Promoting sexuality education through an online interactive game:
Reaching youngsters without limits
CITE Conference Paper 2014
Samuel Chu1, Alvin Kwan1, Rebecca Reynolds2, Robin Mellecker3, Frankie Tam4, Grace Lee5,
Athena Hong6, Ching Yin Leung1
Author Affiliations:
1
Faculty of Education, The University of Hong Kong, Hong Kong SAR, China
2
School of Communication and Information, Rutgers, The State University of New Jersey, New
Brunswick, USA
3
Institute of Human Performance, University of Hong Kong, Hong Kong SAR, China
4
FifthWisdom Technology Limited, Hong Kong SAR, China
5
The Family Planning Association of Hong Kong, Hong Kong China
6
School of Nursing, University of Hong Kong, Hong Kong SAR, China
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Abstract
This paper describes a project which aims to disseminate correct knowledge and positive
attitudes towards sex to teenagers using an interactive game playable on popular interactive
platforms such as iPad, Facebook and the web. 1176 junior secondary students (Forms 1-3)
from six schools were introduced to the game through on-site game sessions conducted by the
research team and members from the Family Planning Association. Pre-and-post tests were
conducted to measure the enhancement of students’ knowledge on safe sex. The effectiveness
of the game was examined through focus group interviews and surveys. The findings indicate
that students’ sex knowledge improved with a medium effect size after playing the game. An
increase of positive attitude towards sex and relationships as well as an enhanced awareness of
making smart sexual choices were also observed. The contributing factors which make the
interactive game successful and insights on how others might replicate the work in other
disciplines in the future are addressed.
Introduction
Growing up in an increasingly complex world, youngsters nowadays are flooded with
confusing messages about sexuality, values and morality. While Hong Kong teenagers are
becoming more open in sexual attitudes, their sexual knowledge and understanding on the
consequences of unprotected sex remains limited (FPAHK, 2011). Proactive measures are
needed to help students acquire proper sexual knowledge. Yet, sex education for Hong Kong
youngsters is still imminent (Che, 2005). A recent survey involving 134 secondary schools
reveal that the average school time spent on sex education programmes in junior secondary
level was only three hours. The tight curriculum schedule coupled with a lack of documented
policy and teachers not feeling ready to teach sex education are constraints for promoting sex
education in schools. (Hong Kong Department of Health, 2014).
Sex education should be delivered in a manner that is engaging and culturally and socially
relevant to the lives of young people in order to increase uptake and learning. Since playing
online games is a massively popular activity among young generation and games also offer
ideal platforms for trying out ideas, and experimenting with decision-making in a risk-free
environment (Trybus 2014), a pioneer Chinese language interactive game app “Making Smart
Choices” (MSC) was co-developed by the Faculty of Education of the University of Hong
Kong (HKU), the Family Planning Association of Hong Kong (FPAHK) and FifthWisdom
Technology Limited for use on iPad, Facebook, as well as the web to provide easy access to
the game and attract the attention of adolescents. While the iPad and the web versions require
registration with a student account to a local educational website, the Facebook version was
made available for all at https://apps.facebook.com/fpasmartchoices.
Game Development Strategy
Participatory Design and Usability Studies
The game entitled “Making Smart Choices” was developed through a participatory design
approach which involves an active role of users in the design process (Reich, 1996) and
expertise of different stakeholders to design, develop, and refine the targeted product (Bergold
& Thomas, 2012). It also involved the application of usability studies (Budiu 2014; Chu 2007;
Neilson 2012) by 17 end-users comprising of 2 project team members and 15 secondary school
students and heuristic evaluation (Nielsen, 1994 & 2012) by 6 experienced web evaluators.
These studies and evaluations resulted in improvements to the design, user friendliness and
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effectiveness of the game interface. Details of the usability testing can be found in Appendix 1
and questions covered in the heuristic evaluation can be found in Appendix 2.
Game Narrative Conceptualization
The app consists of five mini-games offering different scenarios for participants to make
decisions on love and relationship using virtual characters. The information and values
embedded in the game are carefully developed by the Hong Kong Family Association with
reference to sex education in the curriculum of the Life and Society subject prepared by the
Curriculum Development Council in Hong Kong (Curriculum Development Council, 2010).
Each mini-game begins with an introduction to the aims and instructions, followed by one or
more scenarios with each of them styled in comic-strips-like animations. The key purposes of
the five mini-games are listed as follow:





“Love Q&A” - to gain better self-understanding for establishing a healthy love
relationship
“Intimacy Photo” - to learn to set and maintain intimate boundaries
“Escape from Sexual Impulse” - to understand about sexual impulse and considerations
in deciding whether to have sex or not
“Sorting out Safe Sex Knowledge” - to acquire safe sex knowledge including
contraceptives, emergency contraception and prevention of AIDS and sexually
transmissible diseases, as well as awareness of self-protection
“Rank your Options”– knowledge of options and support services in case of unplanned
pregnancy
Architectural Design
LimeJS, an HTML5 game framework is chosen to develop the iPad, Facebook and Web
versions of the game as it allows us to use one single code base for all three different versions.
MySOL database was used to record students’ game score. EdConnect from Hong Kong
Education City (http://www.hkedcity.net/english/) was utilized for user account management
for the IOS and web-based versions of the game.
Methodology
A series of game sessions and workshops for 1,176 secondary 1 to 3 students (between ages
12-16) in six co-ed schools were conducted in late 2013. To examine whether the game app
can enhance students’ safe sex knowledge, pre-test and post-test were embedded at the
beginning and at the end of the game. The two tests consist of six identical multiple choice
questions drawn from a pool of 12 questions related to safe sex knowledge covered in Stage 4
of the mini-game where students are asked to sort out correct safe sex knowledge. The pre-test
appears only once to each student account (i.e. first time player only). The post-test appears
when the player completes all mini-games. Students are free to play the game as many times
as they wish and the game scores are automatically recorded in the database. The pre-test and
the best post-test scores were selected for quantitative analysis. A total of 788 sets of pre-test
and post-test scores were collected. Drop-offs are due to incompletion of the entire game,
incompletion of the post-test or refusal of students or parents’ consent for using the data for
research purposes which resulted in some omission of the data.
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Students’ feedback on the value and effectiveness of the game were collected through
questionnaires and focus group interviews. A total of 1,124 questionnaires were collected.
Responses on the 6-point Likert-type scales were analyzed using SPSS version 20. A mean
score of 3.5 should be seen as neutral. Mean scores of 4.5 and above can be considered clearly
favourable; likewise, scores below 2.5 can be considered clearly unfavourable. Ten focus group
semi-structured interviews involving a total of 57 students were conducted. The interview data
were transcribed.
Results
To examine the effectiveness of the interactive game in enhancing students’ safe sex
knowledge, we first conducted a normality test on the data (n = 788). The results were negative
in both Shapiro-Wilk’s test (p < 0.001) and Kolmogorov-Smirnov’s test (p <0.001). Wilcoxon
signed ranks test was then applied and the results were summarized in Table 1 below:
Table 1. Wilcoxon signed ranks pre-test and post-test scores on safe sex knowledge
Post-test Score – Pre-test Score
Negative ranks
Positive ranks
Ties
Total
n
Mean Rank
Sum of Ranks
117
437
234
788
237
288
27822
125913
The finding indicates that 437 out of 788 students managed to answer more questions on safe
sex correctly after playing the games. The mean scores for the pre-test and post-test are 3.04
and 3.74, respectively. Such an improvement was found to be significant (p < 0.001). The
corresponding effect size is 0.477, indicating a medium effect size after playing the game, i.e.
more than a medium effect (= 0.3) and close to a large effect (= 0.5).
Among the 788 participants, 711 students played the game once, 71 played twice and the
remaining 6 students played three times or more. In order to examine whether students can
achieve a better score by playing the game twice, the same statistic was applied (n = 71). The
mean scores in the pre-test and post-tests are 3.44 and 4.68, respectively. The improvement
was significant (p < 0.001) with a large effect size (= 0.678).
The survey results (n =1124) shows that on average, students agree that the game is fun and
interesting (mean = 4.36). After playing the game, students believed that their ability to make
smart choices in relation to love and sex improved (Section 3: mean scores range from 4.54 to
4.66). In particular, a relatively high agreement is observed on items related to a better
understanding of the risk of sexual behaviors (item 2.9; mean = 4.89), the importance of coming
up with a consensus with their partners when seeking solutions for their problems (item 2.8;
mean = 4.79), and the importance of having the awareness and knowledge to protect themselves
(item 2.6; mean = 4.76). Similar results were obtained from the focus group interviews, which
are evident in the following students’ quotes: “I have learned how to protect myself and how
to have safe sex in order to reduce the chance of getting sexually-transmitted diseases”; “This
game has changed my previous misconception and attitudes towards sex”. “The scenarios and
stimulated conversations in the game are very realistic and can be applied to real life.”; and “I
think stage 3 is very meaningful because apart from reminding if we have the ability to handle
the consequences of having sex, there are also objects which might increase our desire for sex.
For example, sex magazines, and this lets us learn that we can control our desire for sex by
considering different factors.”
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Discussion
Through the interactive game, students had the opportunities to learn correct knowledge about
sex and practice making smart choices on sex and relationships in an interactive and safe
environment. Findings from the quantitative data and the preliminary qualitative analysis
indicate that students’ experience and feedback on the game is positive. Not only did students’
knowledge on safe sex and prevention of sexual transmission diseases are enhanced, their
awareness of self protection and respecting others’ choices are also strengthened.
The holistic approach in the game development and the medium of delivery could be possible
reasons for the positive outcomes observed in this study. By involving experts, key
stakeholders, and partners from Family Planning Association through a participatory design,
key content and the game framework were established and assured. With usability testing and
heuristic evaluation, important design and improvements of the game were made certain. The
collaborative efforts in this study have shown to be critical for the game’s quality assurance.
Game-based learning has shown to provide a risk-free and highly engaging environment in
which students can learn, experiment, and make decision in stimulated situations (Trybus 2014).
It can also provide successful experiences for students. (Betz & Schifano, 2000; Luzzo et al.
1999). In a conservative culture where topics relating to sex is not openly discussed or taught
by parents (Chang, 1991; Okazaki 2002), this innovative game-based approach to disseminate
sex education is found to be effective.
Conclusion
“Making Smart Choices” is a pioneer sex education Mobile App with great educational value
in promoting correct sex knowledge and promote positive attitudes towards sex and
relationship for youngsters. Given that discussions on sex is still taboo in much of the Asian
regions and among families with Chinese origins, we see a great value of our game in
promoting sex education for teenagers in Mainland China, Macau, Taiwan, and other Chinese
speaking teenagers worldwide.
Future educational game developers may consider adopting the participatory design approach
involving end users, experts and stakeholders in the game development process. “Making
Smart Choices” can be translated into different languages and adopted by non-Chinese
speaking countries or regions. Being a self-paced and easily accessible learning tool, “Making
Smart Choices” can reach adolescents without limits.
Acknowledgment
We are extremely grateful to the participants and schools for assisting us with this research
project. We would also like to acknowledge the government Health Care and Promotion Fund
(HCPF) for providing the financial support for this project.
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References
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Betz, E. & Schifano, R. (2000). Evaluation of an intervention to increase realistic selfefficacy and interests in college women. Journal of Vocational Behavior, 56, 35–52.
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York, NY: Penguin Books Ltd.
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Methods. New York, NY: John Wiley & Sons, pp. 25-61.
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http://www.nngroup.com/articles/usability-101-introduction-to-usability/
Okazaki, S. (2002). Influences of culture on Asian Americans’ sexuality. Journal of Sex
Research, 39(1), 34-41.
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Appendix 1
Usability Test on HCPF Sex education Game
This is a pilot test for evaluating the human-computer interaction design of the HCPF Sex
Education Game. Each user is expected to spend no more than 1 hour for the entire test. The
users have to run through the entire game without assistance. After the user has completed the
objectives of the walk-through test, the observer will ask him/her questions on various areas
regarding the gameplay.
Walk-through Test
They have to speak out their thoughts (“think aloud”) when using the game application and the
test observer will observe the user and take notes. The observer will demonstrate to the user
how to “think aloud”. When the user forgets, the observer will remind him/her to think aloud
(explain why he does certain things, e.g. why he makes a certain selection; saying what he sees,
presses, enters).
Sequence:
1. Game Launch: The user should launch the game application and watch the opening
animation. The user shall start the game using the button at the main menu at his
discretion.
2. Login: The user will be given a set of login ID and password for the HKEdCity
EdConnect authentication system. The user has to login to the game using this set of
credentials. Do not provide assistance unless the user has spent unnecessarily long period
of time.
Login ID: xxxx
Password: xxxx
3. Gender and Character Selection: The user should select his/her gender and character in
the game. Do not hint the user.
4. Aim Selection: The user should select his/her aim in the game. Do not hint the user.
5. Pre-Test: The user should answer the 10 questions presented in the test. Do not hint the
user. Record the date and time for the pre-test.
6. Stage 1: The user should proceed the character dialogs and answer 4 questions within the
time limit. Do not hint the user.
7. Debriefing Page of Stage 1: The user should read and proceed to the next Stage. Do not
provide assistance unless the user has spent unnecessarily long period of time.
8. Stage 2: The user should complete the 2 rounds of phototaking. Do not hint the user.
9. Stage 3: The user should explore the rooms and control the desire level bar within the
time limit. Do not hint the user.
10. Debriefing Page of Stage 3: The user should read and proceed to the next Stage. Do not
provide assistance unless the user has spent unnecessarily long period of time.
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11. Stage 4: The user should complete the 6 questions within the time limit. Do not hint
the user.
12. Stage 5: The user should complete the ranking puzzle within the time limit. Do not
hint the user.
13. Ending Page: The user should read and proceed to the final result page. Do not
provide assistance unless the user has spent unnecessarily long period of time.
14. Post-Test: The user should answer the 10 questions presented in the test. Do not hint
the user. Record the date and time for the post-test.
15. About Page: Instruct the user to enter the About Page in case he has not gone through
it yet.
Questions to the User
When the user has completed the walk-through, the observer will ask the user to comment on
the following:
1. (Content) Do you find any difficulty in achieving the objectives of the game?
2. (Content) Do the debriefing messages at the end of the stages help you understand
more on sex and relationships?
3. (Content) Do you think you have enough time to read and play with the time limit?
4. (Design) Does the game make good use of colour? Is there anyway we can improve?
5. (Design) Is the text in the game appropriately sized and easy to read? Is there anyway
we can improve?
6. (Design) Do you find it easy to proceed to the next steps in the game? Is there anyway
we can improve?
7. (Technical Issues) Have you discovered or experienced any glitches that make a less
satisfactory gaming experience?
8. (Technical Issues) If the user has spent too much time and required observer
intervention: What difficulty did you experience in _________ ?
9. Do you have any other comments on the game?
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Appendix 2
Heuristic Evaluation on HCPF Sex education Game
Comment Sheet
Name of Evaluator:
Date:
Game Version (Delete as appropriate): iPad / Facebook / Web
Browser and Version Used (Facebook or web only):
10 Usability Heuristics for User Interface Design (Nielson, 1994)
(http://www.nngroup.com/articles/ten-usability-heuristics/)
Visibility of system status
The system should always keep users informed about what is going on, through
appropriate feedback within reasonable time.
Comments:
Match between system and the real world
The system should speak the users' language, with words, phrases and concepts
familiar to the user, rather than system-oriented terms. Follow real-world
conventions, making information appear in a natural and logical order.
Comments:
User control and freedom
Users often choose system functions by mistake and will need a clearly marked
"emergency exit" to leave the unwanted state without having to go through an
extended dialogue. Support undo and redo.
Comments:
Consistency and standards
Users should not have to wonder whether different words, situations, or actions mean
the same thing. Follow platform conventions.
Comments:
Error prevention
Even better than good error messages is a careful design which prevents a problem
from occurring in the first place. Either eliminate error-prone conditions or check
for them and present users with a confirmation option before they commit to the
action.
Comments:
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Recognition rather than recall
Minimize the user's memory load by making objects, actions, and options visible. The
user should not have to remember information from one part of the dialogue to
another. Instructions for use of the system should be visible or easily retrievable
whenever appropriate.
Comments:
Flexibility and efficiency of use
Accelerators -- unseen by the novice user -- may often speed up the interaction for
the expert user such that the system can cater to both inexperienced and experienced
users. Allow users to tailor frequent actions.
Comments:
Aesthetic and minimalist design
Dialogues should not contain information which is irrelevant or rarely needed. Every
extra unit of information in a dialogue competes with the relevant units of
information and diminishes their relative visibility.
Comments:
Help users recognize, diagnose, and recover from errors
Error messages should be expressed in plain language (no codes), precisely indicate
the problem, and constructively suggest a solution.
Comments:
Help and documentation
Even though it is better if the system can be used without documentation, it may be
necessary to provide help and documentation. Any such information should be easy
to search, focused on the user's task, list concrete steps to be carried out, and not be
too large.
Comments:
Other Comments:
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