Cited As: Chu, S.K.W., Kwan, A., Reynolds, R., Mellecker, R.R., Tam, F., Lee, G., Hong, A.,
& Leung, C.Y. (in press). Promoting sex education among teenagers through an interactive
game: Reasons for success and implications, Games for Health Journal.
Promoting sex education among teenagers through an
interactive game: Reasons for success and implications
Sam Chu1, Alvin Kwan1, Rebecca Reynolds2, Robin R. 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
Corresponding author:
Samuel Kai Wah Chu, Ph.D.
Associate Professor
Head, Division of Information & Technology Studies
Deputy Director, Centre for Information Technology in Education
Faculty of Education, The University of Hong Kong
Pokfulam Road, Hong Kong
Tel: (852) 2241-5894
Fax: (852) 2517-7194
E-mail: samchu@hku.hk
Article type: Original Research
Keywords: Sex education, e-learning, adolescents, game design
Abstract Word Count: 235
Word count: 2,908
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Abstract
Objectives: A game app “Making Smart Choices” (MSC) was developed to fill the gap of
limited easy-to-access resources available on sex education in Hong Kong and to disseminate
correct knowledge and positive attitudes towards sex to teenagers using popular platforms
such as iPad, Facebook and the web.
Subjects and Methods: Three versions of the game (iOS, Facebook and web-based) were
developed using HTML5. A theoretical framework, which involved game-based learning and
participatory design approach was used to design, develop, modify and optimize the game for
use with secondary school students (n = 1,176) aged 12-16 years. Pre-and-post test scores of
students’ safe sex knowledge were compared to test the feasibility of the game. Students’
survey and interviews were analyzed to assess participant feelings and attitudes towards the
game.
Results: Wilcoxon signed rank test indicated that students’ sex knowledge (n =778) improved
with a medium effect size (0.477) after playing the game. An increase in positive attitudes
towards sex and relationship, and awareness of making smart sexual choices were reported
from student surveys and interviews. Students described the game as “interesting”,
“interactive”, “informative” and “real-to-life”.
Conclusions: We advocate that the participatory design approach, which supports
collaboration effects of different stakeholders is an effective framework for developing gamebased learning tools for sex education. Our work provides preliminary findings that suggest
game-based learning, preferably delivered through popular interactive platforms, can be
effective in promoting sex education to teenagers.
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Introduction
Sex education in Hong Kong has been integrated into primary and secondary educational
curriculum for many years, yet efforts to provide quality sex education have been limited and
largely unsuccessful.1 A recent survey conducted by the Hong Kong government with 134
secondary schools, indicated that sex education in junior secondary school level (ages 12 - 16)
is limited to an average of three to four school hours. Limited time and space for sex
education programs coupled with the lack of documented policy, learning and teaching
resources as well as ill equipped teachers are constraints for successful sex education
programs in schools.2. The lack of sex education is further confounded by traditional Chinese
values that limit discussions about healthy sexual behaviors in the home environment.3,4
Engagement in underage sexual intercourse, un-protective sex and limited knowledge of
contraceptive methods have become increasingly apparent among youths in Hong Kong.5,6
According to a recent report published by the Hong Kong Family Planning Association
including the views of 2,934 adolescents, 7 percent of teenage girls and 10 percent of teenage
boys (average age 16.2) have experienced sexual intercourse.7 Remarkably, the mean age of
first sex experience for boys and girls was reported to be at the ages of 14.6 and 15.3 years
respectively7. Among the adolescents reporting sexual intercourse experiences, 22.5 % had
not used contraceptive measures. These sexual behaviors could increase health risks such as
the spread of sexually transmitted infections and unwanted pregnancy.
Although educational resources for sex education are available, attractive and easily
accessible materials specifically tailored for young Hong Kong adolescents remain scarce.
The potential to tap into a popular and attractive learning tool appears to be a promising
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educational approach and could be an effective tool in promoting sex education among ‘Net
Generation’ adolescents drawn to technology and video gaming. In a conservative culture
where topics relating to sex is not openly discussed or taught by parents,3,4 the game-based
approach may also provide a risk-free, non-threatening and highly engaging environment in
which students can learn, explore, experiment, and make decisions in stimulated situations 8-9.
Through this interactive game-based medium, learning potential is maximized.10.
The primary aim of this paper is to describe the development of game-based learning using
participatory design approach and the application of the developed game “Making Smart
Choices” (MSC). Our secondary aims were: 1) elicit adolescents’ greater knowledge and
awareness about sexually transmitted infection prevention; 2) promote knowledgeable
decision-making regarding healthy sexual practices in a fun and interactive way; 3) test the
effectiveness of the game in helping students to acquire safe sex knowledge and to establish
healthy attitudes in handling relationships.
Methodology
“MSC” Development Strategy: Game-based Approach with Participatory Design
In order to increase uptake and learning, sex education should be delivered in a manner that is
engaging as well as culturally and socially relevant to the targeted population. As social
networking has become an increasingly popular activity for Hong Kong adolescents, smart
devices and platforms present vast potential in attracting the attention of Hong Kong
adolescents. We developed “MSC” for use on iPad, the social networking site Facebook, as
well as the web to enable wide dissemination of the game through social networking and
smart devices commonly used by adolescents. While the iPad and the web versions require
registration with a student account to a local educational website, the Facebook version was
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made
widely
available
for
all
interested
adolescents
at
https://apps.facebook.com/fpasmartchoices.
Acceptability, usability and utility are three critical dimensions for effective use of
technologies in education contexts. While acceptability refers to users’ views on the value of
technology (or a game) in fostering learning, e.g. whether the game content is relevant and
the cost is reasonable, whereas usability relates to the user friendliness and effectiveness of
the technology (or game interface) in a given learning context. Utility on the other hand, is
relevance of the tasks in relation to the target outcomes11. These three dimensions can be
recognized through the application of participatory design approach, a methodology
emphasizing the active role of users in the design process12 as well as expertise of different
stakeholders to design, develop, and refine the targeted product.13 The theoretical framework
which guided the development of the game along with its targeted learning outcomes is
presented in Figure 1 below:
Figure 1: A theoretical framework of game-based approach with participatory design
for designing a sex education game
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As indicated in Figure 1, the game content was designed by experts from the Hong Kong
Family Planning Association with experience in developing and disseminating multimedia
resources on sex education. Academics with extensive expertise in education and health
science were responsible for aligning the game content with targeted learning outcomes.
Computer and information science experts provided suggestions on the game framework,
game structure and mechanism, thereby contributing to the acceptability and utility of the
game. The game was developed with target learning outcomes adopted from the International
Technical Guidance on Sexuality Education17. Overall, the information and values embedded
into the game messages fall in line with the learning points related to sex education in the
curriculum of the Life and Society subject prepared by the Curriculum Development
Council18 in Hong Kong. Advanced graphics in the game were created by a software vendor,
Fifthwisdom Technology Limited, specialised in education game development. Usability
tests14-15 with the target users (adolescents) were conducted during different phrases of game
development. Heuristic evaluation16 conducted by computer science experts and experienced
web users were also included.
Game Structure
The app consists of five mini-games offering different scenarios for participants to make
decisions using chosen virtual characters. All the mini-games share a similar structure (see
Figure 2). 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. In each
scenario, the player is given a few choices and is required to choose his/her desired response
to the specific scenario. Educational messages relevant to the scenarios and in response to the
students’ choices are shown after all scenarios of a mini-game are completed.
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Figure 2: Key screen shots of the mini games
The descriptions of mini-games are provided below:
Mini-game 1: Love Q&A
Goal: To gain a better self-understanding for establishing a healthy love relationship.
Description: The player (virtual character) is required to choose his/her desired response
from different scenarios, which involve conflicts with love and relationships.
Mini-game 2: Intimacy Photo
Goal: To set and maintain intimate boundaries and respect the feelings of others.
Description: The player is asked to set the maturity of a relationship (e.g. beginning with
courtship for a few days) for the virtual characters of opposite sexes. The player then selects a
gesture and the physical distance between the two characters. The player takes a photograph
by clicking a camera icon. An educational message is displayed and explains the impact and
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feelings of the virtual characters with respect to the gestures and physical distance set by the
player.
Mini-game 3: Escape from Sexual Impulse
Goal: To understand sexual impulse and considerations prior to engaging in sexual behavior.
Description: Two virtual adolescents in courtship want to watch a DVD movie at home. In
search for the misplaced DVD, the player is required to click on different objects in the living
room and bathroom. When the objects are selected by the player, the character’s impulse for
sex increases or decreases depending on what kind of object is chosen. For example, the
entertainment magazine with photos of sexy images on the bathroom floor increases the
impulse whereas watermelon in the living room decreases the desire for sex. The objective of
the mini-game is for the player to maintain a medium level of sexual impulse.
Mini-game 4: Sorting out Safe Sex Knowledge
Goal: To acquire safer sex knowledge including contraceptives, prevention of sexually
transmissible infections, and awareness of self-protection.
Description: In this mini-game, the player is required to identify correct sex knowledge or
advice suggested by his/her Internet friends by clicking the “like” icon. If the player liked
advice that was incorrect an instant message is displayed with an explanation of why the
advice is incorrect.
Mini-game 5: Rank Your Options
Goal: To be aware of available support services and options in the event of unwanted
pregnancies
Description: This mini-game begins with the players’ friend carrying an unwanted pregnancy.
The player is required to identify various information sources, help, and appropriate options
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for his friend by choosing the icons associated with different sources of assistance such as
Family Planning Association, social workers, parents, etc.
Figure 3: Screenshots of the 5 mini-games
Architectural Design
LimeJS, an HTML5 game framework used for building games for modern touchscreens and
desktop browsers, was chosen as the basis for the development of MSC. A single code base
was used for all three different versions of the game, iOS, Facebook and web-based version.
MySQL database was used for keeping track of the players’ data and behavior in the game.
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To minimize workload on the user account management for the iOS and web-based versions
of the game, a single sign-on solution was integrated into EdConnect from Hong Kong
Education City (http://www.hkedcity.net/english/).
Game Evaluation
To evaluate the effectiveness and acceptance of the app among teenagers, a series of game
sessions for 1,176 secondary school students (ages 12-16) in six co-ed schools were
conducted. Prior to data collection and analysis, informed consents were sought from both the
parents and students, and the institutional board granted ethics. Schools were recruited
through convenience sampling. Each game session lasted for approximately an hour and
participation was voluntary. Students were allowed to play as many times as they liked in the
game session. Pre-test and post-test were embedded at the beginning and at the end of the
game. Each test consisted of six identical multiple choice questions drawn from a pool of 12
questions related to safer sex knowledge that are covered in the mini-game, “Sorting out Safe
Sex Knowledge”. The pre-test was accessible only once for each student account. The posttest appeared once the player completed all five mini-games. Once the tests were complete,
the test scores were automatically recorded into the database. For students who played the
game more than once, their highest post-test scores were used for analysis. A total of 788 sets
of pre-test and post-test scores were collected. The total number is smaller than the actual
number of students who played the game because data from students who did not submit their
consent forms was excluded in the analysis and some students did not complete the post-test
at the end of the game.
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.
For the purpose of our analysis, a mean score of 3.5 was considered neutral. Mean scores that
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were higher than 4 were regarded as edging toward positive, while mean scores lower than 3
were regarded as edging toward negative feedback. Ten focus group semi-structured
interviews involving a total of 57 students were conducted. The interview data were
transcribed and common themes and quotes were recorded.
Data Analysis
Means and standard deviations were calculated and reported for all variables. Data was
analyzed using SPSS version 20. To examine the effectiveness of the interactive game in
enhancing students’ safer sex knowledge, we first conducted normality tests, Shapiro-Wilk’s
test and Kolmogorov-Smirnov test on the game score data (n = 788) and followed up the
analysis with Wilcoxon signed ranks test, a non-parametric test, as questionable normality of
data was found. We calculated the effect size by dividing the Z score by the square root of the
sample size: r = Z/sqrt(N). We used the standard values for r 0.1, 0.3 and 0.519 to substantiate
our results.
Results
The results of the Wilcoxon signed ranks test, the means, standard deviations as well as
affects size for pre and post-test are summarized in Table 1.
Table 1: Pre-test and post-test scores on safer sex knowledge of students using Wilcoxon
signed ranks test
Student group
n
Mean pretest score
Played once
711
3.00
3.63
<.001
0.449
More than once
77
3.42
4.69
<.001
0.688
All
788
3.04
3.74
<.001
0.477
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Mean posttest score
p
Effect size
Among the 788 participants, 711 students played the game once, 77 played more than once.
Difference between pre and post-test scores for the whole group (group that played once +
the group that played more than once) was significant (p <0.001) with a medium effect size
of 0.477. The result indicates that a relatively larger improvement in the mean scores was
found on students who played the game more than once. The mean difference for the two
groups is 0.63 and 1.27, respectively. A larger effect size (0.679) is also noted for students
who played the game more than once.
Key results of the survey supplemented with quotes from the student interviews are shown
below. On average, students agreed that the game was 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), For instance, a
student said, “I find out that there are a lot to be considered before having a decision on
having sex, for example, my family…and many other factors,” and another student reported,
“I’ve learned that I shouldn't be affected by others easily. I have to think carefully before
taking any actions, even though friends around me have had sex before”. A relatively high
agreement was also 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). Corresponding quotes from students include: “I have learned how to protect myself
and how to have safer sex in order to reduce the chance of getting sexually-transmitted
infections”, “Through this game, I have learned how to response/reject others’ (sexual)
requests. We can solve problems or reject others through better communication”, “Lots of fun
and it can enhance of my knowledge of self-protection” and “It is good to learn by going
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through different scenarios in the game so that we know what we should do if we encounter
similar situations in the future.”
Discussion
The participatory design, which emphases the active role and collaboration of key
stakeholders used in this study enhanced acceptability, usability and utility of the MSC game.
These components of the theoretical framework are critical for effective application of
technologies in education contexts. Collaboration of stakeholders has been shown to be
useful in promoting health communication interventions21,
22
and effective in handling
forceful or threatening actions limiting the chances of sexual coercion.23 For this project,
collaborators included an interdisciplinary team of researchers, experts and community
partners with varied expertise in education, health and wellness, sex education and game
development. This collaboration of a wide range of experts, stakeholders and partners
facilitated important design improvements on the game interface, mechanism, and game
instruction for students. The preliminary findings indicate that many students discussed the
game experience in positive terms. Students’ favorable perception of the game as well as an
increase in positive attitudes towards sex and relationships, and awareness of having safer sex
practices and making smart sexual choices reported in the surveys and interviews suggested
that participation of the game session could result in positive influences over future decisionmaking.
Games provide a safe, risk-free simulated environment in which students can experiment,
play, practice decision-making, and test scenarios, with minimal deleterious consequences.
“MSC” is a self-paced learning tool that helps students gain correct knowledge and positive
attitudes towards sex in a fun and interactive way. This innovative approach is attractive in a
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conservative culture, which avoids discussions and topics in reference to sex.4 The results are
particularly significant to the studied population given the limited knowledge on healthy
sexual behavior amongst adolescents in Hong Kong and the lack of appealing tools to teach
sex education in this vulnerable population.
Conclusion
The game app MSC was developed to fill the gap of limited easy-to-access resources
available on sex education in Hong Kong and to disseminate correct knowledge and positive
attitudes towards sex to teenagers using popular platforms such as iPad, Facebook and the
web. This pioneer Chinese language interactive game on sex education has been well
received among Hong Kong adolescents since its introduction. The game-based affordances
of this game has led to positive changes in students’ safe sex knowledge (particularly in those
who repeat gameplay), with student responses indicating a link between gameplay and
potential for behavior change. Given that discussions on sex is still taboo in much of the
Asian regions and among families with Chinese origins, there is great potential for the
“MSC” game in promoting sex education for teenagers in Mainland China, Macau, Taiwan,
and other Chinese speaking teenagers worldwide.
A limitation of our study is that we only collected self-report measure on students’ perceived
usefulness of the game for sex education as assessing sex behavior change using objective
assessment tools is outside the scope of our current study and is noted to be challenging24.
Examining the extent to which “MSC” can lead to actual behavior changes is warranted.
Future educational game developers may consider adopting the participatory design approach
involving end users, experts and stakeholders in the game development process. The current
version of “MSC” was developed for the Hong Kong population. Translation into other
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languages and adaption of the game content according to the laws and culture of particular
countries would widen the outreach into non-Chinese speaking countries/regions.
Acknowledgment
We are grateful to the participants and schools for assisting us with this research project. We
would also like to acknowledge the government’s Health Care and Promotion Fund (HCPF)
for providing the financial support for this project.
Author Disclosure Statement
No competing financial interests exist.
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