on my mind. I have the conviction and energy to carry on, though, and make my life mean something to me and to my children.

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