Animated Video as a Health Promotion Tool to Improve Knowledge and Behavior of Pulmonary TB Patients

1. Introduction

Health research focuses on stunting, tuberculosis, maternal and child health (KIA), infectious and non-infectious diseases, where tuberculosis is among the deadliest diseases in the world (Mohajan, 2015). World Health Organization (WHO) data said that in 2018, 10 million people suffered from tuberculosis with varying severity, with new cases ranging from less than 5 to more than 500 per 100,000 people annually. The highest prevalence of TB cases happens in males aged 15 years and under, accounting for 57% of total TB cases in while females account for 32%, and children under 15 years of age account for 11%. India, China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh, and South Africa are eight of the thirty countries that contribute to the world’s TB cases (WHO, 2019). Data from the Indonesian Ministry of Health shows that 543,874 cases of tuberculosis were reported in Indonesia in 2019, compared to 566,623 cases in 2018 and in 2019, there were 523,614 cases (Iskandar et al., 2023). The cases increase even in 2024, the number reaching 1,092,000 people who suffer from TB. In 2020, the total number of tuberculosis cases in Bali Province was 2,873, with three regencies contributing the highest number of cases: Denpasar City with 1,054 cases, Buleleng Regency with 502 cases, and Badung Regency with 400 cases (Bali, 2021).

Health awareness can ensure the provision of information and knowledge (Setiawati et al., 2024; Wulandari & Prihatin, 2022). Socialization in the health and education sectors is aimed at sharing health information with a community, group, or individual. Health education is an effort to learn about health using various media and technologies to expand public knowledge (Van Teijlingen et al., 2021). Health promotion can be carried out to prevent early TB in the community and among individuals  (Trifitriana, M., Fadilah, M., & Mulawarman, 2020). It can be implemented in the learning process using visual media such as video.

Previous research by (Mardiah et al., 2024), who evaluated the effect of counseling with video animation on 30 respondents of family members of patients treated in the hospital, showed a significant increase in patient knowledge and attitudes in the intervention group compared to the control group. It discusses that videos have proven to be more interesting and effective in conveying health information. Respondents who received counseling through animated videos showed a good understanding of the attitudes to support patients and felt more satisfied with the counseling process. This study concludes that animated videos can be an effective tool in health counseling in hospitals, increasing patient knowledge and attitudes towards pulmonary tuberculosis. Another research specifically in Badung Regency about the category of variables related to TB cases revealed that knowledge was mostly in the poor category, as many as 28 (90.3%), and the most behavioral variables were in the poor behavior category, as many as 30 people (68.2%). The results of the chi-square test obtained a significance of 0.001 for knowledge and 0.001 for behavior, indicating that there is a relationship between knowledge and behavior with the incidence of pulmonary TB (Suyasa et al., 2024).

The background behind the involvement of technology in health education is that conventional education is often less engaging and effective in attracting public attention and interest  (Latif.A.I., Tiala, N.H.& Masahuddin, 2023). Long lectures or static presentations tend to be less able to maintain the audience's focus for a long time. Facing this challenge, the use of animated videos as educational media can be a very innovative and interesting solution (Afiah, A.S.N.,& Soesanti, 2022). Animated videos have strong visual appeal and can convey complex information in a way that is easier to understand. A combination of attractive visuals, clear sound, and structured narrative in animated videos can increase understanding of pulmonary TB prevention (Setyorini, E, H., Ajmala, I.E., Primayanti, I.Yuliani, E.A., & Geriputri, 2020). Moreover, the use of animated videos on social media can be an effective way to increase the reach and effectiveness of health education about pulmonary TB.

This research aims to determine the effectiveness of animated videos in increasing knowledge and changing behavior in an attempt to prevent the transmission of pulmonary TB in Badung Regency.

2. Method

2.1 Study Design

This study employed a quantitative method with a quasi-experimental one-group pre-posttest design. This study implemented an experimental method. Experimental research is known for its most comprehensive quantitative research approach, meaning it meets all the requirements for testing causal relationships (Sahir, 2021). It is a widely used method to determine the effect of one treatment on another under controlled conditions, which fall into three categories: pre-experimental design, true experimental design, and quasi-experimental design.

2.2 Population and Sample

The population is all subjects or objects with specific characteristics to be studied, not only the objects or subjects studied that are studied, but also all the characteristics or traits possessed (Alimul Hidayat, 2012). The population in this study was pulmonary tuberculosis patients registered at 12 community health centers in Badung Regency. This number also becomes the case population, which includes all pulmonary tuberculosis patients registered at 12 community health centers in Badung Regency.

The sample is the number and characteristics of the population that are studied, and conclusions drawn from which the results can represent the condition of a population. The sample size in this study was adopted from the formula for the total population, which was not known for certain, as shown in Eq. 1 (Lemeshow et al., 1997).

Based on Eq. 1, the proportion of TB incidents in Badung Regency of 0.158, CI of 95% and d with a value of 10%, the calculation results obtained a sample of 102 respondents.

2.3 Data Collection and Analysis

In conducting data collection, measurement tools are used to strengthen the research results. It is known that the data collection measurement tools can include questionnaires, observations, interviews, or a combination of the three. This research used a questionnaire as the instrument, containing several questions. This instrument was chosen as the respondents are large and not illiterate. In addition, the questions are able to explore confidential matters. The respondents were exposed to animated videos containing material on preventing the transmission of pulmonary tuberculosis disease delivered through social media. The variables measured are knowledge, attitudes, and actions before and after being given animated videos.  The data collection was conducted using a questionnaire-based interview method before and after the intervention through animated videos on TB prevention. The category is divided into 3 i.e., Good, Fair and Poor. The data analysis used the Wilcoxon statistical test to show the effect of animated video on the knowledge and behavior of the respondents.

3. Results

The results are divided into data on respondents' characteristics, research variables, knowledge, as well as behavior, using the Wilcoxon statistical test.

3.1 Respondents Characteristics

The characteristics of the research respondents are specified by gender, age, residence status, education, and employment status. The minimum age of respondents is 23 years, the maximum is 75 years, with an average age of 44.8 ± 12.1 years. The distribution of respondents based on gender, residence status, education, and employment can be seen in Table 1.

Table1: Respondents' characteristics distribution

Table 1 shows that the 102 respondents, the majority female, i.e., 61 people or 59.8%, and 81 (79.4%) are indigenous. The highest level of education for respondents is senior high school as many as 48 respondents, or 47.1%. Sixty (58.8%) are farmers/laborers.

3.2 Research Variable

3.2.1 Knowledge

Based on the results of the respondents' knowledge questionnaire before and after intervention with animated videos on preventing pulmonary TB in patients in Badung Regency, as shown in Figure 1.

Figure 1: Knowledge category results

As seen in Figure 1 above, there is an increase in knowledge before watching the animated video. Before the intervention was given, the Good category was only 17 respondents (16.7%), and after watching the animated video the Good knowledge category increased for 88 respondents (86.3%). The increase in knowledge in the good category between before and after watching the animated video is 71 respondents (417.65%).

3.2.2 Behavior

The results of the questionnaire on respondents' behavior before and after the intervention are shown in Figure 2.

Figure 2: Behavior category results

Figure 2 above shows that there is an increase in behavior before watching the animated video in the Good category of 27 respondents (26.5%) and after watching the animated video in the Good behavior category of 88 respondents (84.3%). The increase in behavior in the Good category from before and after watching the animated video on pulmonary TB is 59 respondents (218.5%).

3.3 Data Analysis

The Wilcoxon test is used to analyze the data on respondents' knowledge and behavior before and after watching the animated video on preventing pulmonary TB. The results are shown in Table 2.

Table 2: Wilcoxon test results

Data analysis using the Wilcoxon statistical test in Table 2 above shows that the level of knowledge before and after watching the animated video has a significance of 0.000, which means there is a difference in knowledge before and after watching the animated video on preventing pulmonary TB. Meanwhile, the result of the behavior Sig value is 0.000, meaning there is a difference in behavior before and after watching the animated video on preventing pulmonary TB.

4. Discussion

The results of the study show a significant increase in respondents' knowledge levels after watching the animated video on TB prevention. Before the intervention, most respondents had knowledge levels in the fair (71.5%) and poor (11.8%) categories. After watching the video, the proportion of good knowledge increased drastically to 86.3%, while no respondents are in the poor category. The Wilcoxon test shows a significance value of p = 0.000, which means there is a significant difference between knowledge before and after the animated video intervention. The educational variable for most respondents is a Senior High School education.

Education is a human activity, an effort or process of changing behavior towards maturity and the perfection of human life. Knowledge and attitude determine a person’s level of education (Pratiwi et al., 2022; Sibagariang et al., 2025). Education is a planned effort to enable individuals or communities to practice what is taught through educational activities. When highly educated people suffer from illness, they increasingly need health facilities to treat themselves and their families. The higher the level of education, the more people understand that health is an important thing in life, and the greater their desire to seek better health facilities. In addition, individuals with higher education will more easily obtain information to expand their knowledge, and vice versa (Absor 2020). According to research conducted by (Widyastuti 2016), the level of education of TB patients affects their level of knowledge and absorption regarding the prevention of transmission and treatment of TB. Patients who have a low level of knowledge tend not to undergo treatment because, for them, treatment and not treatment will give the same results.

The research reveals that most respondents lacked understanding of TB before watching the video, including its causes, early symptoms, and prevention efforts. Many respondents believed TB was transmitted through direct contact or only affected certain groups. After watching the animated video, their understanding increased significantly. Respondents began to understand that TB is caused by the Mycobacterium tuberculosis bacterium, which is transmitted through droplets from coughing or sneezing. Besides, they also understand that TB can be prevented through clean and healthy living behaviors (PHBS), as well as early detection and appropriate treatment. Effective health promotion must consider predisposing factors (knowledge and attitudes), enabling factors (access to information), and reinforcing factors (environmental support). Animated videos function as a media that can simultaneously enhance predisposing and enabling factors.

Video media is a type of visual presentation in the form of movement that stimulates interest and understanding in viewers (Rizki 2016). Knowledge about how to avoid tuberculosis can be found in various activities, both in electronic media and in health education, as well as awareness campaigns conducted by health workers and school teachers using these media (Aisyah et al., 2020). Visual videos can provide information to the public or individuals. The greatest interest in audiovisual media stems from its ability to provide information in the form of movement, photos, and animations, which can encourage TB prevention behaviors.

Animated video media has proven effective as it delivers information in an engaging, practical, and easily understood manner, accessible to all groups, including those with low literacy levels. Visualizations can take the form of animations that simplify concepts that are difficult to grasp verbally. This is consistent with research conducted by (Putri, A. D., & Sari 2020), which found that the use of animated videos in health education increased participant understanding by 60% compared to printed media. Similarly, research conducted by (Manurung, R., Sari, I. P., & Nasution 2022) found that animation-based educational media significantly improved public understanding of TB, with the percentage of respondents with good knowledge increasing from 43.3% to 80%.

Before intervention, most respondents' behavior was in the Fair (67.6%) and Good (26.5%) categories, with 5.9% still in the Poor category. After treatment, Good behavior increased sharply from 26.5% to 84.3%, with no respondents remaining in the Poor category after watching the animated video. A significance level of 0.000 demonstrates that educational interventions through animated videos are also effective in changing behavior. Changes in a person's health behavior are influenced by knowledge, attitudes, and actions. Increasing knowledge is a crucial first step in changing a person's behavior for a healthier one. Knowledge is the most basic cognitive domain in shaping behavior (Kuo et al., 2024; Schneider et al., 2022). Without knowledge, a person will not understand the importance of preventive measures. Health behavior is influenced by knowledge and awareness. When someone's knowledge increases, they are more likely to make better behavioral changes. People can learn through observation, especially when messages are delivered through models or visual media. In this context, animated videos provide behavioral models that viewers can imitate. Interactive animated media can influence preventive actions because they feel more emotionally and visually involved in the learning process.

The results of this study align with previous research using video as a health education medium for tuberculosis, which showed that audiovisuals combined with video were more effective in improving elementary school students' knowledge and behavior regarding tuberculosis prevention (Fadilah, M., Syakurah, R. A., & Fikri 2019).

Author Contributions: Conceptualization, I Nyoman Gede Suyasa and I G A A Dharmawati.; Methodology, I Nyoman Gede Suyasa and  I G A A Dharmawati.; Software, I Nyoman Jirna.; Validation I Nyoman Purna, Cokorda Dewi Widhya Hana Sundari and Ida Ayu Made Sri Arjani.; Formal Analysis, I Nyoman Gede Suyasa and Nyoman Mastra .; Investigation, I Nyoman Gede Suyasa.; Resources, I G A A Dharmawati and Ida Ayu Made Sri Arjani; Data Curation, I Nyoman Jirna.; Writing – Original Draft Preparation, I Nyoman Gede Suyasa; Writing – Review & Editing, I Nyoman Purna; Visualization, Cokorda Dewi Widhya Hana Sundari.; Supervision, I Nyoman Gede Suyasa.; Project Administration, Ida Ayu Made Sri Arjani.; Funding Acquisition, I Nyoman Gede Suyasa.

Funding: This research and the APC was funded by the Research and Community Services Unit, Poltekkes Kemenkes Denpasar.

Conflicts of Interest: The authors declare no conflict of interest.

Informed Consent Statement/Ethics approval: All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Poltekkes Kemenkes Denpasar No. DP.04.02/F.XXXII.25/0505/2024.

Declaration of Generative AI and AI-assisted Technologies: This study has not used any generative AI tools or technologies in the preparation of this manuscript.