The LOVE (Learning Options through Video Education) study is a sequential, mixed methods pilot study designed to explore factors influencing Black women’s interest in oral PrEP and to assess the feasibility of a brief, culturally tailored eHealth intervention aimed at increasing PrEP awareness and motivation. Figure 1 depicts the study’s phased approach to developing and evaluating an innovative intervention. The four phases included (1) conducting exploratory focus groups to identify barriers and facilitators to PrEP uptake; (2) intervention mapping [38]; (3) development of the 5-minute, 3-part animated video, “Put Yourself First”; and (4) evaluation focus groups to assess the video’s usability, acceptability, and impact on PrEP knowledge. Detailed procedures for Phases 1, 2, and 3, including the literature review process and leadership of the intervention mapping activities, will be reported in a separate manuscript. This paper focuses exclusively on Phase 4, which evaluated the “Put Yourself First” video intervention.

Women were recruited from community-based organizations and through social networking sites in New York City. The study recruited heterosexual Black women residing in New York City. The study prioritized this population due to the city’s disproportionately high HIV prevalence among Black women and the persistent gaps in PrEP awareness and uptake documented in prior research [39]. A member of the research team screened the women based on the following criteria: (1) aged 18 to 25 years; (2) self-identified as heterosexual; (3) self-identified as African American, Black, Caribbean Black, or multiethnic Black; (4) self-reported HIV-negative or with unknown HIV status; (5) reported oral, vaginal, or anal sex with a man in the past 12 months; (6) current or past problematic substance use; and (7) residency in New York City. We screened 78 women, of whom 37 (47%) were eligible and 26 (33%) consented to participate in the study. Reasons for nonparticipation after screening were not systematically collected. No nonparticipants (eg, observers or organizational staff) were present during the focus groups aside from the cofacilitators. Thirteen women from the final sample participated in the explanatory focus group discussions.

Study visits were conducted in English by trained research staff in a private space. The evaluation focus groups were co-led by the first author (a qualitative researcher with doctoral training in public health and extensive experience conducting focus groups with Black women) and a trained research assistant. Both facilitators were identified as Black women, which may have enhanced rapport and comfort among participants. Neither facilitator had prior personal relationships with participants. During recruitment and consent, participants were informed that the purpose of the groups was to gather honest feedback about the “Put Yourself First” video, and facilitators emphasized that there were no right or wrong answers. After rescreening for eligibility, participants underwent a detailed verbal informed consent process prior to data collection commencing. Eligible women were invited to participate in a Brief Assessment Battery (BAB) survey administered by tablet or paper and a focus group. The BAB validated measures to assess women’s initial knowledge of PrEP [40], HIV knowledge [41], sexual behaviors, relationship dynamics [42], self-efficacy [43], and HIV stigma [44]. During Phase 4, participants were recruited to participate in explanatory focus groups to evaluate the video’s effectiveness through 2 focus groups (Group 3: n=7; Group 4: n=6). The first part of the explanatory focus group examined the factors that impede and facilitate PrEP use [6]. Participants were shown the 5-minute educational video, “Put Yourself First” (Figure 2).

A still image from the eHealth intervention’s animated video shows 3 Black women characters engaging in a casual conversation at a café, introducing the topic of PrEP. The central character gestures while discussing PrEP, with the acronym prominently displayed in large white letters and the full term, Preexposure Prophylaxis, in pink text below. This visual design situates PrEP education within a relatable, everyday social setting, reflecting the intervention’s culturally tailored, peer-to-peer communication approach to normalize PrEP discussions among Black women.

After viewing the video, participants completed a postvideo survey to assess the acceptability, perceived impact, and effects on knowledge and intentions. The second part of the explanatory focus groups was conducted to elicit feedback on the video’s usability, structure, and appeal. The focus group guide included questions not only about the video’s content (accuracy, clarity of PrEP information, cultural resonance, and stigma reduction) but also about its format, style, and representation (eg, use of animation, relatability of characters, and overall usability and appeal). The guide ensured that participant feedback addressed both informational and stylistic components of the video. This article is centered on the section of the focus group discussion that addressed the video’s usability, structure, and appeal. The audio-recorded focus groups took approximately 2 hours to complete. Although field notes were not taken, audio recordings were transcribed verbatim to ensure accuracy. This paper was prepared in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist to enhance transparency and rigor in reporting qualitative methods and findings [45].

The postvideo survey was administered immediately after participants watched the animated PrEP video (“Put Yourself First”). The postvideo survey comprises five parts: (1) PrEP knowledge (10 items, “True,” “False,” and “Don't know”) covering core facts such as HIV-negative eligibility, 3-month HIV testing while on PrEP, typical side effects, condom recommendations, distinction from postexposure prophylaxis, and hepatitis B virus considerations; (2) concerns about PrEP (13 items, “Yes,” “No,” and “Don’t know”) assessing safety (long-term and reproductive), side effects, resistance, perceived incomplete protection, daily pill burden, potential risk compensation (self and partners), stigma and privacy, comfort discussing sex with providers, and cost; (3) conditions for uptake (8 items, “Yes,” “No,” and “Don’t know”) eliciting enabling factors such as no-cost access, free HIV testing and monitoring, one-on-one or text-based counseling, group adherence support, and nonclinic access points; (4) acceptability, intentions, and global rating including willingness to recommend the video (Yes or No), a 1-6 overall quality rating, and intentions to consider or recommend PrEP; and (5) narrative engagement and perceived impact plus a brief global appraisal (5-point items) capturing story realism, message salience, character identification and liking, perceived social diffusion, and the likelihood of behaviors such as asking a provider about PrEP, requesting condom use, resisting unwanted sex, and obtaining HIV testing, alongside ratings of interest, usefulness, amount learned, comprehension, and liking.

Descriptive statistics from the surveys were calculated for the participants using IBM SPSS Statistics for Windows, version 29.0.2.0 [46], to summarize the data, including sociodemographic characteristics, sexual behavior, PrEP knowledge, and video acceptability. Pre- and posttest scores for PrEP knowledge were compared using paired-sample t tests for the full sample and within each group. Statistical significance was defined as P≤.05.

Audiotapes of the focus group discussions were transcribed. The transcripts were imported into Dedoose (SocioCultural Research Consultants, LLC) [47] software for coding and analysis. The research team analyzed the transcripts, but they were not returned to the participants for comment. Similarly, participants did not engage in formal member checking of findings, which we note as a methodological limitation. Two lead analysts and a research assistant, trained in qualitative methods, identified codes and used a multilayered strategy based on the topics addressed in the focus group guide. Analysis occurred in multiple stages, corresponding to the inductive approaches of open coding and axial coding used in grounded theory [48,49]. Codes were compared, refined, and reorganized through consensus discussions. To assess the breadth of issues raised, themes from the first focus group were compared to those from the second. While the small sample size precluded claims of definitive saturation, no substantially new themes emerged in the second group beyond those identified in the first. This consistency suggested adequate coverage of core issues for the scope of this exploratory evaluation [50,51]. Thus, we characterize our findings as reflecting preliminary thematic coverage rather than full saturation, consistent with grounded theory approaches in small-sample qualitative studies [52]. Here, we report evaluation findings from the 2 explanatory focus groups that assessed the eHealth video’s effectiveness and acceptability for increasing knowledge and addressing barriers to PrEP uptake among young Black women. All analysts worked independently to identify codes, ensuring that themes were consistently represented in the data.

This study was reviewed and approved by the New York University Institutional Review Board (approval number IRB-FY2017-408). All participants provided written informed consent prior to participation. Participants who completed the focus groups received US $45 in compensation and a 2-fare New York City Metrocard. To protect participant privacy and confidentiality, all data were deidentified, stored in a secure location, and securely transferred electronically to investigators involved in the analysis.

Table 1 presents the sociodemographic characteristics of the participants in the explanatory focus group (N=13). Participants had a mean age of 22 (SD 2.4) years, and the majority were US-born (11/13, 85%). Over half (7/13, 54%) had completed high school or a General Education Diploma, while 38% (5/13) had some college or trade school education, and 8% 1/13) held a college degree; 38% (5/13) were current students. Most participants were unemployed (6/13, 46%) or worked part-time (5/39, 39%), with the majority (10/13, 77%) reporting an annual income of less than US $19,999. All participants had health insurance, and 62% (8/13) had a primary care provider.

Regarding family and relationships, 23% of participants (3/13) had children, and most (8/13, 62%) reported being in a dating relationship, while 31% (4/13) were in a committed relationship. All participants reported having a primary or steady partner, and 39% (5/13) also engaged in sex with nonmain partners; notably, 39% (5/13) indicated their steady partner had other sexual partners. Condomless sex with steady partners was nearly universal (12/13, 92%) and occurred with 60% (3/5) of nonmain partners. Concerning HIV prevention, 69% (9/13) tested for HIV within the past year, and over half (7/13, 54%) reported having a sexually transmitted infection (STI) at some point in their life. While most participants knew about PrEP (10/13, 77%), only 2 (15%) had ever used it. Awareness of postexposure prophylaxis was lower (8/13, 62%), with no reported use.

Table 2 presents the pre- and posttest knowledge scores for the participants by group and collectively. Across all participants (N=13), mean scores increased significantly from 4.6 (SD 2.9) at pretest to 6.5 (SD 1.8) at posttest, for a mean difference of –1.9 points (95% CI –3.7 to –0.14; t₁₂=–2.3; P=.04). Group-level analyses indicated significant gains among Group 3 participants (n=7), whose mean scores improved from 4.2 (SD 2.9) to 6.3 (SD 2.1), a mean difference of –2.0 points (95% CI –3.3 to –0.69; t₆= –3.7; P=.01). Group 4 (n=6) demonstrated improvement as well, with mean scores rising from 5.0 (SD 3.1) to 6.8 (SD 1.5), though the change was not statistically significant (mean difference –1.8; 95% CI –6.4 to 2.7; t₅= –1.04; ns).

Table 3 presents the key barriers and facilitators to PrEP uptake. Barriers to PrEP included concerns about side effects and stigma related to others noticing medication use, each reported by 62% (8/13) of participants, as well as concerns about reproductive health (7/13, 54%). Participants reported cost, daily pill burden, and partner expectations less frequently. Notably, no participants expressed discomfort about discussing sexual health with a provider. In contrast, strong facilitators were identified, particularly access to text-based support (12/13, 92%), counseling about sex and relationships (11/13, 85%), and free HIV testing, monitoring, and one-on-one counseling (10/13, 77%). More than half also reported that free medication (8/13, 62%) and group-based adherence support (7/13, 54%) would enable uptake.

Table 4 presents findings on postviewing acceptability and intentions related to the PrEP video intervention. Most participants (10/13, 77%) reported they would consider using PrEP, and all (13/13, 100%) stated they would recommend it to others. The majority rated the video’s quality as very good (9/13, 69%) or excellent (3/13, 23%), and nearly all found it very or extremely interesting (11/13, 85%) and useful (12/13, 92%). Overall, 62% (8/13) reported learning a great deal of new information, while 92% (12/13) indicated they understood the content very well and liked the video very much.

Table 5 presents data on narrative engagement and the perceived impact of the PrEP video. Most participants found the storyline credible (9/13, 69%) and agreed that the message raised awareness (10/10, 77%) and supported action (8/13, 62%). Overall, 62% (8/13) reported relating to some characters and 31% (4/13) to most or all of them. The main character was universally well-received, with all participants describing her as likable, relatable, and compelling at emphasizing key messages. In terms of behavioral intentions, participants expressed a high likelihood of obtaining HIV testing (11/13, 85%) and asking a provider about PrEP (10/13, 77%), with a moderate likelihood of recommending PrEP (8/13, 62%), requesting condom use (7/13, 54%), and resisting condomless or unwanted sex (6/13, 46%).

The qualitative findings identified 6 areas of focus: viewers’ engagement and perceived impact, relatability through authentic representation, navigating relationships while prioritizing personal health, structural and practical barriers to PrEP adherence, empowerment through health autonomy, and domains requiring further development.

This study evaluated “Put Yourself First,” a culturally tailored, sex-positive, animated eHealth video intervention designed to increase PrEP awareness among young Black women. Participants found the video to be engaging, relatable, and informative, reporting increased knowledge of PrEP, a heightened willingness to consider it, and strong intentions to recommend it to their peers. Participants’ feedback suggested the importance of representation, authenticity, and the normalization of PrEP use for women, indicating the need for culturally resonant multimedia to enhance HIV prevention messaging. However, they also identified several aspects that could be refined to enhance its impact and resonance with the target audience.

Focus group findings demonstrate that the video was both engaging and educational, with participants praising its clarity, appeal, and ability to dispel misconceptions, such as the notion that PrEP is exclusively for gay men, while emphasizing its relevance and safety for women. These results align with prior research highlighting the importance of culturally tailored and gender-specific messaging in increasing PrEP awareness among women [8,53,54]. Importantly, these findings extend earlier exploratory studies [21] by demonstrating that an intervention explicitly grounded in sex-positive and empowerment frameworks can enhance knowledge while also resonating emotionally with the target audience. Previous research has shown that interventions can be enhanced by improving communication about sexual health within a young Black woman’s social network, particularly with emotionally supportive friends and family [55]. The conversational format among friends was viewed as authentic and relatable because it included a peer-to-peer exchange that mirrored participants’ real-life discussions. In edutainment, content is presented in ways that feel authentic and familiar, such as the script of the video, which conveys information on PrEP through a conversation among friends [37]. This educational method allowed the participants to see themselves or people like them. When people see peers (or peer characters) discussing, modeling, or demonstrating healthy behaviors, it helps participants believe that the behavior is possible, socially acceptable, and relevant [37]. The peer-to-peer exchange also models collectivism among Black women and communities [54].

At the same time, women identified relational challenges, particularly the tension between prioritizing their own health and concerns about partner perceptions, which reflects broader gendered and racialized dynamics that influence sexual health decision-making among Black women [6,55-57]. This reflects intersectional dynamics that Black women experience [6,55], where their overlapping identities, gendered expectations, and experience of racialized stigma impact structural inequities and constrain women’s HIV prevention options. Finally, the video’s framing of PrEP as an act of self-care and empowerment resonated strongly, affirming women’s right to make autonomous decisions about their sexual health. This finding contributes to the literature on sex-positive and empowerment-based approaches to HIV prevention, emphasizing the importance of interventions that affirm pleasure, center health autonomy and agency rather than relying solely on risk framing [58,59]. Together, these insights suggest that narrative-based, culturally resonant, and empowerment-framed interventions may be particularly effective for increasing PrEP engagement among Black women.

Although the video has notable strengths, participants noted several challenges that could limit its acceptability. While the video was informative, some participants found the use of animation somewhat limiting in fostering deep emotional connection and trust. They suggested incorporating real-life testimonials from women who use PrEP, live-action scenarios, or documentary-style storytelling on topics such as conversations with partners, health care visits, or navigating daily life while on PrEP, to enhance authenticity and relatability in PrEP-focused edutainment content [60]. There was a strong desire to see more authentic scenarios depicting real challenges women face when discussing PrEP with partners and health care providers, such as fear of judgment, accusations of infidelity, or adverse partner reactions. This aligns with prior studies highlighting the central role of interpersonal stigma and relationship dynamics in shaping women’s PrEP decision-making [6]. While women view PrEP as a tool for maintaining health and relationships, women’s romantic feelings and expectations can affect their risk perceptions and interest in using PrEP [61]. Imbalanced relationship dynamics, including power struggles, infidelity concerns, and trust issues, significantly influenced women’s PrEP decisions [62]. In addition, framing PrEP within a sex-positive, empowering context that aligns with women’s reproductive values may increase uptake [31,63]. These strategies not only enhance authenticity but also align with principles of edutainment, where culturally resonant narratives and modeled behaviors transform health information into engaging, meaningful content that promotes learning and supports behavior change.

Along with increasing awareness, participants emphasized the importance of directly tackling the institutional constraints that influence women’s PrEP decisions. They described persistent challenges, such as PrEP stigma, frequent medical visits, medical mistrust, and challenges with daily pill adherence, which often parallel their experiences with birth control [64-66]. Although the video demonstrated PrEP’s effectiveness, it did not fully address structural concerns, such as navigating the health care system, financial accessibility, or alternative care models, including pharmacy-based PrEP access or telehealth services [67-69]. Taken together, these findings emphasize the importance of advancing practice innovations that reduce both structural and interpersonal barriers through accessible care models, stigma-free environments, and culturally responsive provider communication. To enhance the impact of future interventions, messaging should include practical strategies to overcome these barriers, such as highlighting mail-order PrEP services, home HIV or STI testing kits, and financial assistance programs [68]. At the same time, future research is needed to evaluate multilevel strategies that address these barriers and generate evidence on how best to sustain equitable PrEP uptake among Black women. Such efforts will be crucial to ensuring that PrEP implementation not only increases awareness but also translates into meaningful improvements in HIV prevention outcomes [69]. Finally, these findings suggest the importance of expanding insurance coverage, integrating PrEP into reproductive and primary care services, and funding community-based initiatives that directly address the structural inequities limiting Black women’s access to HIV prevention [70].

In addition to addressing these structural barriers, it is crucial to consider how the “Put Yourself First” video can be disseminated most effectively. The findings emphasize the importance of designing HIV prevention interventions that not only raise awareness but also facilitate direct connections to services. Future dissemination strategies should leverage trusted community-based organizations, college health centers, sexual and reproductive health clinics, and digital platforms (both social networks and institutional services) to maximize reach and engagement among young Black women [9,10,13]. To ensure that the awareness generated by the video translates into tangible access to PrEP-related services and strengthens its real-world impact, direct referral pathways could be embedded within these dissemination channels, such as integrating links to PrEP locators, telehealth services, or peer navigation programs [54,67-69]. By pairing education with actionable referral tools, the intervention can more directly support women in moving from interest to uptake. These strategies can help bridge the persistent gap between PrEP awareness and actual uptake, ensuring that dissemination efforts are linked to concrete service access and continuity of care [26,28].

Several limitations warrant consideration. The findings are based on a small sample of young Black women from a single urban location, which limits their generalizability. Future work should extend recruitment to multiple geographic regions, including the South and rural communities where HIV disparities are most pronounced. Black women’s experiences are diverse and shaped by intersecting factors such as age, sexuality, and socioeconomic status. Future studies should purposively sample across these intersecting identities to capture heterogeneity within the population. While knowledge gains and acceptability outcomes were encouraging, the findings should be interpreted with caution, as they were not uniformly significant across all groups (eg, Group 4). Participants continued to express concerns about side effects, daily adherence, and structural barriers, such as frequent medical visits and medical mistrust. The evaluation was limited to immediate outcomes and did not assess downstream behaviors such as PrEP initiation or adherence. Participants also explicitly called for greater realism through live-action or testimonial-based storytelling and requested deeper engagement with structural barriers such as stigma, provider bias, and medical mistrust. These mixed findings temper the conclusions and highlight the need for future studies to address both behavioral and structural outcomes in addition to knowledge and acceptability. Longitudinal and controlled studies are needed to evaluate whether such interventions increase actual PrEP uptake and adherence. By incorporating these refinements, future studies can better bridge the gap between pilot findings and real-world application, ensuring that dissemination strategies not only raise awareness but also facilitate access and sustained use of PrEP.

Although no new themes emerged after the second focus group, the small qualitative sample limits the claim of saturation. Focus group methodologists typically recommend 3-5 groups per relatively homogeneous population to ensure adequate coverage of perspectives, suggesting that saturation should be monitored across, rather than within, groups [71,72]. While Guest and colleagues [73] demonstrated that most themes emerge within 6-12 participants, a benchmark often used to justify 2-3 focus groups for achieving saturation. This analysis of the explanatory focus groups aligns with this range, as it is a relatively homogeneous sample and the study consisted of targeted research questions. Additionally, focus group settings may have introduced social desirability bias, potentially leading participants to overemphasize favorable responses about the video. This study did not include specific methodological steps recommended by COREQ. For example, reasons for nonparticipation were not collected, field notes were not taken during focus groups, and transcripts were not returned to participants for validation. While focus groups were co-led by trained facilitators who shared social identities with participants, reflexivity was addressed through consensus-based coding discussions rather than participant checking of themes. These omissions may have limited opportunities to triangulate interpretations or further ensure the credibility of findings. Despite these limitations, the study provides critical insights into the acceptability and impact of a culturally tailored, sex-positive eHealth intervention video, offering a valuable foundation for refining and scaling PrEP promotion strategies for young Black women. This study reinforces existing research that demonstrates the effectiveness of culturally relevant, video-based educational interventions in improving engagement and increasing knowledge of PrEP among Black women [21,27,74].

This study highlights the critical need for culturally tailored interventions to enhance PrEP awareness and uptake among young Black women. This research emphasizes the importance of using sex-positive, engaging, and culturally affirming sexuality educational tools to address the ongoing barriers of stigma, misinformation, and health care inequities. By embedding PrEP within sex-positive and empowerment frameworks, this study contributes novel evidence that HIV prevention can be framed not only as risk reduction but also as a pathway to autonomy, intimacy, and pleasure. The findings show that eHealth interventions, especially edutainment animated videos, can effectively raise awareness, dispel misconceptions, and encourage informed decision-making regarding PrEP. These findings will guide future iterations, examining the long-term effects of eHealth video interventions on PrEP uptake and adherence and ensuring that dissemination strategies extend beyond awareness to support real-world access and sustained PrEP use. Ultimately, this study emphasizes the transformative potential of culturally competent and innovative health communication strategies in tackling disparities and empowering Black women to take control of their sexual health. Centering women’s voices, addressing structural barriers, and affirming pleasure and agency must remain central as PrEP interventions continue to evolve.