Evaluating the Impact of the Hepatitis B Foundation’s International Storytelling Program on Empowerment, Advocacy, and Stigma Reduction

Evaluating the Impact of the Hepatitis B Foundation’s International Storytelling Program on Empowerment, Advocacy, and Stigma Reduction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating the Impact of the Hepatitis B Foundation’s International Storytelling Program on Empowerment, Advocacy, and Stigma Reduction Michelle Liu, Bright Ansah, Noah Michael Trudeau, Stella Dlamini, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9419489/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Hepatitis B remains a major global public health challenge, characterized by low awareness, underdiagnosis, limited access to care, and pervasive stigma. Stigma and misinformation discourage disclosure, delay testing, and reduce engagement in treatment and prevention. Storytelling has emerged as a promising health communication tool to humanize disease experiences, reduce stigma, and promote advocacy. This study evaluates the Hepatitis B Foundation’s International Storytelling Program and its impact on storytellers’ empowerment, confidence, stigma experiences, perceived community impact, and advocacy engagement. Methods A mixed-methods evaluation was conducted. Eligible participants were adults who had recorded personal hepatitis B stories through the program. Quantitative data were collected via an immediate post-recording survey (n = 25) and a follow-up survey 3–6 months later (n = 11), assessing satisfaction, emotional responses, confidence, stigma experiences, and advocacy activities. Descriptive statistics were calculated. Fifteen participants were interviewed qualitatively; these individuals were part of an eligible pool of storytellers spanning 22 countries. Interviews were transcribed and analyzed thematically with double coding for reliability. Quantitative and qualitative findings were integrated to provide a comprehensive understanding of program impacts. Results Participants reported high satisfaction with the storytelling process and immediate personal benefits: 76% felt empowered, 92% felt confident sharing their story, and 96% felt prepared to advocate for hepatitis B awareness. At follow-up, 73% reported increased comfort discussing hepatitis B, 73% noted personal growth, and 64% felt more connected to the hepatitis B community. Over half shared their stories publicly, and 64% felt empowered to become advocates. Qualitative analysis revealed themes including hepatitis B as a social and emotional condition shaped by stigma, storytelling as a tool for reframing illness identity, emotional processing and acceptance, increased willingness to disclose, transition into advocacy roles, and community-level ripple effects such as encouraging testing and education. Conclusions The International Storytelling Program is a practical, impactful approach for empowering individuals affected by hepatitis B and promoting advocacy and stigma reduction globally. Personal narratives serve as a valuable complement to traditional public health strategies by fostering engagement, awareness, and community mobilization. Trial registration Not applicable. Hepatitis B HBV storytelling stigma patient advocacy community engagement evaluation mixed-methods Figures Figure 1 Background Hepatitis B remains a major global public health challenge, with an estimated 250 million people living with chronic infection worldwide and more than 1.1 million deaths each year from cirrhosis and hepatocellular carcinoma [ 1 , 2 ]. Hepatitis B is a liver disease caused by infection with the hepatitis B virus (HBV), which can lead to both acute and chronic hepatitis B infection and can result in long-term liver complications. Despite the availability of an effective vaccine to prevent infection and antiviral therapies that can prevent transmission and reduce disease progression, hepatitis B continues to be underdiagnosed, undertreated, and poorly understood in many parts of the world [ 3 ]. Limited awareness, structural barriers to testing and care, and persistent stigma contribute to delayed diagnosis and prevent individuals from accessing routine monitoring and treatment [ 3 ]. These challenges disproportionately affect populations facing social and health inequities, including immigrant and refugee communities, people living in low- and middle-income countries, and individuals with constrained access to culturally and linguistically appropriate health information [ 4 , 5 ]. Hepatitis B-related stigma further exacerbates these barriers. Misconceptions about transmission, moral judgment attached to infection, and fears of discrimination can influence individuals’ daily lives, relationships, employment opportunities, and care-seeking behaviors [ 6 ]. Stigma and discrimination often lead to silence, concealment, and social isolation, creating deep emotional and psychological burdens for people living with chronic hepatitis B [ 6 ]. For many, the decision to disclose their diagnosis carries significant personal risk, shaped by cultural norms, misinformation, and community attitudes related to hepatitis B [ 7 ]. Storytelling has emerged as a promising health communication strategy for addressing these complex social and structural challenges. Storytelling leverages personal narratives from individuals affected by hepatitis B to deliver more relatable messages than traditional health education [ 8 ]. Research in areas such as HIV/AIDS, cancer survivorship, and mental health demonstrates that storytelling can reduce stigma, promote empathy, increase engagement with health services, and empower individuals by validating lived experiences and expanding representation within public health conversations [ 8 , 9 ]. Storytelling also offers a mechanism for reclaiming identity, fostering self-efficacy, and strengthening readiness for advocacy among individuals directly impacted by hepatitis B [ 10 ]. The Hepatitis B Foundation’s International Storytelling Program (#BtheVoice) provides people living with hepatitis B globally and their loved ones an opportunity to share their lived experiences through recorded video narratives. This program builds upon the Foundation’s national #justB storytelling campaign, launched in the United States in 2017, which engaged North American storytellers to raise awareness and reduce stigma through personal narratives. In 2020, the Foundation expanded these efforts globally through the International Storytelling Program, creating a platform for individuals outside North America–including people living with hepatitis B, family members, community health workers, and healthcare providers–to share their experiences with a global audience. Collectively, these storytelling initiatives have reached audiences across diverse regions and have been used widely to raise awareness, counter misinformation, and humanize the realities of living with chronic hepatitis B. However, there remains a paucity of research examining how participation in storytelling initiatives influences storytellers’ sense of empowerment, identity, and stigma experiences, particularly in the context of living with hepatitis B. While a formal evaluation has been conducted for the North American-based #justB storytelling program, a systematic evaluation of the international storytelling program’s impact has never been conducted [ 10 ]. Given the distinct cultural, linguistic, and structural contexts shaping hepatitis B lived experiences globally, evaluating the international program is essential for understanding its reach, effectiveness, and impact beyond North America. This study is guided by stigma theory and empowerment theory, which together provide a conceptual framework for understanding how storytelling may shape stigma processes, identity reconstruction, and advocacy engagement among individuals living with hepatitis B. This study aims to evaluate the impact of the International Storytelling Program on storytellers and their perceived impact on their communities. We examined the programs’ influence on storytellers’ personal growth, empowerment, confidence, and advocacy engagement, as well as their perceptions of how sharing their stories may have influenced community awareness, attitudes, and stigma related to hepatitis B. By integrating qualitative and quantitative data, this evaluation provides critical insights into the role of storytelling as a public health tool for reducing stigma, promoting advocacy, and strengthening community engagement in hepatitis B awareness efforts. Methods This study employs a mixed-methods approach, combining quantitative and qualitative data collection to comprehensively evaluate the Hepatitis B Foundation’s International Storytelling Program on storytellers’ experiences, empowerment, and perceptions of stigma. Quantitative data captured immediate and longer-term effects of participation, while qualitative interviews provided in-depth analysis into emotional, social, and behavioral changes resulting from the storytelling process. Data from both sources were analyzed separately and then integrated to produce a comprehensive understanding of program impacts on storytellers. Participants Eligible participants were adults (18 years or older) who had recorded personal stories about their experiences with hepatitis B. Eligible storytellers were recruited via email from the Foundation’s program participant pool, which includes 162 individuals who have recorded stories since the program’s inception in 2020. Participation is entirely voluntary. Among eligible participants, there were 35 females and 127 males. Eligible participants represented 22 countries across Africa (Nigeria, Tanzania, Uganda, Ghana, Sierra Leone, Burundi, Kenya, Malawi), Asia (Taiwan, Philippines, Uzbekistan, India, China), and Europe (United Kingdom, Romania, Moldova, Russia, Germany, Switzerland, France). This diverse representation ensured a range of cultural and regional perspectives. The International Storytelling Program (#BtheVoice) is a global effort to elevate the voices of those living with hepatitis B. In contrast, the #justB Storytelling campaign focuses on hepatitis B patients in North America. #JustB storytellers were not included in this evaluation, given that a separate evaluation has been conducted on it previously. Via email, all eligible storytellers were invited to participate in the immediate post-recording survey, follow-up survey, and qualitative interviews. Participation in each component was voluntary, and participants could select which parts of the evaluation they wished to complete. As a result, sample sizes varied across study components, and participants were not required to complete all components. Some participants contributed to more than one component, while others participated in only one. This self-selection reflects the voluntary nature of program evaluation participation and may account for differences in response rates across methods. Participants provided informed consent prior to survey completion or interviews. A subset of 15 storytellers (10 males and 5 females) who responded to the recruitment email, expressed interest in participating, and met the eligibility criteria were purposively selected for semi-structured interviews. Recruitment continued until the target sample size was reached. Participants were not selected based on satisfaction or engagement level, but on availability and willingness to participate. In the initial recruitment email, participants were asked to indicate which of the follow-up surveys they were interested in. These follow-up surveys were only completed by those who indicated their interest, hence the difference in total participation numbers. The eligible participants were from three WHO regions: the Western Pacific Region, the African Region, and the European Region. To be eligible for the interview, participants must have a) shared their hepatitis B story in 2024 or 2025, b) created a publicly shareable video story, and c) been part of the ongoing hepatitis B storytelling campaign. All storytellers had either personal experience living with hepatitis B; an immediate family member affected, or worked directly with people living with hepatitis B. Data Collection Procedures Quantitative Data Collection The Immediate Impact Survey (1-month post-recording) was developed by the study team to assess participants’ experiences with the storytelling recording process. The survey was designed based on program objectives and prior evaluation tools used within the International Storytelling Program. It included 16 items and assessed participants’ satisfaction with the storytelling process, emotional and personal responses, confidence in sharing their story, perceived preparedness for future advocacy, and suggestions for program improvement. The survey consisted of a combination of Likert-scale and multiple-choice questions. It was designed to take approximately 10–15 minutes to complete. Participants completed the survey online via Qualtrics, one month after recording their story. Invitations were distributed via email, and participation was voluntary. A total of 25 participants (n = 25) completed the survey. A full list of survey questions and response options is provided in Appendix A . The Follow-Up Impact Survey was developed by the study team to assess longer-term outcomes of participation in the International Storytelling Program. The survey evaluated changes in participants’ comfort discussing hepatitis B, stigma and discrimination experiences, advocacy engagement, and personal and professional growth, as well as perceived community-level ripple effects of storytelling (e.g., perceived changes in awareness, attitudes, and behaviors within their communities). The survey consisted of approximately 20 items, including a combination of open ended, multiple-choice, and Likert-scale questions organized around five domains: stigma reduction, public awareness and education, confidence in storytelling, advocacy engagement, and long-term personal impact. The survey was administered online via Qualtrics, 3–6 months after participants recorded their stories. Invitations were distributed via email, and participation was voluntary. Eleven participants (n = 11) completed the survey. The survey required approximately 10–15 minutes to complete. Follow‑up surveys were completed only by participants who indicated interest during initial recruitment, resulting in a smaller follow‑up sample size. A full list of survey items is provided in Appendix B . Qualitative Data Collection Open-ended, semi-structured interviews were conducted to explore participants’ experiences with the storytelling program and its impact on personal growth, community engagement, advocacy, and perceptions of stigma. Interviews were conducted in English by trained research team members via Zoom or telephone, lasting 30–45 minutes, audio-recorded, transcribed verbatim, and de-identified for analysis. Participants provided written or verbal consent prior to participation and were informed that they could decline to answer any questions if they felt uncomfortable. The interview guide ( Appendix C ) was developed based on program goals, prior literature on storytelling and health communication, and input from the evaluation team. Key areas of inquiry included: Storytelling Experience : Participants described the storytelling process, emotions experienced before, during, and after recording, program support, challenges, and aspects of the process they found most valuable. Impact on Public Awareness and Stigma Reduction : Questions explored whether participants shared their story, perceived changes in community awareness of hepatitis B, feedback received, and the role of storytelling in reducing stigma. Personal Growth and Advocacy : Participants reflected on personal impacts of sharing their story, involvement in advocacy or educational activities, and confidence in continuing to engage in hepatitis B advocacy. Program Feedback and Suggestions : Participants provided recommendations for improving the program, advice for future storytellers, and additional reflections on their experiences. Probes were included to encourage participants to elaborate on their experiences and provide detailed insights. Data collection continued until saturation was achieved, with no new themes emerging after 15 interviews. This study was approved by the Heartland Institutional Review Board [070925 − 1229]. Qualitative Analysis A qualitative content analysis approach was used to analyze interview transcripts. A preliminary codebook was created to guide the organization of data, and codes were developed by review of the literature ( a priori ) and through line-by-line reading of a subsample of queries [ 11 ]. Each code was given a specific definition to ensure coding accuracy and to improve intercoder reliability [ 12 ]. Data coding and analysis was facilitated using NVivo 15 software (QRS International, Doncaster, Australia). All data were independently double coded by two members of the research team to ensure coding accuracy. Inter-coder reliability (ICR) was assessed using the kappa coefficient, with a target threshold of ≥ 0.70 to indicate acceptable agreement. Overall coding agreement was substantial across all coders (ML, CF, BA, NT, SD). Discrepancies in coding were resolved through discussion between the two coders, with consensus reached through iterative review and agreement. Following coding, the research team organized data into thematic categories describing participants lived experiences, emotional responses, stigma and discrimination contexts, and perceptions of the storytelling program’s broader impact. Quotes are identified by de-identified participant file numbers (e.g., File 1, File 2) to maintain confidentiality. Results Immediate Impact Survey Results (n = 25) Participants reported overwhelmingly positive experiences with the storytelling process. Fourteen (57%) rated their experience as excellent, nine (38%) as good, and one (5%) as fair. One participant did not respond to this question, as survey questions were optional. All participants (25/25) reported that instructions and guidance were clear, and 23/25 (92%) felt comfortable sharing their story. All participants felt they had sufficient time to express themselves, while six (24%) experienced technical difficulties. Participants reported strong personal and emotional benefits which included feeling empowered [19/25 (76%)] and feeling relieved [13/25 (52%)]. Additionally, three (12%) reported feeling nervous, and one (4%) reported feeling vulnerable. Confidence was high, with 20/25 (80%) feeling very confident and 20/25 (80%) reporting personal benefits from sharing their story. After recording, 21/25 (84%) felt prepared to share their story with a wider audience, 24/25 (96%) felt more confident advocating for hepatitis B awareness, 24/25 (96%) expressed interest in future storytelling or advocacy activities, and 24/25 (96%) would recommend the program. Follow-Up Impact Survey Results (n = 11) At three to six months of post-recording, participants reported sustained psychosocial and advocacy-related impacts (Table 1 ). Notably, most participants reported increased comfort sharing their story or hepatitis B status, with 73% indicating they felt much more comfortable. Similarly, 73% reported personal growth and plans to continue advocacy or education efforts. Indicators of empowerment and stigma reduction were also prominent: 64% reported reduced personal stigma and felt empowered to engage in hepatitis B advocacy. Over half (55%) described a strong positive long-term impact on their lives, and 55% had already shared their story publicly. While fewer participants observed clear shifts in community perceptions, uncertainty remained high (55%), suggesting that broader community-level change may require longer-term or more widespread storytelling efforts. These findings should be interpreted cautiously given the small follow-up sample size. Table 1 Sustained Program Impacts at 3–6 Months (n = 11) Theme Outcome n (%) Story Sharing Shared story publicly 6 (55%) Community Perception Significant change 2 (18%) Small change 2 (18%) No change 1 (9%) Unsure 6 (55%) Comfort Sharing Much more comfortable 8 (73%) Somewhat more comfortable 1 (9%) No change 2 (18%) Stigma Reduction Personal stigma reduction 7 (64%) Community-level stigma reduction 7 (64%) Advocacy Engagement Participated in activities 4 (36%) Plan to engage 3 (27%) Felt empowered to advocate 7 (64%) Growth & Connection Personal growth 8 (73%) Increased community connection 7 (64%) Long-Term Impact Strong positive life impact 6 (55%) Plan continued advocacy 8 (73%) Results of Interviews Analysis revealed five interrelated themes describing the lived experience of those living with hepatitis B and the transformative role of storytelling. The sample included 15 participants (F = 5; M = 10) representing diverse geographic regions, including the Western Pacific Region (Philippines), African Region (Nigeria, Malawi, Ghana, Burundi, Uganda, Kenya), and European Region (Uzbekistan). Participants described hepatitis B as a deeply stigmatizing and emotionally burdensome condition shaped by misinformation and structural barriers. Storytelling functioned not only as an educational strategy, but as a mechanism for identity reconstruction, stigma disruption, and community advocacy. The following sections describe these themes in detail, highlighting the social and emotional impact of hepatitis B, the role of storytelling, and participants’ recommendations for program improvements. Hepatitis B as a Social and Emotional Condition, Not Just a Clinical Diagnosis Participants consistently described hepatitis B not merely as a biomedical condition, but as a profoundly social and emotional experience shaped by misinformation, stigma, and structural inequities. Low levels of public awareness were described as key drivers of stigma. Participants noted that misconceptions about casual transmission and exaggerated fears of contagion often manifested in the stigmatization or mistreatment of PLWHB. In many contexts, the fear of discrimination extended beyond casual interactions and into family life, employment, and community participation. One participant explained the breadth of these potential consequences, noting that disclosure could provoke challenges “from relatives, from your immediate family, sometimes from your wife, from your husband...from your children, from extended family members, friends, policy, co-workers" (File 15). Such accounts illustrate how stigma surrounding hepatitis B permeates multiple domains of social life, producing a climate in which silence and concealment become strategies for self-protection. This pervasive social stigma contributed to profound internalized stigma and emotional distress among participants. Participants described feelings of fear, uncertainty, and hesitation about revealing their status even within spaces intended for advocacy. One participant explained, “I [am] afraid to share and hesitate to share my story because I’m worried about how other people will react, because [of] discrimination” (File 2). The anticipation of negative reactions from others–including rejection, blame, or social exclusion–frequently discouraged individuals from openly discussing their diagnosis. In some cases, the level of stigma within local contexts was so intense that participants were willing to share their experiences only under conditions of anonymity. As one participant summarized, “We are ready to share our stories, but we are not ready to show our faces because...the stigma here and the discrimination is very, very high” (File 11). Storytelling as a Tool for Reframing the Disease Participants described storytelling as a tool for reaching individuals who may be silently living with hepatitis B. Hearing others speak openly about their experiences was described as encouragement for those who conceal their diagnosis, which also helps them to re-establish their identity beyond their HBV infection. One participant stated, “The fact that people are coming up and speaking about [hepatitis B] convinces others that it is not a death sentence. So, I think, this can encourage someone who has been hiding to, rethink that there is no need to hide” (File 12). Participants also described storytelling as a powerful tool for increasing the visibility of people affected by hepatitis B and amplifying their voices. Sharing lived experiences was seen as a tool to raise awareness and advocacy, especially targeting policymakers. One participant explained, “Storytelling is incredibly powerful. It brings real-life experiences to light, especially to those who are afraid to speak up. And it is a way for us to be seen and to be heard by health authorities, especially the policymakers and the people who may not understand what hepatitis is” (File 10). In addition, participants described their involvement in the storytelling program as facilitating emotional processing and acceptance of their diagnosis. Although recounting that the process sometimes evoked challenging emotions, participants reported that sharing their stories helped them accept their diagnosis and strengthened their motivation to educate others. One participant reflected, “When I was talking about my experience, I was reminiscing about my struggles and experience. It brought up a lot of emotions at that time, but I realized that being able to speak about my experience of having hepatitis B was a process. It was a process of accepting my condition, and that acceptance gives me the strength to share my story with others” (File 10). Another participant similarly described that storytelling helped them process their fear and gain control to use their position for raising awareness and challenging stigma, “When the invite came, it wasn’t easy [to make the decision], but I realized that sharing my story would have a huge impact on everyone who is going to hear it. That [helped] clear [my] fears and [reduce the] stigma and discrimination [in] my mind” (File 15). Storytelling as Stigma Reduction and Educational Strategies Storytelling functioned as both a stigma-reduction and educational strategy, fostering personal growth and confidence among participants, increasing willingness to disclose hepatitis B status, supporting transitions into advocacy roles, and generating broader ripple effects within their communities. Participants described a range of engagement following storytelling, including informal education, peer support, community navigation, and advocacy. Advocacy was expressed along a spectrum, ranging from individual community education to engagement with health institutions and policymakers. These distinctions are important, as not all educational activities were framed by participants as formal advocacy. All participants reported an increase in their personal growth and confidence as lived experience storytellers. One individual described, “I think the impact has been very positive on my life. And through my own activities, the people who are living with hepatitis B that are connected to me, that I relate with, are also gaining confidence and then seeing the reason why they should carry on with life” (File 16). Some participants reported that being storytellers increased their willingness to disclose their status to others in their communities. “I already have a whole bunch of doctors, nurses, [and] people from my own family. They have formed a group going from one village to another as a result of my storytelling, to create awareness [about] the stigma, [which can be] devastating” (File 5). Interviewees also described the community-level ripple effects of sharing their lived experiences/stories: “I see more and more people are coming and asking me how to get tested, how to get a vaccine. This comfort[s] me because it is a positive impact” (File 14). A different participant also shared, “It has really impacted positively on the lives of my community, my family, [and] my friends. I have been able to convince quite a good number of people to go for testing” (File 5). Another participant added, “That story, hearing [it] from somebody from another country, in another place, can inspire that person to continue to have hope, have faith. So, I think [it is] not just for [one]self, but [also] to help inspire others” (File 16). Additionally, participants mentioned that they noticed their transition from storytellers into educational roles, “The impact is every single day, almost every day, I get, [to hear] their stories, when they go for proper tests or especially those who are living with the disease. They will send their tests [or] reports to me [and] then I forward [them] to the appropriate quarters [doctor]” (File 15). Recommendations for Improving Storytelling Participants recommended increasing accessibility to the storytelling program and enhancing linguistic inclusivity to improve its reach and relevance across affected communities. One participant emphasized the importance of expanding storytelling beyond English-language formats to better engage Chinese-speaking populations: “I think if you’re really looking at the Chinese side, it means this kind of storytelling should not be just in English… maybe in the future, we can make the storytelling in Mandarin and Cantonese” (File 3). Participants underscored the importance of trauma-informed facilitation in fostering a safe and supportive storytelling environment. Facilitator guidance was described as instrumental in helping participants process difficult emotions and gain confidence in sharing their experiences: “…the facilitator was helpful, very patient and supportive throughout the recording… it is a course [journey] to accept my condition, and that acceptance gives me the strength to share my story with others” (File 10). Participants also highlighted the need for more stories and storytellers to share their lived experiences. One participant described, “We need more people to come up. We need more stories. I am looking forward to a time when a fair percentage of people living with hepatitis B would just be out there and talking about it. Because one way of [addressing] prevention and stigma would be to just talk about it” (File 12). Another participant echoed, “But we should not be discouraged. We should focus on sharing our story so others can also take notes or [lessons] from it. I would recommend this particular program to everyone. If you have any story to share concerning your experience [with] hepatitis B in general, I encourage you to come out and share because after sharing [your story], you are going to save [the] lives of [many]” (File 15). Discussion Both qualitative and quantitative findings aligned and reinforced each other. Immediate impact survey findings showed high levels of empowerment, confidence, and advocacy readiness, suggesting early psychosocial benefits of participation in the storytelling program. Findings from this evaluation suggest that the Hepatitis B Foundation’s International Storytelling Program has meaningful impacts on participants, promoting empowerment, personal growth, and advocacy engagement. Participants also described how connecting with other storytellers fostered a sense of understanding and mutual support, highlighting the empowering role of shared lived experience. Storytelling provided opportunities for emotional processing and acceptance of one’s diagnosis, helping participants reframe their experiences beyond stigma and misinformation. Participants also described how connecting with other storytellers fostered a sense of understanding and mutual support; being in a community with individuals who have similar experiences has been found to empower individuals [ 13 ]. As previously documented in the literature, sharing personal experiences provided a safe space to be heard and empowered participants to speak openly about their health [ 14 ]. Additionally, storytelling offered a platform to inspire broader community action around hepatitis B awareness, screening, and vaccination. These qualitative findings align with quantitative results demonstrating high levels of satisfaction, empowerment, confidence, and advocacy engagement immediately post-participation and at follow-up. Beyond individual-level effects, storytelling also functioned as an educational and stigma-reduction strategy. Participants described the program as a tool to reach individuals who may be silently living with hepatitis B, encouraging them to reconsider hiding their diagnosis and helping them reclaim their identity beyond infection. Sharing lived experiences also allowed participants to increase the visibility of people affected by hepatitis B, amplify their voices to policymakers, and influence perceptions in their communities. These results are consistent with previous research demonstrating that narrative storytelling improves health knowledge, increases engagement with health services, and reduces stigma across a range of health conditions [ 15 , 16 ]. The study highlights the transformative role of storytelling in reframing hepatitis B as a social and emotional condition, rather than a clinical diagnosis. Participants consistently described the emotional burden of stigma and structural barriers, with storytelling serving as a mechanism to reduce internalized stigma, increase disclosure, and foster community-level ripple effects, including encouraging testing, vaccination, and education. Many participants reported that sharing their story motivated others to take positive actions, reinforcing the broader public health impact of personal narratives [ 9 ]. Stigma theory and empowerment theory provide a useful framework for interpreting the findings of this study. Stigma theory helps explain the ways participants navigated internalized, anticipated, and enacted stigma, while empowerment theory frames the program’s impact on participants’ sense of agency, self-efficacy, and capacity to act as advocates within their communities [ 17 , 18 ]. This combination of theories underscores storytelling as both a personal and social intervention, offering participants tools for emotional coping, identity reconstruction, and community engagement [ 19 ]. These relationships are illustrated in Fig. 1 , which presents the conceptual framework linking storytelling participation to stigma reduction and empowerment pathways. Participants emphasized increasing accessibility and language inclusivity, consistent with evidence that culturally and linguistically tailored health communication is more effective. Expanding storytelling beyond English-language formats may further engage diverse communities and maximize impact. Trauma-informed facilitation was described as crucial for fostering a safe, supportive environment that allows participants to process difficult emotions and build confidence, consistent with public health literature on trauma‑informed approaches that strengthen community engagement and empathetic practice. Overall, this evaluation suggests that structured storytelling programs are a feasible, acceptable, and impactful strategy to empower individuals, reduce stigma, and promote advocacy globally. These insights can inform enhancements to program design, including targeted training, curated story selection for maximum impact, and strategies to strengthen advocacy initiatives worldwide. Limitations and Strengths Limitations Potential limitations include selection bias, as participants are self-selected and may differ from the broader hepatitis B population. Therefore, results may not be generalizable to all individuals living with hepatitis B, particularly those who have not participated in storytelling programs or who reside in regions not represented in this study. In addition, not all storytellers in the program participated in the evaluation, meaning the findings may not fully represent the experiences of the entire storyteller cohort. Pre-existing relationships between researchers and participants could have influenced responses. Additionally, responses may have been influenced by social desirability bias given participants’ relationship to the program and its facilitators. Future research may consider the use of an independent interviewer to minimize the effect of participant-researcher relationships. Language barriers and cultural differences also presented challenges: some participants had difficulty understanding interview questions, and interpretation of survey and interview items, particularly around concepts such as stigma and advocacy, may have varied across cultural contexts. A subset of participants also confused the concepts of stigma and discrimination, which may have influenced responses and the interpretation of findings in these areas. Practical and technical challenges further affected data collection. Connectivity issues, including limited Wi-Fi or unstable access to Zoom, along with other technical difficulties, may have disrupted communication or limited participants’ engagement during interviews. Time zone differences additionally made scheduling interviews difficult, potentially affecting participation and the completeness of the data. To address this, the research team offered flexible interview scheduling across multiple time zones and provided alternative timing options to accommodate participants’ availability. Finally, the small sample size for the follow-up survey (n = 11) limits the ability to draw robust conclusions regarding long-term impacts. Strengths This study has several strengths. It represents one of the first evaluations of a global hepatitis B storytelling program incorporating both qualitative and quantitative data from participants across multiple countries. The inclusion of storytellers from diverse geographic and cultural backgrounds enhances the study’s relevance to global hepatitis B communities and contributes to a growing evidence base on narrative-based health communication in hepatitis B. Additionally, the mixed-methods design allowed for a more comprehensive understanding of both immediate and longer-term impacts of storytelling, capturing not only measurable outcomes but also rich lived experiences of empowerment, stigma reduction, and advocacy engagement. Conclusions The International Storytelling Program demonstrates that structured, supportive storytelling empowers people living with hepatitis B, reduce stigma, and foster advocacy at both personal and community levels. By leveraging lived experiences, the program provides a scalable model for integrating narrative interventions into public health initiatives. These findings underscore the importance of culturally and linguistically inclusive approaches while highlighting storytelling as a feasible, effective, and impactful tool for global hepatitis B awareness and stigma reduction. Abbreviations HBV Hepatitis B Virus Declarations Ethics Approval and consent to participate This study was approved by the Heartland Institutional Review Board (HIRB 070925-1229). No identifiable information was included, and all participants provided informed consent prior to study participation and informed that they may withdraw at any time. Confidentiality was maintained throughout the study, and participation was voluntary. Researchers maintain awareness of pre-existing relationships with participants and mitigate bias by emphasizing the voluntary nature of participation. This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for publication Consent for publication of anonymized data was obtained from all participants. Data Availability De-identified quantitative survey data (collected via Qualtrics) and qualitative interview transcripts are securely stored by the Hepatitis B Foundation research team and are not deposited in a public repository. These data may be available from the corresponding author upon reasonable request, subject to institutional approval and compliance with participant consent agreements and applicable data protection regulations. Requests for access will be reviewed to ensure that participant confidentiality and ethical obligations are maintained. Competing Interests In the past 36 months, the Hepatitis B Foundation has received outreach and public health grants from BMS, GSK, Gilead Sciences, Grifols, Aligos, nChroma, Precision Biosciences, Mirum, Vir Biotechnology, Roche, and Exact Sciences. Bright Ansah reports on involvement in projects that have received funding from pharmaceutical companies, including GSK. Funding The Hepatitis B Foundation #justB and #BtheVoice storyteller programs are funded through general operating support by the Hepatitis B Foundation. Authors’ Contributions Study conception and design: AQ, ML, CF, BA; Program development: CF, ML; Data collection: CF, ML, AQ, BA, NT, SD; Data analysis: CF, ML, AQ, BA, NT, SD; Drafting the manuscript: CF, ML, AQ, BA, NT, SD; Critical revision and supervision: CF, YI, CC; All authors read and approved the final manuscript. Acknowledgements We sincerely thank all participants for sharing their lived experiences and for the time and effort they dedicated to this study, including coordinating across different time zones and schedules. References World Health Organization, Hepatitis B. Available from: https://www.who.int/news-room/fact-sheets/detail/hepatitis-b . Accessed 13 March 2026. World Health Organization. Global hepatitis report 2024: action for access in low- and middle-income countries. Geneva: World Health Organization; 2024. National Academies of Sciences, Engineering, and Medicine. Eliminating the public health problem of hepatitis B and C in the United States: phase one report. Washington (DC): National Academies; 2016. World Health Organization. Global health sector strategy on viral hepatitis 2016–2021. Geneva: World Health Organization; 2016. National Academies of Sciences, Engineering, and, Medicine. A national strategy for the elimination of hepatitis B and C: phase two report. Washington (DC): National Academies; 2017. Lee H, Fawcett J, Kim D, Yang JH. Correlates of hepatitis B virus-related stigmatization experienced by Asians: a scoping review of literature. Asia Pac J Oncol Nurs. 2016;3(4):324–34. 10.4103/2347-5625.195896 . Le TV, Vu TTM, Mai HT, et al. Social determinants of stigma and discrimination in Vietnamese patients with chronic hepatitis B. Int J Environ Res Public Health. 2019;16(3):398. 10.3390/ijerph16030398 . Dahlstrom MF. Using narratives and storytelling to communicate science with nonexpert audiences. Proc Natl Acad Sci U S A. 2014;111(Suppl 4):13614–20. Zeelen J, Metseagharun T, Boersma M, Jansen W. Beyond silence and rumor: Storytelling as an educational tool to reduce the stigma around HIV/AIDS in South Africa. Health Educ. 2010;110(5):382–98. Alber JM, Cohen C, Racho R, Freeland C, Ghazvini S, Tolentino B, Almeida R, Silliman M. Exploring the impact of storytelling on storytellers in a hepatitis B health communication context. Patient Educ Couns. 2020;103(9):1760–6. 10.1016/j.pec.2020.03.026 . Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. 10.1177/1049732305276687 . Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago (IL): Aldine; 1967. Borondy-Jenkins F, Ansah B, Chen J, Goldring A, Ibrahim Y, Issa S, Lesidrenska S, Machado T, Moore H, Njouom R, Okinedo P, Racho R, Scott L, Zovich B, Cohen C. Global hepatitis B and D community advisory board: expectations, challenges, and lessons learned. Front Public Health. 2024;12:1437502. 10.3389/fpubh.2024.1437502 . Pallai EL, Tran K. Narrative health: using story to explore definitions of health and address bias in health care. Perm J. 2019;23:18–052. 10.7812/TPP/18-052 . Zhuang J, Guidry A. Does storytelling reduce stigma? A meta-analytic view of narrative persuasion on stigma reduction. Basic Appl Soc Psychol. 2022;44(4):25–37. 10.1080/01973533.2022.2039657 . Heley K, Kennedy-Hendricks A, Niederdeppe J, Barry CL. Reducing health-related stigma through narrative messages. Health Commun. 2020;35(7):849–60. 10.1080/10410236.2019.1598614 . Goffman E. Stigma: notes on the management of spoiled identity. New York: Simon & Schuster; 1963. Zimmerman MA. Empowerment theory: psychological, organizational and community levels of analysis. In: Rappaport J, Seidman E, editors. Handbook of Community Psychology. Boston (MA): Springer; 2000. pp. 43–63. Heisler M. Actively engaging patients through storytelling to enhance health outcomes. Patient Educ Couns. 2011;85(3):e1–2. 10.1016/j.pec.2011.03.004 . Additional Declarations Competing interest reported. In the past 36 months, the Hepatitis B Foundation has received outreach and public health grants from BMS, GSK, Gilead Sciences, Grifols, Aligos, nChroma, Precision Biosciences, Mirum, Vir Biotechnology, Roche, and Exact Sciences. Bright Ansah reports on involvement in projects that have received funding from pharmaceutical companies, including GSK. Supplementary Files AppendixAImmediateImpactSurvey.docx Appendix A: Immediate Impact Survey AppendixBFollowUpImpactSurvey.docx Appendix B: Follow-Up Impact Survey AppendixCInterviewGuide.docx Appendix C: Semi-Structured Interview Guide Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 07 May, 2026 Reviews received at journal 06 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviews received at journal 26 Apr, 2026 Reviewers agreed at journal 19 Apr, 2026 Reviewers invited by journal 17 Apr, 2026 Editor invited by journal 17 Apr, 2026 Editor assigned by journal 16 Apr, 2026 Submission checks completed at journal 16 Apr, 2026 First submitted to journal 14 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9419489","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625763457,"identity":"d54ed613-2faf-471b-a2b1-485ed5516d72","order_by":0,"name":"Michelle Liu","email":"","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Liu","suffix":""},{"id":625763461,"identity":"02a72e0f-592b-4a6b-bc3d-66910722e0ce","order_by":1,"name":"Bright Ansah","email":"","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":false,"prefix":"","firstName":"Bright","middleName":"","lastName":"Ansah","suffix":""},{"id":625763463,"identity":"3791f144-b4ba-4f73-82c8-5d11abb48741","order_by":2,"name":"Noah Michael Trudeau","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYHACNgh1AIg/NjAwGBCnJQGihXEmyVqYeYnRYs7e/OwB4497iX3Hm59J2+6wyTNnYD728QseLZY9x8wNGBKKE2eeOWYmnXsmrdiygS15tgweLQY3EswkGBISEjcAGdK5bYcTNxzgMWaWwKsl/RtEy/3n36Qt2/4ToyUHZguPmTRj2wGwFsYP+LScOVMmkZCWYDzzTE6xZW9bcrFlM1syMx4dDAbH27dJfLBJkO07fnzjjZ9tdnnAMDzM+AOfHhBIQGEDrWDmIaQFQzthW0bBKBgFo2AkAQC1+lEgdr5FWgAAAABJRU5ErkJggg==","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":true,"prefix":"","firstName":"Noah","middleName":"Michael","lastName":"Trudeau","suffix":""},{"id":625763466,"identity":"13438ccc-49e4-4b89-96ca-c2c4059aa4d2","order_by":3,"name":"Stella Dlamini","email":"","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":false,"prefix":"","firstName":"Stella","middleName":"","lastName":"Dlamini","suffix":""},{"id":625763468,"identity":"31ad737e-b39e-4c66-b261-48e75bc802ba","order_by":4,"name":"Anousha Qureshi","email":"","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":false,"prefix":"","firstName":"Anousha","middleName":"","lastName":"Qureshi","suffix":""},{"id":625763470,"identity":"e758aeca-f6d1-4a90-aff5-fb02a502e395","order_by":5,"name":"Yasmin Ibrahim","email":"","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":false,"prefix":"","firstName":"Yasmin","middleName":"","lastName":"Ibrahim","suffix":""},{"id":625763474,"identity":"a597c71c-f462-44de-953b-7d9173fa749b","order_by":6,"name":"Chari Cohen","email":"","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":false,"prefix":"","firstName":"Chari","middleName":"","lastName":"Cohen","suffix":""},{"id":625763481,"identity":"0dde6b4f-f3fa-4200-b3ca-8262268d66c5","order_by":7,"name":"Catherine Freeland","email":"","orcid":"","institution":"Hepatitis B Foundation","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Freeland","suffix":""}],"badges":[],"createdAt":"2026-04-14 20:53:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9419489/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9419489/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107839017,"identity":"753d68a7-15c9-4522-abe5-1acaec869c0f","added_by":"auto","created_at":"2026-04-26 17:14:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":955462,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9419489/v1/1e538856e99aaad24115d33d.png"},{"id":107870380,"identity":"a740b6d7-b44d-437b-9885-4bc62a54cf1f","added_by":"auto","created_at":"2026-04-27 07:39:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1027388,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9419489/v1/a7e3f76a-42a6-407e-8e13-f658c2abc1bc.pdf"},{"id":107839016,"identity":"2561b729-42c8-4f90-8b60-69c0371c86b8","added_by":"auto","created_at":"2026-04-26 17:14:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":45274,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix A: Immediate Impact Survey\u003c/p\u003e","description":"","filename":"AppendixAImmediateImpactSurvey.docx","url":"https://assets-eu.researchsquare.com/files/rs-9419489/v1/341232a5c5ab0ad28092f613.docx"},{"id":107839018,"identity":"e097a7fc-ecc3-4f87-97c9-03e948e6a204","added_by":"auto","created_at":"2026-04-26 17:14:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":46426,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix B: Follow-Up Impact Survey\u003c/p\u003e","description":"","filename":"AppendixBFollowUpImpactSurvey.docx","url":"https://assets-eu.researchsquare.com/files/rs-9419489/v1/58a632b4bb424ccef7ad8538.docx"},{"id":107839019,"identity":"a109fbd1-4e1c-4043-b7e8-69cdc9e40219","added_by":"auto","created_at":"2026-04-26 17:14:52","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":45449,"visible":true,"origin":"","legend":"\u003cp\u003e\u0026nbsp;Appendix C: Semi-Structured Interview Guide\u003c/p\u003e","description":"","filename":"AppendixCInterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-9419489/v1/12ffd15e55257bb24726b839.docx"}],"financialInterests":"Competing interest reported. In the past 36 months, the Hepatitis B Foundation has received outreach and public health grants from BMS, GSK, Gilead Sciences, Grifols, Aligos, nChroma, Precision Biosciences, Mirum, Vir Biotechnology, Roche, and Exact Sciences. Bright Ansah reports on involvement in projects that have received funding from pharmaceutical companies, including GSK.","formattedTitle":"Evaluating the Impact of the Hepatitis B Foundation’s International Storytelling Program on Empowerment, Advocacy, and Stigma Reduction","fulltext":[{"header":"Background","content":"\u003cp\u003eHepatitis B remains a major global public health challenge, with an estimated 250\u0026nbsp;million people living with chronic infection worldwide and more than 1.1\u0026nbsp;million deaths each year from cirrhosis and hepatocellular carcinoma [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Hepatitis B is a liver disease caused by infection with the hepatitis B virus (HBV), which can lead to both acute and chronic hepatitis B infection and can result in long-term liver complications. Despite the availability of an effective vaccine to prevent infection and antiviral therapies that can prevent transmission and reduce disease progression, hepatitis B continues to be underdiagnosed, undertreated, and poorly understood in many parts of the world [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Limited awareness, structural barriers to testing and care, and persistent stigma contribute to delayed diagnosis and prevent individuals from accessing routine monitoring and treatment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These challenges disproportionately affect populations facing social and health inequities, including immigrant and refugee communities, people living in low- and middle-income countries, and individuals with constrained access to culturally and linguistically appropriate health information [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHepatitis B-related stigma further exacerbates these barriers. Misconceptions about transmission, moral judgment attached to infection, and fears of discrimination can influence individuals\u0026rsquo; daily lives, relationships, employment opportunities, and care-seeking behaviors [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Stigma and discrimination often lead to silence, concealment, and social isolation, creating deep emotional and psychological burdens for people living with chronic hepatitis B [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. For many, the decision to disclose their diagnosis carries significant personal risk, shaped by cultural norms, misinformation, and community attitudes related to hepatitis B [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStorytelling has emerged as a promising health communication strategy for addressing these complex social and structural challenges. Storytelling leverages personal narratives from individuals affected by hepatitis B to deliver more relatable messages than traditional health education [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Research in areas such as HIV/AIDS, cancer survivorship, and mental health demonstrates that storytelling can reduce stigma, promote empathy, increase engagement with health services, and empower individuals by validating lived experiences and expanding representation within public health conversations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Storytelling also offers a mechanism for reclaiming identity, fostering self-efficacy, and strengthening readiness for advocacy among individuals directly impacted by hepatitis B [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Hepatitis B Foundation\u0026rsquo;s International Storytelling Program (#BtheVoice) provides people living with hepatitis B globally and their loved ones an opportunity to share their lived experiences through recorded video narratives. This program builds upon the Foundation\u0026rsquo;s national #justB storytelling campaign, launched in the United States in 2017, which engaged North American storytellers to raise awareness and reduce stigma through personal narratives. In 2020, the Foundation expanded these efforts globally through the International Storytelling Program, creating a platform for individuals outside North America\u0026ndash;including people living with hepatitis B, family members, community health workers, and healthcare providers\u0026ndash;to share their experiences with a global audience. Collectively, these storytelling initiatives have reached audiences across diverse regions and have been used widely to raise awareness, counter misinformation, and humanize the realities of living with chronic hepatitis B.\u003c/p\u003e \u003cp\u003eHowever, there remains a paucity of research examining how participation in storytelling initiatives influences storytellers\u0026rsquo; sense of empowerment, identity, and stigma experiences, particularly in the context of living with hepatitis B. While a formal evaluation has been conducted for the North American-based #justB storytelling program, a systematic evaluation of the international storytelling program\u0026rsquo;s impact has never been conducted [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Given the distinct cultural, linguistic, and structural contexts shaping hepatitis B lived experiences globally, evaluating the international program is essential for understanding its reach, effectiveness, and impact beyond North America. This study is guided by stigma theory and empowerment theory, which together provide a conceptual framework for understanding how storytelling may shape stigma processes, identity reconstruction, and advocacy engagement among individuals living with hepatitis B.\u003c/p\u003e \u003cp\u003eThis study aims to evaluate the impact of the International Storytelling Program on storytellers and their perceived impact on their communities. We examined the programs\u0026rsquo; influence on storytellers\u0026rsquo; personal growth, empowerment, confidence, and advocacy engagement, as well as their perceptions of how sharing their stories may have influenced community awareness, attitudes, and stigma related to hepatitis B. By integrating qualitative and quantitative data, this evaluation provides critical insights into the role of storytelling as a public health tool for reducing stigma, promoting advocacy, and strengthening community engagement in hepatitis B awareness efforts.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employs a mixed-methods approach, combining quantitative and qualitative data collection to comprehensively evaluate the Hepatitis B Foundation\u0026rsquo;s International Storytelling Program on storytellers\u0026rsquo; experiences, empowerment, and perceptions of stigma. Quantitative data captured immediate and longer-term effects of participation, while qualitative interviews provided in-depth analysis into emotional, social, and behavioral changes resulting from the storytelling process. Data from both sources were analyzed separately and then integrated to produce a comprehensive understanding of program impacts on storytellers.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eEligible participants were adults (18 years or older) who had recorded personal stories about their experiences with hepatitis B. Eligible storytellers were recruited via email from the Foundation\u0026rsquo;s program participant pool, which includes 162 individuals who have recorded stories since the program\u0026rsquo;s inception in 2020. Participation is entirely voluntary. Among eligible participants, there were 35 females and 127 males. Eligible participants represented 22 countries across Africa (Nigeria, Tanzania, Uganda, Ghana, Sierra Leone, Burundi, Kenya, Malawi), Asia (Taiwan, Philippines, Uzbekistan, India, China), and Europe (United Kingdom, Romania, Moldova, Russia, Germany, Switzerland, France). This diverse representation ensured a range of cultural and regional perspectives. The International Storytelling Program (#BtheVoice) is a global effort to elevate the voices of those living with hepatitis B. In contrast, the #justB Storytelling campaign focuses on hepatitis B patients in North America. #JustB storytellers were not included in this evaluation, given that a separate evaluation has been conducted on it previously.\u003c/p\u003e \u003cp\u003eVia email, all eligible storytellers were invited to participate in the immediate post-recording survey, follow-up survey, and qualitative interviews. Participation in each component was voluntary, and participants could select which parts of the evaluation they wished to complete. As a result, sample sizes varied across study components, and participants were not required to complete all components. Some participants contributed to more than one component, while others participated in only one. This self-selection reflects the voluntary nature of program evaluation participation and may account for differences in response rates across methods.\u003c/p\u003e \u003cp\u003e Participants provided informed consent prior to survey completion or interviews. A subset of 15 storytellers (10 males and 5 females) who responded to the recruitment email, expressed interest in participating, and met the eligibility criteria were purposively selected for semi-structured interviews. Recruitment continued until the target sample size was reached. Participants were not selected based on satisfaction or engagement level, but on availability and willingness to participate. In the initial recruitment email, participants were asked to indicate which of the follow-up surveys they were interested in. These follow-up surveys were only completed by those who indicated their interest, hence the difference in total participation numbers. The eligible participants were from three WHO regions: the Western Pacific Region, the African Region, and the European Region. To be eligible for the interview, participants must have a) shared their hepatitis B story in 2024 or 2025, b) created a publicly shareable video story, and c) been part of the ongoing hepatitis B storytelling campaign. All storytellers had either personal experience living with hepatitis B; an immediate family member affected, or worked directly with people living with hepatitis B.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Data Collection\u003c/h2\u003e \u003cp\u003eThe Immediate Impact Survey (1-month post-recording) was developed by the study team to assess participants\u0026rsquo; experiences with the storytelling recording process. The survey was designed based on program objectives and prior evaluation tools used within the International Storytelling Program. It included 16 items and assessed participants\u0026rsquo; satisfaction with the storytelling process, emotional and personal responses, confidence in sharing their story, perceived preparedness for future advocacy, and suggestions for program improvement.\u003c/p\u003e \u003cp\u003eThe survey consisted of a combination of Likert-scale and multiple-choice questions. It was designed to take approximately 10\u0026ndash;15 minutes to complete. Participants completed the survey online via Qualtrics, one month after recording their story. Invitations were distributed via email, and participation was voluntary. A total of 25 participants (n\u0026thinsp;=\u0026thinsp;25) completed the survey.\u003c/p\u003e \u003cp\u003eA full list of survey questions and response options is provided in \u003cb\u003eAppendix A\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe Follow-Up Impact Survey was developed by the study team to assess longer-term outcomes of participation in the International Storytelling Program. The survey evaluated changes in participants\u0026rsquo; comfort discussing hepatitis B, stigma and discrimination experiences, advocacy engagement, and personal and professional growth, as well as perceived community-level ripple effects of storytelling (e.g., perceived changes in awareness, attitudes, and behaviors within their communities). The survey consisted of approximately 20 items, including a combination of open ended, multiple-choice, and Likert-scale questions organized around five domains: stigma reduction, public awareness and education, confidence in storytelling, advocacy engagement, and long-term personal impact.\u003c/p\u003e \u003cp\u003eThe survey was administered online via Qualtrics, 3\u0026ndash;6 months after participants recorded their stories. Invitations were distributed via email, and participation was voluntary. Eleven participants (n\u0026thinsp;=\u0026thinsp;11) completed the survey. The survey required approximately 10\u0026ndash;15 minutes to complete. Follow‑up surveys were completed only by participants who indicated interest during initial recruitment, resulting in a smaller follow‑up sample size. A full list of survey items is provided in \u003cb\u003eAppendix B\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Data Collection\u003c/h3\u003e\n\u003cp\u003eOpen-ended, semi-structured interviews were conducted to explore participants\u0026rsquo; experiences with the storytelling program and its impact on personal growth, community engagement, advocacy, and perceptions of stigma. Interviews were conducted in English by trained research team members via Zoom or telephone, lasting 30\u0026ndash;45 minutes, audio-recorded, transcribed verbatim, and de-identified for analysis. Participants provided written or verbal consent prior to participation and were informed that they could decline to answer any questions if they felt uncomfortable.\u003c/p\u003e \u003cp\u003eThe interview guide (\u003cb\u003eAppendix C\u003c/b\u003e) was developed based on program goals, prior literature on storytelling and health communication, and input from the evaluation team. Key areas of inquiry included:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eStorytelling Experience\u003c/em\u003e: Participants described the storytelling process, emotions experienced before, during, and after recording, program support, challenges, and aspects of the process they found most valuable.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eImpact on Public Awareness and Stigma Reduction\u003c/em\u003e: Questions explored whether participants shared their story, perceived changes in community awareness of hepatitis B, feedback received, and the role of storytelling in reducing stigma.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003ePersonal Growth and Advocacy\u003c/em\u003e: Participants reflected on personal impacts of sharing their story, involvement in advocacy or educational activities, and confidence in continuing to engage in hepatitis B advocacy.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eProgram Feedback and Suggestions\u003c/em\u003e: Participants provided recommendations for improving the program, advice for future storytellers, and additional reflections on their experiences.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cp\u003eProbes were included to encourage participants to elaborate on their experiences and provide detailed insights. Data collection continued until saturation was achieved, with no new themes emerging after 15 interviews. This study was approved by the Heartland Institutional Review Board [070925\u0026thinsp;\u0026minus;\u0026thinsp;1229].\u003c/p\u003e\n\u003ch3\u003eQualitative Analysis\u003c/h3\u003e\n\u003cp\u003eA qualitative content analysis approach was used to analyze interview transcripts. A preliminary codebook was created to guide the organization of data, and codes were developed by review of the literature (\u003cem\u003ea priori\u003c/em\u003e) and through line-by-line reading of a subsample of queries [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Each code was given a specific definition to ensure coding accuracy and to improve intercoder reliability [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Data coding and analysis was facilitated using NVivo 15 software (QRS International, Doncaster, Australia). All data were independently double coded by two members of the research team to ensure coding accuracy. Inter-coder reliability (ICR) was assessed using the kappa coefficient, with a target threshold of \u0026ge;\u0026thinsp;0.70 to indicate acceptable agreement. Overall coding agreement was substantial across all coders (ML, CF, BA, NT, SD).\u003c/p\u003e \u003cp\u003eDiscrepancies in coding were resolved through discussion between the two coders, with consensus reached through iterative review and agreement.\u003c/p\u003e \u003cp\u003eFollowing coding, the research team organized data into thematic categories describing participants lived experiences, emotional responses, stigma and discrimination contexts, and perceptions of the storytelling program\u0026rsquo;s broader impact. Quotes are identified by de-identified participant file numbers (e.g., File 1, File 2) to maintain confidentiality.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eImmediate Impact Survey Results (n\u0026thinsp;=\u0026thinsp;25)\u003c/h2\u003e \u003cp\u003eParticipants reported overwhelmingly positive experiences with the storytelling process. Fourteen (57%) rated their experience as excellent, nine (38%) as good, and one (5%) as fair. One participant did not respond to this question, as survey questions were optional. All participants (25/25) reported that instructions and guidance were clear, and 23/25 (92%) felt comfortable sharing their story. All participants felt they had sufficient time to express themselves, while six (24%) experienced technical difficulties.\u003c/p\u003e \u003cp\u003eParticipants reported strong personal and emotional benefits which included feeling empowered [19/25 (76%)] and feeling relieved [13/25 (52%)]. Additionally, three (12%) reported feeling nervous, and one (4%) reported feeling vulnerable. Confidence was high, with 20/25 (80%) feeling very confident and 20/25 (80%) reporting personal benefits from sharing their story. After recording, 21/25 (84%) felt prepared to share their story with a wider audience, 24/25 (96%) felt more confident advocating for hepatitis B awareness, 24/25 (96%) expressed interest in future storytelling or advocacy activities, and 24/25 (96%) would recommend the program.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFollow-Up Impact Survey Results (n = 11)\u003c/h3\u003e\n\u003cp\u003eAt three to six months of post-recording, participants reported sustained psychosocial and advocacy-related impacts (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Notably, most participants reported increased comfort sharing their story or hepatitis B status, with 73% indicating they felt much more comfortable. Similarly, 73% reported personal growth and plans to continue advocacy or education efforts.\u003c/p\u003e \u003cp\u003eIndicators of empowerment and stigma reduction were also prominent: 64% reported reduced personal stigma and felt empowered to engage in hepatitis B advocacy. Over half (55%) described a strong positive long-term impact on their lives, and 55% had already shared their story publicly.\u003c/p\u003e \u003cp\u003eWhile fewer participants observed clear shifts in community perceptions, uncertainty remained high (55%), suggesting that broader community-level change may require longer-term or more widespread storytelling efforts. These findings should be interpreted cautiously given the small follow-up sample size.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSustained Program Impacts at 3\u0026ndash;6 Months (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStory Sharing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShared story publicly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCommunity Perception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSignificant change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmall change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eComfort Sharing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuch more comfortable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (73%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat more comfortable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStigma Reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal stigma reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity-level stigma reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAdvocacy Engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipated in activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlan to engage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFelt empowered to advocate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGrowth \u0026amp; Connection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal growth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (73%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreased community connection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLong-Term Impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrong positive life impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlan continued advocacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (73%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eResults of Interviews\u003c/h2\u003e \u003cp\u003eAnalysis revealed five interrelated themes describing the lived experience of those living with hepatitis B and the transformative role of storytelling. The sample included 15 participants (F\u0026thinsp;=\u0026thinsp;5; M\u0026thinsp;=\u0026thinsp;10) representing diverse geographic regions, including the Western Pacific Region (Philippines), African Region (Nigeria, Malawi, Ghana, Burundi, Uganda, Kenya), and European Region (Uzbekistan). Participants described hepatitis B as a deeply stigmatizing and emotionally burdensome condition shaped by misinformation and structural barriers. Storytelling functioned not only as an educational strategy, but as a mechanism for identity reconstruction, stigma disruption, and community advocacy. The following sections describe these themes in detail, highlighting the social and emotional impact of hepatitis B, the role of storytelling, and participants\u0026rsquo; recommendations for program improvements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHepatitis B as a Social and Emotional Condition, Not Just a Clinical Diagnosis\u003c/h2\u003e \u003cp\u003eParticipants consistently described hepatitis B not merely as a biomedical condition, but as a profoundly social and emotional experience shaped by misinformation, stigma, and structural inequities. Low levels of public awareness were described as key drivers of stigma. Participants noted that misconceptions about casual transmission and exaggerated fears of contagion often manifested in the stigmatization or mistreatment of PLWHB. In many contexts, the fear of discrimination extended beyond casual interactions and into family life, employment, and community participation. One participant explained the breadth of these potential consequences, noting that disclosure could provoke challenges \u0026ldquo;from relatives, from your immediate family, sometimes from your wife, from your husband...from your children, from extended family members, friends, policy, co-workers\" (File 15). Such accounts illustrate how stigma surrounding hepatitis B permeates multiple domains of social life, producing a climate in which silence and concealment become strategies for self-protection.\u003c/p\u003e \u003cp\u003eThis pervasive social stigma contributed to profound internalized stigma and emotional distress among participants. Participants described feelings of fear, uncertainty, and hesitation about revealing their status even within spaces intended for advocacy. One participant explained, \u0026ldquo;I [am] afraid to share and hesitate to share my story because I\u0026rsquo;m worried about how other people will react, because [of] discrimination\u0026rdquo; (File 2). The anticipation of negative reactions from others\u0026ndash;including rejection, blame, or social exclusion\u0026ndash;frequently discouraged individuals from openly discussing their diagnosis. In some cases, the level of stigma within local contexts was so intense that participants were willing to share their experiences only under conditions of anonymity. As one participant summarized, \u0026ldquo;We are ready to share our stories, but we are not ready to show our faces because...the stigma here and the discrimination is very, very high\u0026rdquo; (File 11).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStorytelling as a Tool for Reframing the Disease\u003c/h2\u003e \u003cp\u003eParticipants described storytelling as a tool for reaching individuals who may be silently living with hepatitis B. Hearing others speak openly about their experiences was described as encouragement for those who conceal their diagnosis, which also helps them to re-establish their identity beyond their HBV infection. One participant stated, \u0026ldquo;The fact that people are coming up and speaking about [hepatitis B] convinces others that it is not a death sentence. So, I think, this can encourage someone who has been hiding to, rethink that there is no need to hide\u0026rdquo; (File 12).\u003c/p\u003e \u003cp\u003e Participants also described storytelling as a powerful tool for increasing the visibility of people affected by hepatitis B and amplifying their voices. Sharing lived experiences was seen as a tool to raise awareness and advocacy, especially targeting policymakers. One participant explained, \u0026ldquo;Storytelling is incredibly powerful. It brings real-life experiences to light, especially to those who are afraid to speak up. And it is a way for us to be seen and to be heard by health authorities, especially the policymakers and the people who may not understand what hepatitis is\u0026rdquo; (File 10).\u003c/p\u003e \u003cp\u003eIn addition, participants described their involvement in the storytelling program as facilitating emotional processing and acceptance of their diagnosis. Although recounting that the process sometimes evoked challenging emotions, participants reported that sharing their stories helped them accept their diagnosis and strengthened their motivation to educate others. One participant reflected, \u0026ldquo;When I was talking about my experience, I was reminiscing about my struggles and experience. It brought up a lot of emotions at that time, but I realized that being able to speak about my experience of having hepatitis B was a process. It was a process of accepting my condition, and that acceptance gives me the strength to share my story with others\u0026rdquo; (File 10). Another participant similarly described that storytelling helped them process their fear and gain control to use their position for raising awareness and challenging stigma, \u0026ldquo;When the invite came, it wasn\u0026rsquo;t easy [to make the decision], but I realized that sharing my story would have a huge impact on everyone who is going to hear it. That [helped] clear [my] fears and [reduce the] stigma and discrimination [in] my mind\u0026rdquo; (File 15).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStorytelling as Stigma Reduction and Educational Strategies\u003c/h2\u003e \u003cp\u003eStorytelling functioned as both a stigma-reduction and educational strategy, fostering personal growth and confidence among participants, increasing willingness to disclose hepatitis B status, supporting transitions into advocacy roles, and generating broader ripple effects within their communities. Participants described a range of engagement following storytelling, including informal education, peer support, community navigation, and advocacy. Advocacy was expressed along a spectrum, ranging from individual community education to engagement with health institutions and policymakers. These distinctions are important, as not all educational activities were framed by participants as formal advocacy.\u003c/p\u003e \u003cp\u003eAll participants reported an increase in their personal growth and confidence as lived experience storytellers. One individual described, \u0026ldquo;I think the impact has been very positive on my life. And through my own activities, the people who are living with hepatitis B that are connected to me, that I relate with, are also gaining confidence and then seeing the reason why they should carry on with life\u0026rdquo; (File 16). Some participants reported that being storytellers increased their willingness to disclose their status to others in their communities. \u0026ldquo;I already have a whole bunch of doctors, nurses, [and] people from my own family. They have formed a group going from one village to another as a result of my storytelling, to create awareness [about] the stigma, [which can be] devastating\u0026rdquo; (File 5).\u003c/p\u003e \u003cp\u003eInterviewees also described the community-level ripple effects of sharing their lived experiences/stories: \u0026ldquo;I see more and more people are coming and asking me how to get tested, how to get a vaccine. This comfort[s] me because it is a positive impact\u0026rdquo; (File 14). A different participant also shared, \u0026ldquo;It has really impacted positively on the lives of my community, my family, [and] my friends. I have been able to convince quite a good number of people to go for testing\u0026rdquo; (File 5). Another participant added, \u0026ldquo;That story, hearing [it] from somebody from another country, in another place, can inspire that person to continue to have hope, have faith. So, I think [it is] not just for [one]self, but [also] to help inspire others\u0026rdquo; (File 16). Additionally, participants mentioned that they noticed their transition from storytellers into educational roles, \u0026ldquo;The impact is every single day, almost every day, I get, [to hear] their stories, when they go for proper tests or especially those who are living with the disease. They will send their tests [or] reports to me [and] then I forward [them] to the appropriate quarters [doctor]\u0026rdquo; (File 15).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for Improving Storytelling\u003c/h2\u003e \u003cp\u003eParticipants recommended increasing accessibility to the storytelling program and enhancing linguistic inclusivity to improve its reach and relevance across affected communities. One participant emphasized the importance of expanding storytelling beyond English-language formats to better engage Chinese-speaking populations: \u0026ldquo;I think if you\u0026rsquo;re really looking at the Chinese side, it means this kind of storytelling should not be just in English\u0026hellip; maybe in the future, we can make the storytelling in Mandarin and Cantonese\u0026rdquo; (File 3). Participants underscored the importance of trauma-informed facilitation in fostering a safe and supportive storytelling environment. Facilitator guidance was described as instrumental in helping participants process difficult emotions and gain confidence in sharing their experiences: \u0026ldquo;\u0026hellip;the facilitator was helpful, very patient and supportive throughout the recording\u0026hellip; it is a course [journey] to accept my condition, and that acceptance gives me the strength to share my story with others\u0026rdquo; (File 10).\u003c/p\u003e \u003cp\u003eParticipants also highlighted the need for more stories and storytellers to share their lived experiences. One participant described, \u0026ldquo;We need more people to come up. We need more stories. I am looking forward to a time when a fair percentage of people living with hepatitis B would just be out there and talking about it. Because one way of [addressing] prevention and stigma would be to just talk about it\u0026rdquo; (File 12). Another participant echoed, \u0026ldquo;But we should not be discouraged. We should focus on sharing our story so others can also take notes or [lessons] from it. I would recommend this particular program to everyone. If you have any story to share concerning your experience [with] hepatitis B in general, I encourage you to come out and share because after sharing [your story], you are going to save [the] lives of [many]\u0026rdquo; (File 15).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBoth qualitative and quantitative findings aligned and reinforced each other. Immediate impact survey findings showed high levels of empowerment, confidence, and advocacy readiness, suggesting early psychosocial benefits of participation in the storytelling program. Findings from this evaluation suggest that the Hepatitis B Foundation\u0026rsquo;s International Storytelling Program has meaningful impacts on participants, promoting empowerment, personal growth, and advocacy engagement. Participants also described how connecting with other storytellers fostered a sense of understanding and mutual support, highlighting the empowering role of shared lived experience. Storytelling provided opportunities for emotional processing and acceptance of one\u0026rsquo;s diagnosis, helping participants reframe their experiences beyond stigma and misinformation. Participants also described how connecting with other storytellers fostered a sense of understanding and mutual support; being in a community with individuals who have similar experiences has been found to empower individuals [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As previously documented in the literature, sharing personal experiences provided a safe space to be heard and empowered participants to speak openly about their health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, storytelling offered a platform to inspire broader community action around hepatitis B awareness, screening, and vaccination.\u003c/p\u003e \u003cp\u003eThese qualitative findings align with quantitative results demonstrating high levels of satisfaction, empowerment, confidence, and advocacy engagement immediately post-participation and at follow-up. Beyond individual-level effects, storytelling also functioned as an educational and stigma-reduction strategy. Participants described the program as a tool to reach individuals who may be silently living with hepatitis B, encouraging them to reconsider hiding their diagnosis and helping them reclaim their identity beyond infection. Sharing lived experiences also allowed participants to increase the visibility of people affected by hepatitis B, amplify their voices to policymakers, and influence perceptions in their communities. These results are consistent with previous research demonstrating that narrative storytelling improves health knowledge, increases engagement with health services, and reduces stigma across a range of health conditions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study highlights the transformative role of storytelling in reframing hepatitis B as a social and emotional condition, rather than a clinical diagnosis. Participants consistently described the emotional burden of stigma and structural barriers, with storytelling serving as a mechanism to reduce internalized stigma, increase disclosure, and foster community-level ripple effects, including encouraging testing, vaccination, and education. Many participants reported that sharing their story motivated others to take positive actions, reinforcing the broader public health impact of personal narratives [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStigma theory and empowerment theory provide a useful framework for interpreting the findings of this study. Stigma theory helps explain the ways participants navigated internalized, anticipated, and enacted stigma, while empowerment theory frames the program\u0026rsquo;s impact on participants\u0026rsquo; sense of agency, self-efficacy, and capacity to act as advocates within their communities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This combination of theories underscores storytelling as both a personal and social intervention, offering participants tools for emotional coping, identity reconstruction, and community engagement [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These relationships are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which presents the conceptual framework linking storytelling participation to stigma reduction and empowerment pathways.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eParticipants emphasized increasing accessibility and language inclusivity, consistent with evidence that culturally and linguistically tailored health communication is more effective. Expanding storytelling beyond English-language formats may further engage diverse communities and maximize impact.\u003c/p\u003e \u003cp\u003eTrauma-informed facilitation was described as crucial for fostering a safe, supportive environment that allows participants to process difficult emotions and build confidence, consistent with public health literature on trauma‑informed approaches that strengthen community engagement and empathetic practice. Overall, this evaluation suggests that structured storytelling programs are a feasible, acceptable, and impactful strategy to empower individuals, reduce stigma, and promote advocacy globally. These insights can inform enhancements to program design, including targeted training, curated story selection for maximum impact, and strategies to strengthen advocacy initiatives worldwide.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Strengths\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003ePotential limitations include selection bias, as participants are self-selected and may differ from the broader hepatitis B population. Therefore, results may not be generalizable to all individuals living with hepatitis B, particularly those who have not participated in storytelling programs or who reside in regions not represented in this study. In addition, not all storytellers in the program participated in the evaluation, meaning the findings may not fully represent the experiences of the entire storyteller cohort.\u003c/p\u003e \u003cp\u003ePre-existing relationships between researchers and participants could have influenced responses. Additionally, responses may have been influenced by social desirability bias given participants\u0026rsquo; relationship to the program and its facilitators. Future research may consider the use of an independent interviewer to minimize the effect of participant-researcher relationships. Language barriers and cultural differences also presented challenges: some participants had difficulty understanding interview questions, and interpretation of survey and interview items, particularly around concepts such as stigma and advocacy, may have varied across cultural contexts. A subset of participants also confused the concepts of stigma and discrimination, which may have influenced responses and the interpretation of findings in these areas.\u003c/p\u003e \u003cp\u003ePractical and technical challenges further affected data collection. Connectivity issues, including limited Wi-Fi or unstable access to Zoom, along with other technical difficulties, may have disrupted communication or limited participants\u0026rsquo; engagement during interviews. Time zone differences additionally made scheduling interviews difficult, potentially affecting participation and the completeness of the data. To address this, the research team offered flexible interview scheduling across multiple time zones and provided alternative timing options to accommodate participants\u0026rsquo; availability. Finally, the small sample size for the follow-up survey (n\u0026thinsp;=\u0026thinsp;11) limits the ability to draw robust conclusions regarding long-term impacts.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis study has several strengths. It represents one of the first evaluations of a global hepatitis B storytelling program incorporating both qualitative and quantitative data from participants across multiple countries. The inclusion of storytellers from diverse geographic and cultural backgrounds enhances the study\u0026rsquo;s relevance to global hepatitis B communities and contributes to a growing evidence base on narrative-based health communication in hepatitis B. Additionally, the mixed-methods design allowed for a more comprehensive understanding of both immediate and longer-term impacts of storytelling, capturing not only measurable outcomes but also rich lived experiences of empowerment, stigma reduction, and advocacy engagement.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe International Storytelling Program demonstrates that structured, supportive storytelling empowers people living with hepatitis B, reduce stigma, and foster advocacy at both personal and community levels. By leveraging lived experiences, the program provides a scalable model for integrating narrative interventions into public health initiatives. These findings underscore the importance of culturally and linguistically inclusive approaches while highlighting storytelling as a feasible, effective, and impactful tool for global hepatitis B awareness and stigma reduction.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatitis B Virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics Approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Heartland Institutional Review Board (HIRB 070925-1229). No identifiable information was included, and all participants provided informed consent prior to study participation and informed that they may withdraw at any time. Confidentiality was maintained throughout the study, and participation was voluntary. Researchers maintain awareness of pre-existing relationships with participants and mitigate bias by emphasizing the voluntary nature of participation. This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication of anonymized data was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Availability\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDe-identified quantitative survey data (collected via Qualtrics) and qualitative interview transcripts are securely stored by the Hepatitis B Foundation research team and are not deposited in a public repository. These data may be available from the corresponding author upon reasonable request, subject to institutional approval and compliance with participant consent agreements and applicable data protection regulations. Requests for access will be reviewed to ensure that participant confidentiality and ethical obligations are maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting Interests\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the past 36 months, the Hepatitis B Foundation has received outreach and public health grants from BMS, GSK, Gilead Sciences, Grifols, Aligos, nChroma, Precision Biosciences, Mirum, Vir Biotechnology, Roche, and Exact Sciences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBright Ansah reports on involvement in projects that have received funding from pharmaceutical companies, including GSK.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Hepatitis B Foundation #justB and #BtheVoice storyteller programs are funded through general operating support by the Hepatitis B Foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthors\u0026rsquo; Contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: AQ, ML, CF, BA; Program development: CF, ML; Data collection: CF, ML, AQ, BA, NT, SD; Data analysis: CF, ML, AQ, BA, NT, SD; Drafting the manuscript: CF, ML, AQ, BA, NT, SD; Critical revision and supervision: CF, YI, CC; All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all participants for sharing their lived experiences and for the time and effort they dedicated to this study, including coordinating across different time zones and schedules.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization, Hepatitis B. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/hepatitis-b\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/hepatitis-b\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 13 March 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global hepatitis report 2024: action for access in low- and middle-income countries. Geneva: World Health Organization; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Academies of Sciences, Engineering, and Medicine. Eliminating the public health problem of hepatitis B and C in the United States: phase one report. Washington (DC): National Academies; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global health sector strategy on viral hepatitis 2016\u0026ndash;2021. Geneva: World Health Organization; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Academies of Sciences, Engineering, and, Medicine. A national strategy for the elimination of hepatitis B and C: phase two report. Washington (DC): National Academies; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee H, Fawcett J, Kim D, Yang JH. Correlates of hepatitis B virus-related stigmatization experienced by Asians: a scoping review of literature. Asia Pac J Oncol Nurs. 2016;3(4):324\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/2347-5625.195896\u003c/span\u003e\u003cspan address=\"10.4103/2347-5625.195896\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe TV, Vu TTM, Mai HT, et al. Social determinants of stigma and discrimination in Vietnamese patients with chronic hepatitis B. Int J Environ Res Public Health. 2019;16(3):398. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph16030398\u003c/span\u003e\u003cspan address=\"10.3390/ijerph16030398\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahlstrom MF. Using narratives and storytelling to communicate science with nonexpert audiences. Proc Natl Acad Sci U S A. 2014;111(Suppl 4):13614\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeelen J, Metseagharun T, Boersma M, Jansen W. Beyond silence and rumor: Storytelling as an educational tool to reduce the stigma around HIV/AIDS in South Africa. Health Educ. 2010;110(5):382\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlber JM, Cohen C, Racho R, Freeland C, Ghazvini S, Tolentino B, Almeida R, Silliman M. Exploring the impact of storytelling on storytellers in a hepatitis B health communication context. Patient Educ Couns. 2020;103(9):1760\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pec.2020.03.026\u003c/span\u003e\u003cspan address=\"10.1016/j.pec.2020.03.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1049732305276687\u003c/span\u003e\u003cspan address=\"10.1177/1049732305276687\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago (IL): Aldine; 1967.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorondy-Jenkins F, Ansah B, Chen J, Goldring A, Ibrahim Y, Issa S, Lesidrenska S, Machado T, Moore H, Njouom R, Okinedo P, Racho R, Scott L, Zovich B, Cohen C. Global hepatitis B and D community advisory board: expectations, challenges, and lessons learned. Front Public Health. 2024;12:1437502. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2024.1437502\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2024.1437502\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePallai EL, Tran K. Narrative health: using story to explore definitions of health and address bias in health care. Perm J. 2019;23:18\u0026ndash;052. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7812/TPP/18-052\u003c/span\u003e\u003cspan address=\"10.7812/TPP/18-052\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhuang J, Guidry A. Does storytelling reduce stigma? A meta-analytic view of narrative persuasion on stigma reduction. Basic Appl Soc Psychol. 2022;44(4):25\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/01973533.2022.2039657\u003c/span\u003e\u003cspan address=\"10.1080/01973533.2022.2039657\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeley K, Kennedy-Hendricks A, Niederdeppe J, Barry CL. Reducing health-related stigma through narrative messages. Health Commun. 2020;35(7):849\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10410236.2019.1598614\u003c/span\u003e\u003cspan address=\"10.1080/10410236.2019.1598614\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoffman E. Stigma: notes on the management of spoiled identity. New York: Simon \u0026amp; Schuster; 1963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerman MA. Empowerment theory: psychological, organizational and community levels of analysis. In: Rappaport J, Seidman E, editors. Handbook of Community Psychology. Boston (MA): Springer; 2000. pp. 43\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeisler M. Actively engaging patients through storytelling to enhance health outcomes. Patient Educ Couns. 2011;85(3):e1\u0026ndash;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pec.2011.03.004\u003c/span\u003e\u003cspan address=\"10.1016/j.pec.2011.03.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hepatitis B, HBV, storytelling, stigma, patient advocacy, community engagement, evaluation, mixed-methods","lastPublishedDoi":"10.21203/rs.3.rs-9419489/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9419489/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHepatitis B remains a major global public health challenge, characterized by low awareness, underdiagnosis, limited access to care, and pervasive stigma. Stigma and misinformation discourage disclosure, delay testing, and reduce engagement in treatment and prevention. Storytelling has emerged as a promising health communication tool to humanize disease experiences, reduce stigma, and promote advocacy. This study evaluates the Hepatitis B Foundation\u0026rsquo;s International Storytelling Program and its impact on storytellers\u0026rsquo; empowerment, confidence, stigma experiences, perceived community impact, and advocacy engagement.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods evaluation was conducted. Eligible participants were adults who had recorded personal hepatitis B stories through the program. Quantitative data were collected via an immediate post-recording survey (n\u0026thinsp;=\u0026thinsp;25) and a follow-up survey 3\u0026ndash;6 months later (n\u0026thinsp;=\u0026thinsp;11), assessing satisfaction, emotional responses, confidence, stigma experiences, and advocacy activities. Descriptive statistics were calculated. Fifteen participants were interviewed qualitatively; these individuals were part of an eligible pool of storytellers spanning 22 countries. Interviews were transcribed and analyzed thematically with double coding for reliability. Quantitative and qualitative findings were integrated to provide a comprehensive understanding of program impacts.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants reported high satisfaction with the storytelling process and immediate personal benefits: 76% felt empowered, 92% felt confident sharing their story, and 96% felt prepared to advocate for hepatitis B awareness. At follow-up, 73% reported increased comfort discussing hepatitis B, 73% noted personal growth, and 64% felt more connected to the hepatitis B community. Over half shared their stories publicly, and 64% felt empowered to become advocates. Qualitative analysis revealed themes including hepatitis B as a social and emotional condition shaped by stigma, storytelling as a tool for reframing illness identity, emotional processing and acceptance, increased willingness to disclose, transition into advocacy roles, and community-level ripple effects such as encouraging testing and education.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe International Storytelling Program is a practical, impactful approach for empowering individuals affected by hepatitis B and promoting advocacy and stigma reduction globally. Personal narratives serve as a valuable complement to traditional public health strategies by fostering engagement, awareness, and community mobilization.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Evaluating the Impact of the Hepatitis B Foundation’s International Storytelling Program on Empowerment, Advocacy, and Stigma Reduction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-26 17:14:43","doi":"10.21203/rs.3.rs-9419489/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"285279601832375807020273770465542250838","date":"2026-05-07T16:26:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T00:45:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"195453372965349396096078136981868798431","date":"2026-05-06T06:48:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-26T14:26:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221030212790889797149749703928925826269","date":"2026-04-19T15:55:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-17T13:58:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-17T08:38:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-16T23:58:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-16T23:58:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-14T20:36:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fef0f66b-b043-4da6-a40c-3bf1bffcc681","owner":[],"postedDate":"April 26th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"285279601832375807020273770465542250838","date":"2026-05-07T16:26:06+00:00","index":37,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T00:45:57+00:00","index":36,"fulltext":""},{"type":"reviewerAgreed","content":"195453372965349396096078136981868798431","date":"2026-05-06T06:48:52+00:00","index":34,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T17:14:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-26 17:14:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9419489","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9419489","identity":"rs-9419489","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}