the document - Health Interventions (SASH)

Tackling Sensitive Issues using a
game-based environment: Serious
Game for relationships and sex
education (RSE)
Katherine Browna, Sylvester Arnabb, Julie Bayleya, Katie Newbya, Puja Joshia, Becky
Judda, Alison Baxtera, & Samatha Clarkeb
Applied Research Centre for Health & Lifestyle Intervention, Coventry University
Serious Games Institute, Coventry University
Abstract. Experience of sexual coercion during adolescence can lead to a range of
adverse psychological and physical health outcomes. Working to eliminate
coercive sexual experiences for young people is therefore important for enhancing
wellbeing in this population. Delivering good quality relationships and sex
education (RSE) can help to achieve this aim. Engaging young people on sensitive
subjects such as this can be challenging and using Serious Gaming technology
may help educators and young people to overcome this. This paper describes the
use of Intervention mapping (IM) in the development of a serious game on the
topic of sexual coercion for RSE. IM is an iterative process that draws on
stakeholder engagement and the theory and evidence base for what works, to
support health improvement intervention planning. Serious game developers took
the game concept plan and transformed it into an interactive game show, led by a
teacher or facilitator to engage students in game play and discussion around the
issue of sexual coercion. The final product known as PR:EPARe (Positive
Relationships: Eliminating Coercion and Pressure in Adolescent Relationships) is
currently the subject of a cluster Randomised Controlled Trial (RCT) in local
schools which will assess whether change objectives relating to psychological
preparedness to deal with sexual coercion has improved compared with controls.
This works represents the first attempt to use IM in the development of a Serious
Game and the use of Serious Gaming for RSE delivery. Stakeholders are
supporting plans for sustainability of the product once RCT results are established.
Keywords. Serious game; Relationships & Sex Education; Sexual coercion;
Intervention Mapping; adolescents.
Experience of sexual coercion during adolescence can lead to a range of adverse
psychological and physical health outcomes. There is a strong link between incidence
of sexual coercion in young people and increased sexual risk-taking, rates of sexually
transmitted infections (STIs) and unwanted or unintended pregnancy. Working to
reduce and eliminate coercive sexual experiences amongst adolescents and young
people is therefore an important component of approaches needed to enhance sexual
health and wellbeing in this population. Delivering good quality relationships and sex
education (RSE) in schools and other educational settings, can help to achieve this aim.
Within the UK there is growing determination that RSE ought to not only provide
young people with knowledge about reproduction, contraception and prevention of STI
transmission, but also tackle issues related to the nature of sexuality and relationships.
It should encourage the acquisition of skills and attitudes which allow pupils to manage
their relationships in a responsible and healthy manner. In addition, one of the
challenges of delivering RSE is to do so in a way that both engages the young people
involved and draws on the evidence-base about what will work to ensure positive
With this perspective, we aimed to capitalise on the ability of games technologies
to engage target audiences who may already use interactive technology recreationally;
conveying instructional outcomes to audiences who may sometimes be more resistant
to formal teaching methods. We aimed to assess whether an interactive Serious Game
could have a positive influence on outcomes for RSE and to draw on the theory and
evidence-base for supporting learning and behavioral change in the development
2. Methods
An Intervention Mapping approach (Bartholomew et al., 2011) was applied to the
development and design of the Serious Game. Needs assessment was conducted with a
range of stakeholders which included input from young people (n=25), sexual health
service (n=4) and local authority commissioners (n=5), and those involved in sexual
health education (n=6). Over the course of several meetings, stakeholders identified
experience of pressure/coercion in sexual relationships as a priority topic for RSE.
They identified Year 9 students (aged 13-14 years) as the priority target group for
RSE on this topic. An ongoing and iterative process of further stakeholder
engagement, and systematic literature review led to the development of a series of
change objectives (e.g. Young people will be able to recognize different types and
levels of coercion; young people will develop an expectation that there will be negative
consequences of allowing coercion to continue) for the serious game and evidencebased techniques that would directly address the change objectives were scoped out
and applied in the concept design. Throughout the process stakeholders were updated
on progress and asked to feedback and provide input and ideas.
Once the concept was fully conceived it was passed to the Serious Game
developers for translation into an interactive game. A script to apply to the game was
developed and young people from the local stakeholder groups auditioned to provide
game audio for characters’ voices.
User engagement and usability within a classroom context were major priorities
for the development build. A combination of highly stylized 3D and 2D graphics and
characters with audio based interaction have been used to create a dynamic game to
build and maintain motivation to play. Conceptually, the user is placed within a high
fidelity game show environment, providing an entertaining platform in which the
subject matter is addressed. Adopting this mechanic, PRE:PARe avoids type heavy
interfaces which can gradually decrease attention in users. Allowances for group
discussions as are also integrated within the game mechanics through use of a pause
button. A timer supports pace-setting and a menu function puts control in the hands of
the educational facilitator in selecting the most appropriate content for their students. A
scoring system mechanic supports the provision of feedback to game players and helps
to build a sense of purpose and achievement. By applying these specific games
mechanics, PRE:PARe provides a virtual educational platform that attempts to
maximise usability and engagement for both user and educationalist.
The final product is known as PR:EPARe (Positive Relationships: Eliminating Pressure
and coercion in Adolescent Relationships). PR:EPARe is currently the subject of a
cluster randomised controlled trial (RCT) in RSE lessons across 3 secondary schools in
Warwickshire. It is predicted that young people in the intervention condition will
demonstrate greater psychological preparedness, in-line with our identified change
objectives, for recognising and responding to sexual coercion, compared with controls.
Data collection will be completed during March 2012 and results will be available from
April 2012 and included in subsequent dissemination.
This work represents the first application of an Intervention Mapping approach to the
development of a Serious Game. The process brings together the expertise of a range of
stakeholders and partners to produce a unique and innovative tool for improving
wellbeing in young people. Provided RCT results demonstrate a positive effect, the
PR:EPARe serious game will become part of RSE provision in extended learning
centres and schools in Coventry and Warwickshire from September 2012. The
PR:EPARe project team are working to ensure the game has a sustainable impact on
local RSE delivery. We are working on early commercialization plans that may help to
further improve and develop the game and develop further resources to address wider
RSE relevant issues.
Bartholomew, L.K., Parcel, G.S., Kok, G. et al (2011). Planning Health Promotion
Programs: An Intervention Mapping approach. 3 rd edition. Jossey-Bass: San Francisco.