Access the full text.
Sign up today, get DeepDyve free for 14 days.
Loading next page...
/lp/jmir-publications/development-of-a-mobile-game-to-influence-behavior-determinants-of-hiv-tukrXOvdbV
- Publisher
- JMIR Publications
- Copyright
- Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
- ISSN
- 2291-9279
- DOI
- 10.2196/13695
- Publisher site
- See Article on Publisher Site
Abstract
Background: Opportunities in digital distribution place mobile games as a promising platform for games for health. However, designing a game that can compete in the saturated mobile games market and deliver persuasive health messages can feel like an insurmountable challenge. Although user-centered design is widely advocated, factors such as the user’s subject domain expertise, budget constraints, and poor data collection methods can restrict the benefits of user involvement. Objective: This study aimed to develop a playable and acceptable game for health, targeted at young key populations in the Philippines. Methods: Authors identified a range of user-centered design methods to be used in tandem from published literature. The resulting design process involved a phased approach, with 40 primary and secondary users engaged during the initial ideation and prototype testing stages. Selected methods included participatory design workshops, playtests, playability heuristics, and focus group discussions. Subject domain experts were allocated roles in the development team. Data were analyzed using a framework approach. Conceptual frameworks in health intervention acceptability and game design guided the analysis. In-game events were captured through the Unity Analytics service to monitor uptake and game use over a 12-month period. Results: Early user involvement revealed a strong desire for online multiplayer gameplay, yet most reported that access to this type of game was restricted because of technical and economic constraints. A role-playing game (RPG) with combat elements was identified as a very appealing gameplay style. Findings guided us to a game that could be played offline and that blended RPG elements, such as narrative and turn-based combat, with match-3 puzzles. Although the game received a positive response during playtests, gameplay was at times perceived as repetitive and predicted to only appeal to casual gamers. Knowledge transfer was predominantly achieved through interpretation of the game’s narrative, highlighting this as an important design element. Uptake of the game was positive; between December 1, 2017, and December 1, 2018, 3325 unique device installs were reported globally. Game metrics provided evidence of adoption by young key populations in the Philippines. Game uptake and use were substantially higher in regions where direct engagement with target users took place. Conclusions: User-centered design activities supported the identification of important contextual requirements. Multiple data collection methods enabled triangulation of findings to mediate the inherent biases of the different techniques. Game acceptance is dependent on the ability of the development team to implement design solutions that address the needs and desires of target users. If target users are expected to develop design solutions, they must have adequate expertise and a significant role within http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al the development team. Facilitating meaningful partnerships between health professionals, the games industry, and end users will support the games for health industry as it matures. (JMIR Serious Games 2019;7(4):e13695) doi: 10.2196/13695 KEYWORDS HIV; video games; health communication; persuasive communication; games; experimental; user-centered design health services [14]. A recent meta-analysis of 54 digital games Introduction for healthy lifestyle promotion found small but significant effects on behavior, determinants, and clinical outcomes, The Philippines’ HIV Epidemic demonstrating the potential benefits [15]. The Philippines has the fastest growing HIV epidemic in the Mobile games contain structural elements that effectively engage Southeast Asia region. The dominant mode of transmission users [16], and it is through these elements that mobile games reported in the Philippines is sexual contact among males who could influence behavior determinants. Players can model have sex with males (MSM) and transgender women (TGW). health-related behavior and witness positive and negative As of 2017, the Joint United Nations Programme on HIV and outcomes within a safe environment. Well-designed narratives, AIDS reported the HIV prevalence rate at 0.1% for general adult integrated with the gameplay, can foster identification with the population (aged 15-49 years), 0.3% among young men (aged characters, thereby increasing a player’s sense of personal risk 10-24 years), 4.9% among MSM, and 1.7% among TGW [1]. or self-efficacy in overcoming barriers to HIV services [17]. Specific data for TGW are limited [2]; however, a Positive portrayals of characters living with HIV may help form cross-sectional study in Cebu City in 2015 showed an 11.8% beliefs that players can also remain or become their desired self HIV prevalence rate in this group [3]. Cases are forecast to triple after a positive diagnosis. Influence may also be found from in the next 10 years, with the majority of new infections among the complex interplay between digital gaming and social young MSM (aged 15-24 years) [4]. Since the first reported behavior [18]. Even a single-player mobile game can trigger case in 1984, the National HIV/AIDS and Antiretroviral Therapy meaningful social interactions, from recommending a new game Registry of the Philippines has confirmed 59,135 cases as of to offering advice on how to complete a challenge. For example, September 2018, of which 28% were aged between 15 and 24 a player may recommend the game to a peer or family member years and 51% were aged between 25 and 34 years at the time who they believe could benefit from the health-related content. of diagnosis. The proportion of HIV-positive cases in the 15- Narratives and characters within the game could also trigger to 24-years age group has almost tripled in the last 10 years [5]. meaningful conversations within social groups. Such use of the Young key populations worldwide pose a complex public health game could generate social pressure about health-related challenge; transmission rates are high, diagnosis is often behavior. delayed, and linkage to care and treatment is poor among those A Need for User-Centered Design in Games for Health found to be infected [6]. Barriers to HIV services vary across contexts. In the Philippines, intrapersonal and social barriers Rittel and Webber [19] defined the term wicked problem as a exist alongside health system and economic barriers. Recurring design problem that cannot be solved in a stepwise themes associated with barriers to HIV services in the literature problem-solving manner. Game development is riddled with include low perceived risk of HIV infection; fear of losing wicked problems. They are inherently interactive, and any access or status in important social spheres as a repercussion of interactive component must be tested with users. Even a simple accessing HIV services; lack of awareness or negative game has an interconnected system as its backbone; any change perceptions of treatment; belief that clinics do not provide to 1 component of the game will have ramifications to all confidential or private services; and restricted access to testing connected components. Furthermore, game development is services because of time constraints, economic constraints, and bound by countless budget, technical, user, and market legal constraints for those aged under 18 years [7-11]. constraints. As a solution to wicked problems, some game developers turned to user-centered design [20]. User-centered Why Play Mobile Games? design is an iterative process; using a range of research As the HIV epidemic worsens, social changes are occurring for techniques, feedback is obtained from users at different stages young people in the Philippines. Increased online connectivity, of product development to ensure their needs and preferences a growing economy, and prevalent mobile device use has are considered in the design [21]. This design approach was changed the way people spend their time and socialize. This established in the software industry to identify and rectify change has generated new possibilities for the public health usability issues and expanded for use in game design to evaluate sector to deliver targeted health messages [12]. Utilizing experiential aspects, supporting the development of games that technology already popular among adolescents and young adults are both functional and fun. User involvement in game design may provide access to individuals who do not otherwise engage may have benefits with regard to the effectiveness of the game, with traditional forms of HIV education and advocacy [13]. although the evidence is mixed when reviewed in the context Mobile games, in particular, offer a promising platform to of games for healthy lifestyle promotion [22]. The core principle address the knowledge gaps, perceptions, social pressure, and behind this theory is that, for a game to be effective, it must be self-stigma that deter young key populations from accessing acceptable and appropriate. This can only be achieved through http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al consultation with target users, especially if the developers do research with target users and HIV service providers in the not share the same characteristics as them. User involvement regions of Davao and Manila. Data were collected through focus is also predicted to improve user adoption and enable developers group discussions (FGDs) with HIV services providers, in-depth to critically reflect on the value and consequences of a game interviews with MSM and TGW, and an online survey on when vulnerable groups are involved [23]. Thus, user-centered enablers and barriers to HIV services. Findings from the design methods must encompass interpretation and emotional formative research are not included in detail in this paper. The response to health-related content in the game as well as framework references modifying factors relevant to the evaluating usability. Philippines’ HIV testing context such as health system and legal and economic constraints. Given that the target audience for As the purpose of our game expanded beyond entertainment, the game will be young MSM and TGW, we do not expect the we developed a theory of behavior change (Figure 1) to guide game to impact modifying factors but note that these are the design process [24]. Context-specific learning objectives important considerations in the evaluation of the game’s were generated through a review of the literature and formative perceived effectiveness. Figure 1. Integrative model of predictive behaviour and predicted game influence. In this paper, we describe the user-centered design process for and the Philippines. Final design choices were made by the a mobile game titled Battle in the Blood and explore the effect game’s coproducers: a British behavioral scientist specializing of user-centered design techniques on the game’s acceptability in game design for health system benefit (CH); the director of as a health intervention and uptake among target users. an independent game development company, with over 10 years industry experience, based in Scotland; and a Filipino clinical epidemiologist (EB). The process was divided into 3 phases Methods and aligned with development milestones for the game (Figure Overview 2). Internal playtests were frequently conducted by members of the project team and their immediate networks. Change Battle in the Blood was developed from 2016 to 2018 through requests and bugs were recorded and shared with the a collaborative effort with experts from the United Kingdom development team using Google Docs. http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al Figure 2. Development process. participants were divided into teams (maximum 6 participants Selection of User Centered Design Methods in a team) to develop pitches for games to promote HIV services, A literature review was conducted to identify a range of which they then presented and discussed. HIV clinic counselors user-centered design methods to be used in a combined were present at both workshops to answer any questions the approach. Methods were selected based on their fit to the participants had regarding HIV and provided information on question the development team wanted to answer and the HIV service provision in the Philippines. The session was audio available resources. The resulting design process involved a recorded and transcribed, and photos were taken to record the phased approach, with primary and secondary users engaged human scatter graphs and visuals from the game pitches. during the initial ideation and prototype testing stages. Resources Analysis were prioritized to capture important contextual requirements and evaluate educational and experiential aspects of the game. Transcripts and session outputs were analyzed using a Selected methods included participatory design workshops [25], framework approach [27] to identify a set of recommended extended playtests [20], playability heuristics [26], FGDs, and game features. A 4-day workshop was conducted with the full game analytics. development team to translate the list of recommended game features into a game design document. Game features were also As the methods for each phase were distinct, recruitment, data connected to the context-specific learning objectives outlined collection, and analysis have been described for each. Data were in Figure 1. collected in the cities of Manila and Davao. The study was part of a much larger project, which included assessment of a rapid Phase 2: Prototype Testing diagnostic algorithm for HIV, that was being piloted in these Playtesting sessions and FGDs were conducted to assess the cities. acceptability and playability of the beta game build. Phase 1: Game Design Recruitment To determine important contextual requirements and user Participants were older than 18 years and self-identified as preferences, design workshops with Filipino gamers were MSM. This study aimed to ensure that the narratives and art conducted during the initial specification and ideation stage. style were appealing, relatable, and inoffensive to the target Subject experts in clinical practices for HIV and the Philippines users. Participants were recruited using social networking sites, HIV epidemic were allocated informant roles in the game including Facebook, Grindr, Growlr, and PlanetRomeo, known development team. as popular networking sites for the MSM and TGW community. Peer counselors from HIV testing services were also recruited Recruitment as they were predicted to be an important user group for the Filipino individuals older than 18 years who regularly played game. digital games or were involved in game development or electronic sports, regardless of sexual identity, were invited to Overall, 5 FGDs and playtesting sessions involving a total of participatory design workshops via social networking sites, 22 participants were conducted between August 20, 2017, and including Facebook and Steam forums. It was theorized that November 18, 2017; 4 sessions were conducted in Manila (17 the game would need to be appealing and accessible to a range participants, all MSM) and 1 in Davao (5 participants, all peer of gamer types and that gamer type would not be dictated by counselors and MSM). Game changes and bug fixes were sexual identity. A total of 18 participants were divided into 2 implemented between each testing session. groups (11 and 7). Participants were aged between 21 and 30 Data Collection years and were a mixed group of MSM and non-MSM. Sessions were facilitated by UK and Filipino researchers (CH, Data Collection EB, EG, and JD). User testing was divided into 3 activities: (1) Group sessions were facilitated by UK and Filipino researchers participants’ screens and faces were video recorded as they (CH, EB, EG, and JD), in which (1) participants responded to played the game for 30 to 45 min, (2) all animations in the game questions by creating a human scatter graph indicating their were played on a big screen and a short discussion was held by level of agreement to different statements by their physical participants for each one, and (3) a group discussion was proximity to the statement placed on the floor, creating an instant conducted on the perceived acceptability of the game. visual of the group’s perception and experience of mobile games Analysis and games for health; (2) group discussions were held on design Analysis of data from the game testing sessions was divided and technical enablers and barriers to digital gaming; and (3) into 2 parts. The first part utilized playability heuristics to http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al identify and fix design flaws. Playability heuristics are a set of could be marked as a violation of gameplay heuristic GP1, “the qualities by which a game’s engagement and usability can be game provides clear goals” (Figure 3). This is an example of assessed. They are typically used by game developers and what is termed a playability violation. Playability reports were professional game testers. We adapted an existing list of developed independently by 2 researchers (CH and EG). The playability heuristics for mobile games [26] to use as a coding reports described each playability violation and gave framework to analyze the video recordings and transcripts recommendations for game improvements. The reports were (Figure 3). Screen recordings were primarily used to identify compared and discussed by the game development team before technical and usability issues, whereas transcripts were more agreeing on a final list of game changes. Where feasible, conducive to recognizing different experiential aspects. For changes were implemented before the next game testing session. example, expressions of confusion by the player when they lost Software bugs and technical issues were also recorded, and fixes a level, especially when followed by repeated failed attempts, were implemented. Figure 3. Playability heuristics for mobile game for health. UI: user interface. http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al The second part of the data analysis utilized the transcription presented on the app store page, and in the game when access of the group discussions to assess the acceptability of the game was requested. as a health intervention. Data analysis was informed by a general The game was made available on the Apple App Store and inductive approach, aligning emerging themes identified in the Google Play on November 27, 2017, and was officially launched transcripts with the following predetermined constructs of health during World AIDS Day celebrations in the Davao Region on intervention acceptability: affective attitude, burden, ethicality, December 1, 2017. Marketing events for the game included intervention coherence, opportunity costs, perceived local television appearances by project staff, printed and online effectiveness, and self-efficacy [28]. news articles, exhibitions at health- and game-related conferences in the National Capital Region and Davao Region, Quality Assurance: Phases 1 and 2 social media advertisements on Facebook and Twitter, and All qualitative data collected were translated into English for posters displayed in 4 HIV testing and counseling clinics (3 in analysis (EG), and the translation was checked for accuracy by Manila and 1 in Davao). The game analytics span a 12-month members of the research team. Analysis was led by a UK period from December 1, 2017, to December 1, 2018. researcher (CH) with regular consultation and input from the full project team to improve quality and depth. All design Data Collection choices resulting from the data were reviewed by the Data were automatically gathered from devices with the game development team before implementation. installed through the Unity Analytics service, version 2017.1 by Unity Technologies. For data to be sent from the device, the Phase 3: Game Analytics user must have opened the game at least once while the device Recruitment was connected to the internet. Events are stored locally on the Game use data were obtained from users who installed the game device when the game is played offline and sent the next time and gave permission for the app to access device storage. the game is opened and the device is connected. All data points Geolocation data were obtained from users who granted access were stored in the Unity Data Store. The game metrics (Table to their devices’ location data and played the game with GPS 1) were exported and converted into a readable format for use switched on. Information about why data were being gathered in statistical analysis software. and reassurances that all data would be kept anonymous were Table 1. Game metrics. Segment Metrics Active player metrics Daily active users; monthly active users; and new users (unique device installs) Session metrics Sessions per day; sessions per user; total daily playing time; and total playing time per active user Retention metrics Day 1, 7, and 30 retention Platform segment Total Android and iOS users Custom segments Level events—reports each time a level is completed or failed, and the players end score; link event—reports the click- through rate of all in-game links to external information; question events—reports the response to all in-game questions, including a set of demographic questions; geolocation per session—reports the device’s current location at the start of a session to 2 decimal places; and app version Results Analysis Descriptive statistical analysis was conducted in Microsoft Phase 1: Game Design Excel, version 1812. Spatial analysis was conducted in QGIS, Direction on game elements to support health-related behavior version 3.2.3. change first emerged through the human scatter graph activity. Ethical Assurance: All Phases Figure 4 demonstrates that the 2 groups had varied perceptions Legal advice was sought to ensure that management of game on the effectiveness of games for health-related behavior change. analytics complied with the 2018 European Union General Data Participants were questioned as to why they had chosen their Protection Regulation. place on the graph. Perceived limitations of the game’s effectiveness were centered around beliefs that changes in Ethical approval for the project was obtained from the ethics knowledge would not be sufficient to change behavior and that committees at the University of the Philippines College of the use of technical language would make the game’s content Medicine and Liverpool School of Tropical Medicine (research inaccessible, as illustrated by the following quote: protocol 16-017). http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al Figure 4. Human scatter graph on perceptions of the effectiveness of games for health behavior change. elements intertwined and where reality and fantasy existed in I’m still not convinced with the knowledge part the same space. because, as with some health conditions, even with some health benefits and stuff, there will be some Multiplayer gameplay was reported to be a strong motivator for things that a player will not understand, especially if repeated gameplay and was perceived to play a role in the it’s scientific jargon...but I do believe that behavior effectiveness of the game, as illustrated by the following quote: can change especially if it’s immersive and it is an ...they say that no man is an island. So, I think it experience that will change your perspective on very would affect the behaviour of the person if there is a different matters. [Group 2: Respondent B] community that pushes you. Someone playing alone Facilitators to behavior change centered around the use of will say “I’m just alone, nobody will care if I do this immersive experiences that could change perspectives and or do that.” But if you know somebody else is pushing generate social interactions between users, as illustrated by the you, it will affect your behaviour, it drives you as a following quote: person. [Group 1: Respondent I] Because whenever I’m playing games, they would However, participants also reported that access to these types often ask me “Hi [name]! What’s that game? Is that of games was restricted because of the requirement of a stable available in iOS? Is it available in the Android Play internet connection: Store?” Right after I told them about it, they would I have external and internal factors why I leave the go check out the game and download it. So, it’s not game. The external factor is whenever the game just me but also them that learns from the game. requires internet connection because the internet, the [Group 1: Respondent J] wireless data in the Philippines is not that good. During group discussion, the game’s narrative was identified [Group 1: Respondent E] as an important feature. If done well, it fostered an identification This presented a dilemma for the game design. On the one hand, with the game characters and motivated the players to overcome multiplayer gameplay was a very desirable game style among challenges in the gameplay to witness the story unfold. The the participants as they could participate in discussions about narrative was identified as the logical place to communicate HIV, behavior, and personal values and coconstruct their own why it was important to know one’s HIV status. Participants narratives about a desired future. This was further evidenced felt that the game should not provide technical information on by the market success of multiplayer mobile games in the HIV or HIV services but should focus on telling an emotionally Philippines. On the other hand, we did not have the resources driven story and provide the player choice over the narrative to develop and maintain an online multiplayer platform, and direction. known issues around internet connectivity would restrict access When the groups were divided into teams (2 teams in each to the game. group) to pitch their HIV advocacy games, 3 out of the 4 teams presented a similar concept of a hero sent on a quest to fight or evade the HIV virus, where story and role-playing game (RPG) http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al a traditional Filipino amulet believed to have magical powers. Combining Feasibility With Desire This amulet allows the player to travel back in time and change Findings from the phase 1 game design workshops directed the how the story ends for this character by encouraging him to game’s overarching narrative and the integration of gameplay undergo a HIV test. and storytelling. Players take on the role of the protagonist, entering the blood stream in an antiretroviral (ARV) pill capsule The game can be played and completed offline. Online features and battling anthropomorphic viruses, bacteria, and cancer cells include a global leader board, ranking players by their total using a weaponized mechanical suit. The gameplay combines score, and hyperlinks to websites containing information on match-3 puzzles with turn-based combat; players connect icons HIV and HIV services in the Philippines. The file size of the on a puzzle board that represent condoms, ARVs, healthy living, game was also restricted to 53.4 MB on Android and 70 MB health care, and time. Connecting the icons builds up the on iOS to reduce the risk of failed download attempts from the player’s defense and attack status during the rounds of combat. app stores. This in turn had ramifications for animations and The match-3 game style was selected because of the availability sounds in the game, both of which can substantially increase of prebuilt game assets and source code, which substantially the file size. To maintain a small file size, the number of sound reduced the development time and enabled the team to allocate effects and music tracks in the game was limited and animated time to the custom animations. stories were presented in a dynamic 2-dimensional comic book style, where static images moved across the screen to give the The gameplay is segmented with a series of 8 animated stories scenes depth and movement. about people living with HIV that the player helps by progressing through the game. The difficulty of the levels and Integration of Context-Specific Learning Objectives the types of enemy units are connected with the story line. For Table 2 details the design choices made in relation to the example, if the character in the story line is diagnosed with context-specific learning objectives outlined in Figure 1. gonorrhea, an enemy unit representing gonococcus appears during the gameplay. In the game’s final mission, the player is Figure 5 uses screenshots from the game to illustrate some of introduced to a character with AIDS in critical condition; it is the design choices made. A table summarizing the phase 1 revealed that he has never been tested for HIV, treatment fails, design process (Multimedia Appendix 1) and the game design and the character dies. Throughout the game, the player is document, version 0.15, (Multimedia Appendix 2) are included awarded with fragments that combine to form an anting-anting, as Multimedia Appendices. Table 2. Theory of behavior change design choices. Context-specific learning objective Game design element To believe that you can live a fulfilling life after a positive diagnosis The animated stories depict people living with HIV pursuing their ambi- tions, being socially active, or spending time with their family. For exam- ple, a transgender character enters a beauty pageant and, as she takes her medication in the dressing room, the text reads, “I fought to be my true gender, I can win this fight too.” This particular story line was selected because of the cultural relevance pageantry has in the Philippines and the great esteem in which Filipinos hold the contestants. To know that HIV treatment makes your immune system stronger and Antiretroviral tablets feature in every animated story except the one where more able to fight off illness; reduces the risk of transmitting the virus to the character dies. Treatment is also shown to improve the physical appear- someone else; reduces the effect of the illness on quality of life; and, if ance of the characters in the later missions. Players can earn an extra life started early, leads to a significant reduction in the risk of death during gameplay by answering a multiple-choice question. Some questions address knowledge on treatment effects, and feedback containing the right answer is given. Hyperlinks to websites containing information on HIV treatment are included throughout the game, and the click-through rate is measured. To know that HIV testing and treatment services are available for free in In the animated stories, the words “Free HIV tests” appear in the back- the Philippines and that results are given on the same day ground of all the clinic waiting room scenes. The rapid testing procedure is depicted in the first 3 animations. Multiple-choice questions address the availability of free testing and the time taken for the client to receive their results in the Philippines. Hyperlinks to websites containing informa- tion on HIV services in the Philippines are included throughout the game, and the click-through rate is measured. To recognize common coinfections and signs of HIV infection and to Enemy units in the game include representations of gonorrhea, tuberculosis, know that symptoms may not appear until long after infection hepatitis B, herpes, and cancer. Common signs of HIV infection are de- picted in the animated stories, and some characters show no symptoms. To know that there is a risk of HIV transmission among heterosexuals The first animated story depicts a heterosexual couple. In several other animated stories, the character’s sexuality is ambiguous. To know the location of HIV services A hyperlink to a website containing the contact information and location of all testing sites in the Philippines is featured throughout the game. http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al Figure 5. Screenshots Battle in the Blood v1.4. recognizing the unique benefits of treatment for each character, Phase 2: Prototype Testing as illustrated by the following quote: Table 3 summarizes the final agreed list of playability violations Ever since the guy was given the ARVs, his fear of and the game changes made as a result. him having STDs or socializing with people is now Learning Achieved Predominantly Through gone, and he was able to not be afraid to connect with Interpretation of the Animated Narratives other people. [GameTester_MSM] Participants repeatedly drew inferences between the presence of ARVs and the positive outcome in the short-animated stories, Table 3. Playability violations and game changes. Playability heuristic Evidence of violation Game change GP5: There are no repetitive or bor- Participants felt bored and disengaged with the animation On the second playthrough, a title screen appears ing tasks when the first half of the story line was repeated. Video with the text “Previously on Battle in the footage demonstrated that players did not realize they could Blood…Skip?” skip the recap by tapping anywhere on the screen. GU1: Audio-visual representations Players reported the icons as unintuitive because the color The design of the icons was adjusted to correspond support the game of the icons did not correspond with the combat status bars visually with the attack and defense bars. that they effected. Video footage showed players taking decisions based solely on the length of the chain, not the color of the icons, and becoming frustrated when they re- peatedly lost a level. GU11: The game contains help Participants did not feel that the onboarding was compre- When a new game mechanic is triggered, a dialog hensive enough, and new mechanics in the game were not box appears that explains the new mechanic using explained. a small amount of text and images. This information can also be accessed via the game’s menu and via the level-pause screen. GP6: The players can express Participants stated that they did not like the mechanical Avatar appears animated in the level-complete or themselves suit as they had spent time customizing the avatar but rarely -fail screen. saw it in the game as most of it was covered. GP2: The player is rewarded, and Participants stated that they wanted to be able to earn in- Implementing an in-game currency system and the rewards are meaningful; GP5: game currency by completing the levels, which could be custom character upgrades would have required There are no repetitive or boring spent on upgrading or customizing their character. They additional resources and delayed the planned launch tasks also felt this would make the gameplay feel less repetitive. of the game. The change request was logged but not implemented for the pilot. In addition to the inferred benefits of HIV treatment, participants had changed his personal understanding of when to undergo a also identified messages about the consequences of delayed HIV test, as shown by the following conversation: access to HIV services. One participant reported that the game http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al For me it’s better to test at the earliest, so you can experienced one but thankfully I haven’t got HIV. know if you’re positive and prevent it earlier. [GameTester_MSM] [PhaseTwo_GameTester_MSM] The game follows the stories of 8 different characters diagnosed So, before you played the game, you just know that with HIV. Each character is unique in its sexuality, gender, you need to get tested when? [Interviewer] appearance, and behavior. Therefore, a user is likely to empathize with or relate to some but not all characters in the Only if you’re already having symptoms. game. As game characters are presented in a predetermined [PhaseTwo_GameTester_MSM] sequence, some users may never witness a character that they Participants interpreted the stories based on their current share commonalities with, reducing the potential impact of the knowledge and personal values. In 1 case, this led to the message in-game narrative for certain users based on their progress in of the story being repeatedly challenged: the game. The representation of different sexualities and genders ...he was told that he has Gonorrhoea and he was was well received by participants as they acknowledged that it then given pills to cure it and the HIV treatment. With could help to address misconceptions that HIV only effects that, he told himself that this could save his life and MSM, indicating that the design flaw was the delivery of the then could continue living his life normally. And then narratives rather than the inclusion of multiple character types. he was seen to be at the bar again. But it was Gameplay Perceived as Enjoyable but Potentially Limited somehow an off for me because it gave me the in Appeal impression that just because there’s treatment, you Despite a positive response from the participants, in which can go on with your promiscuous activity all your gameplay was described as “enjoyable, addictive, and life. [PhaseTwo_GameTester_MSM] challenging,” there were indications that the game would have Some counterarguments were expressed because of preexisting a limited appeal. In the first instance, participants had very low knowledge, namely, a lack of awareness that ARVs can reduce expectations for the game and expressed surprise at playing a the viral load to the point where the individual is no longer game comparable with commercial games on the app stores. In infectious and social norms in which sexual promiscuity is 1 FGD, participants identified 2 categories of gamers, casual perceived as an undesirable trait. Most participants concluded and hardcore, and discussed which category the game would that the character in this particular animation was sexually appeal to and why. A casual gamer was perceived to be someone promiscuous because the story centered around a nightclub, and who occasionally engaged with digital games as a form of he was diagnosed with HIV and gonorrhea. In this case, the distraction, whereas a hardcore gamer’s life would revolve narrative appeared to challenge stigmatizing perceptions around around digital games. Most agreed that the game would have sexual promiscuity and its association with HIV. little to no appeal for hardcore gamers. For casual gamers, the Although participants felt that the health-related messages were consensus was that the game would be appealing but required reinforced in the turn-based combat levels, most of the learning an effective marketing and deployment strategy to overcome outcomes were achieved through interpretation of the animated competition from similar games. Offline gameplay was narratives and the discussions they triggered. A potential concern perceived to be a strong motivator, regardless of gamer type, is that the animations were perceived to be disconnected from, as it would enable players to alleviate boredom when they were and less engaging than, the gameplay. During the prototype unable to access features on their devices that required an testing session, all in-game animations were played in sequence internet connection. Marketing Battle in the Blood as a game through a projector, and participants intently watched and about HIV was perceived to have 2 effects on the appeal; in discussed each animation. Interpretation of the narrative may most cases, it would arouse curiosity or tap into a desire to learn, be significantly different by a user casually playing the game whereas in some cases, it could be off-putting. Participants felt alone, with no direct incentive to focus on and analyze the that the game’s marketing should also be targeted toward parents content. and should offer information on the age appropriateness of the content. Identification With Game Characters Phase 3: Game Analytics Animated narratives where the players shared a set of commonalities with the character diagnosed with HIV elicited Game analytics reported 3325 unique device installs globally a stronger emotional reaction than those where the characters during a 12-month period. The game received an average of 10 did not share similar demographics or behaviors. The story of installs per day. Installs peaked during active and incentivized a young MSM who resorts to solicitation to afford to play games marketing events; the maximum number of installs in 1 day was at an internet café was reported to be the most impactful story 367 at the time of the World AIDS Day launch event in Davao. line by almost all game testers. This was likely because of the Unity Analytics provided a more accurate report of game uptake recruitment strategy, as most game testers were part of the young and reach than the app store services because of the common MSM community and had a strong interest in gaming: practice of using third-party apps, such as SHAREit, to access Well it seems relatable for me because I’m a gamer. the game via Bluetooth and avoid data costs. Installs via this And I have a friend who does that thing sometimes. method would not have been captured by the analytics services And thankfully he hasn’t got any HIV. It’s relatable provided by the Apple App Store or Google Play at the time of to me because well, I know those who did, I the study. http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al National Capital Region and Davao Region. Furthermore, Regional Game Uptake 54.01% (1796/3325) of the users reported their age, gender, and Geolocation data were collected for at least one play session gender of sexual partners; of these users, 28.06% (504/1796) from 50.77% (1688/3325) of users. Of the users from whom reported as being sexually active MSM. Within the sexually geolocation data were collected, 85.36% (1441/1688) were active MSM category, 47.8% (241/504) reported their age as located in the Philippines (Figure 6). Game use was concentrated between 25 and 34 years, 26.1% (132/504) as between 20 and in urbanized areas. Uptake of the game was highest in the 24 years, and 7.1% (36/504) as between 10 and 19 years. Figure 6. Cluster point map of the location of Battle in the Blood installations in the Philippines. Points clustered at 4mm. Number in circle represents total number of users which installed Battle in the Blood in that location. Total number of user records from the game analytics that contain geolocation data and have played the game in the Philippines=1441. Region level shape file from Humanitarian Data Exchange. http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al Overall, 2 factors are believed to have contributed to the the solution for which was informed by the experience and best substantially higher uptake among target users in the regions judgment of the game’s coproducers [19]. The reported low of Davao and Manila. First, several promotional exhibitions for rates of game completion indicated that optimal design solutions the game were held by project staff in these regions. The were not achieved by the game’s producers. exhibitions often included prize giveaways for those who User-Centered Design and Community Adoption downloaded the game, indicating a dependency on these types Results from the game analytics indicated that users’ of active and incentivized marketing events. Self-reported data involvement in the game development process had a positive indicated that marketing events targeting adolescent users were impact on uptake among target users. However, the extent of potentially lacking. Second, user-centered design activities were that impact cannot be determined from the available data. For conducted in these regions with influencers in both the gaming example, although unique device installs were substantially and HIV community, and it is likely that they also played a role higher in regions where user-centered design activities took in promoting the game. place, the proportion of installs credited to such activities cannot Low Rates of Game Completion be determined, especially with the presence of targeted and As of December 1, 2018, 14.98% (498/3325) of users were incentivized promotional events in those regions. Further studies reported to have completed level 45 and 4.00% (133/3325) were are recommended to explore the correlation between user reported to have completed level 90, the last level in the game. involvement and community adoption of games for health. The Factors believed to have contributed to the reported low rates way in which target users involved in the design are credited of game completion are the gameplay being perceived as may also be an important factor to consider. repetitive and having limited appeal and missing data because Narratives in Games for Health of the provision of offline gameplay. Storytelling has long been established as an effective means of Additional factors impacting uptake and progression will be attitude and behavior change [17], and this was reflected in the explored further through interviews with end users and findings during the user-centered design process. This also follow-up interviews with participants involved in the design highlights the importance of having an experienced narrative process. designer as part of the development team to work in partnership with the subject domain and behavioral experts. Assessment of Identification of Access Issue on Android Devices the game’s acceptability found that mobile game design that Game analytics and app store reviews were monitored accommodates typical user behavior is not always conducive throughout the 12-month period. Monitoring activities supported to effective storytelling. To be suitable for use in a public space, the identification of an access issue on Android devices, which the animated stories had to be highly captivating to retain focus was related to app permissions managed by the Google Play while also allowing the player to disengage without missing store. A fix was launched on November 5, 2018. Between vital information. Although Battle in the Blood made some October 5, 2018, and November 4, 2018, the average number headway in delivering a narrative that was accessible and of daily active users was 16, and this increased to 40 in the accommodated typical user behavior, a lack of interaction, an month following the fix. obscure link to the gameplay, delivery through linear episodes, and limited character identification may have rendered the Discussion animated stories ineffective in generating new knowledge and perceptions when the game is played outside a facilitated Establishing Design Solutions Through User-Centered gameplay session. These design flaws could be addressed Design through the inclusion of additional branching narratives driven User-centered design methods supported the identification of by player choice, forming a stronger link between the gameplay contextual requirements for the game [22]. Qualitative methods and cause and effect sequences in the narrative, inclusion of provided a deep understanding of the important factors that both stories based on true events, allowing players to select narratives motivated and enabled gameplay, which are likely to have they are interested in, and facilitating group gameplay sessions contributed to the reported uptake and use of the game. The where players are encouraged to discuss their interpretation of human scatter graph method and game pitches enabled the narratives as part of the game’s distribution strategy. participants to reflect on their views and the views of others, Multiple Data Collection Methods to Mediate Biases which, in turn, ignited valuable discussion on the qualities the game required to both be appealing and deliver persuasive health Telemetry and geolocation data are widely used in the mobile messages. Although findings from phase 1 influenced the games industry to improve app revenue. There are countless creative direction of the game, each design choice made by the articles ranking key performance indicators by their value to development team was prefixed with a discussion on what was app developers. In response to demand, a range of services are feasible within the predetermined budget and development time now available that process large volumes of data into actionable frame. For example, during phase 1, an action RPG in which information with very low setup costs. In the case of the Unity the player could control their character’s strength and traits was Analytics service (version 2017.1), standard metrics can be found to be highly desirable, but adequate resources were not obtained by toggling a switch in the Unity game engine. available to implement a stable and balanced underlying Although generating income may not be a primary goal, it could mathematical model for this feature. In this case, the design be argued that analytical services that capture data during workshops supported the identification of a wicked problem, http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al gameplay are currently underutilized in games for health this may have also created a bias toward individuals with a development and evaluation [29]. In contrast to FGDs, telemetry vested interest in health advocacy and game design. and geolocation data collected through the game are not biased The timing for phase 2 protype testing was not ideal, which is by the presence of a researcher; however, emotive responses to believed to have impacted the changes implemented in the game gameplay cannot be captured this way. Thus, it is important not design. to focus solely on 1 data collection technique but rather to triangulate results from a range of different data sources to Certain terms used by the participants did not have a direct mitigate bias while providing a more complete picture of game English translation, which, at times, led to ambiguity in the data performance. during the translation process. This study explored the effect of user involvement on health Conclusions intervention acceptability and community adoption and By involving users from the outset, the development team was described in detail the methods used. Further evaluation of the guided toward narratives that were shown to be relatable and game has been conducted to explore the game’s effect on understandable and to gameplay that provided enjoyment. The knowledge, attitudes, and HIV service use among target users, resulting product is a game that is accessible, simple, and the results of which will be published in a separate paper. entertaining because of universally recognized game mechanics, small file size, and offline gameplay. At a minimum, games for Limitations health should involve target users in early stages of the design As with all qualitative research, findings cannot be applied to process as a relatively cost-effective method of cataloging the wider population with certainty. Perceptions from aged important contextual requirements and user preferences. If target under 18 years and subjects outside Manila and Davao were not users are to be tasked with developing design solutions, then captured. Although the project team failed to recruit TGW interaction with the development team must go beyond FGDs. during phases 1 and 2 of the game development process, they For the target user to be a valued member of the game were included during the formative research stage, which development team, they must have adequate expertise in design, informed the conceptual framework for the game (Figure 1). a shared goal, and be properly credited and compensated for Feedback on how the transgender character in the game was their contributions [22]. Increased reporting of design portrayed was provided by TGW known to the research team approaches and stronger collaboration among health in the Philippines in an informal capacity. professionals, the entertainment games industry, and end users The authors note that the recruitment strategy and use of FGDs will support the games for health industry as it matures. is likely to have resulted in a bias toward participants less Restructuring projects to involve users before determining the encumbered by stigma toward their sexuality or HIV status. development budget will enable design choices to be driven Given that recruitment advertisements stated that participants more by user requirements and less by what is feasible. would be inputting into the design of an HIV advocacy game, Acknowledgments The authors wish to acknowledge the game development team at EM Studios and Bobby Farmer (coproducer), Craig Gardiner (lead artist), Aitor Prado (lead coder), and Stuart Henderson (coder), whose hard work and passion were integral to the project. The authors would like to thank all the participants who devoted their time to partake in the study, and the authors would also like to acknowledge the contributions made by the Philippines Department of Health’s National HIV and Sexually Transmitted Infection Prevention Program, LoveYourself Philippines, Klinika Bernardo-Quezon City Health Office, Davao Social Hygiene Clinic-Davao City Health Office, Dr Rhoda Myra Garces-Bacsal, Dr Jose Gerard Belimac, Dr Stefanie Gregorius, and Dr Marlize Coleman. This project was funded by the Newton Agham Grant through the UK Medical Research Council and Philippines Council of Health Research and Development, Department of Science and Technology. Authors' Contributions CH analyzed the data and wrote the manuscript. CH and EB produced the game. All authors inputted into the study design, game design, data analysis, and manuscript. EG and TS coordinated the recruitment and data collection activities and transcribed and translated the data. Conflicts of Interest None declared. Multimedia Appendix 1 Summary of phase 1 design process. [DOCX File , 18 KB-Multimedia Appendix 1] http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al Multimedia Appendix 2 Battle in the Blood game design document v0.15. [DOCX File , 3318 KB-Multimedia Appendix 2] References 1. The Joint United Nations Programme on HIV/AIDS. UNAIDS Philippines Country Factsheet. URL: https://www.unaids.org/ en/regionscountries/countries/philippines [accessed 2017-12-01] 2. Bumanglag KC. Enhancing HIV/AIDS surveillance in the Philippines to ensure the transgender population's visibility. Am J Public Health 2018 Jan;108(1):58-60. [doi: 10.2105/AJPH.2017.304158] [Medline: 29211538] 3. Department of Health website. 2015. Integrated HIV behavioral and serologic surveillance: 2015 fact sheet. URL: https:/ /www.doh.gov.ph/sites/default/files/publications/Philippines_2015_IHBSS_Fact_Sheets_Nov2017_22JUN2016.pdf [accessed 2017-12-01] 4. Department of Health website. 2016. The State of the Philippine HIV Epidemic 2016 Facing Challenges, Forging Solutions. URL: https://www.doh.gov.ph/sites/default/files/publications/ publication__nonSerials_State%20of%20HIV%20Epidemic%20in%20the%20Philippines.pdf [accessed 2017-12-01] 5. AIDS Data Hub. 2018. HIV / AIDS and ART Registry of the Philippines. URL: http://www.aidsdatahub.org/ hivaids-and-art-registry-philippines-march-2018-epidemiology-bureau-department-health-2018 [accessed 2017-12-01] 6. Wong VJ, Murray KR, Phelps BR, Vermund SH, McCarraher DR. Adolescents, young people, and the 90-90-90 goals: a call to improve HIV testing and linkage to treatment. AIDS 2017 Jul 1;31(Suppl 3):S191-S194 [FREE Full text] [doi: 10.1097/QAD.0000000000001539] [Medline: 28665876] 7. Adia A, Bermudez A, Callahan M, Hernandez L, Imperial R, Operario D. 'An Evil Lurking Behind You': drivers, experiences, and consequences of HIV-related stigma among men who have sex with men with HIV in Manila, Philippines. AIDS Educ Prev 2018 Aug;30(4):322-334. [doi: 10.1521/aeap.2018.30.4.322] [Medline: 30148671] 8. van Wijngaarden JW, Ching AD, Settle E, van Griensven F, Cruz RC, Newman PA. 'I am not promiscuous enough!': exploring the low uptake of HIV testing by gay men and other men who have sex with men in Metro Manila, Philippines. PLoS One 2018;13(7):e0200256 [FREE Full text] [doi: 10.1371/journal.pone.0200256] [Medline: 29979766] 9. Canoy NA, Ofreneo MA. Struggling to care: a discursive-material analysis of negotiating agency among HIV-positive MSM. Health (London) 2017 Nov;21(6):575-594. [doi: 10.1177/1363459315628040] [Medline: 26851265] 10. Burki T. HIV in the Philippines. Lancet Infect Dis 2017 Jun;17(6):589-590. [doi: 10.1016/S1473-3099(17)30256-6] [Medline: 28555587] 11. Koirala S, Deuba K, Nampaisan O, Marrone G, Ekström AM, CAT-S group. Facilitators and barriers for retention in HIV care between testing and treatment in Asia-A study in Bangladesh, Indonesia, Lao, Nepal, Pakistan, Philippines and Vietnam. PLoS One 2017;12(5):e0176914 [FREE Full text] [doi: 10.1371/journal.pone.0176914] [Medline: 28459881] 12. KPMG Global. 2018. IT Report: Philippines Investment Guide. URL: https://home.kpmg/ph/en/home/insights/2017/12/ it-report-philippines.html [accessed 2017-12-01] 13. Newzoo. 2017. The Filipino Gamer. URL: https://newzoo.com/insights/infographics/the-filipino-gamer/ [accessed 2017-08-20] 14. Hightow-Weidman LB, Muessig KE, Bauermeister J, Zhang C, LeGrand S. Youth, technology, and HIV: recent advances and future directions. Curr HIV/AIDS Rep 2015 Dec;12(4):500-515 [FREE Full text] [doi: 10.1007/s11904-015-0280-x] [Medline: 26385582] 15. DeSmet A, van Ryckeghem D, Compernolle S, Baranowski T, Thompson D, Crombez G, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med 2014 Dec;69:95-107 [FREE Full text] [doi: 10.1016/j.ypmed.2014.08.026] [Medline: 25172024] 16. Prensky M. Fun, play and games: what makes games engaging. In: Digital Game-Based Learning. United States: Paragon House; 2001:1-31. 17. Shen F, Han J. Effectiveness of entertainment education in communicating health information: a systematic review. Asian J Commun 2014;24(6):605-616. [doi: 10.1080/01292986.2014.927895] 18. Kort YA, IJsselsteijn WA, Poels K. Digital games as social presence technology : development of the Social Presence in Gaming Questionnaire (SPGQ). In: Presence 2007 : the 10th Annual International Workshop on Presence. Barcelona: Starlab; 2007:1-9. 19. Rittel HW, Webber MM. Dilemmas in a general theory of planning. Policy Sci 1973;4(2):155-169. [doi: 10.1007/BF01405730] 20. Pagulayan R, Keeker K, Fuller T, Wixon D, Romero R, Gunn DV. User-centered design in games. In: Sears A, Jacko JA, editors. Human-Computer Interaction Handbook: Fundamentals, Evolving Technologies and Emerging Applications. Boca Raton: CRC Press; 2007:883-906. 21. Giacomin J. What is human centred design? Des J 2014;17(4):606-623. [doi: 10.2752/175630614X14056185480186] 22. DeSmet A, Thompson D, Baranowski T, Palmeira A, Verloigne M, de Bourdeaudhuij I. Is participatory design associated with the effectiveness of serious digital games for healthy lifestyle promotion? A meta-analysis. J Med Internet Res 2016 Apr 29;18(4):e94 [FREE Full text] [doi: 10.2196/jmir.4444] [Medline: 27129447] http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hemingway et al 23. Mayer I, Bekebrede G, Harteveld C, Warmelink H, Zhou Q, van Ruijven T, et al. The research and evaluation of serious games: toward a comprehensive methodology. Br J Educ Technol 2014;45(3):502-527. [doi: 10.1111/bjet.12067] 24. Conner M. Cognitive determinants of health behavior. In: Steptoe A, editor. Handbook Of Behavioral Medicine: Methods And Applications. New York, NY: Springer; 2010:19-30. 25. Jessen S, Mirkovic J, Ruland CM. Creating gameful design in mHealth: a participatory co-design approach. JMIR Mhealth Uhealth 2018 Dec 14;6(12):e11579 [FREE Full text] [doi: 10.2196/11579] [Medline: 30552080] 26. Korhonen H, Koivisto EM. Playability Heuristics for Mobile Multi-player Games. In: Proceedings of the 2nd international conference on Digital interactive media in entertainment and arts. 2007 Presented at: DIMEA'07; September 19-21, 2007; Perth, Australia p. 28-35. 27. Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse Res 2011;18(2):52-62. [doi: 10.7748/nr2011.01.18.2.52.c8284] [Medline: 21319484] 28. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res 2017 Jan 26;17(1):88 [FREE Full text] [doi: 10.1186/s12913-017-2031-8] [Medline: 28126032] 29. Smith SP, Blackmore K, Nesbitt K. A meta-analysis of data collection in serious games research. In: Loh CS, Sheng Y, Ifenthaler D, editors. Serious Games Analytics: Methodologies for Performance Measurement, Assessment, and Improvement. Switzerland: Springer International Publishing; 2015:31-55. Abbreviations ARV: antiretroviral FGD: focus group discussion MSM: males who have sex with males RPG: role-playing game TGW: transgender women Edited by G Eysenbach; submitted 25.02.19; peer-reviewed by P Newman, T Kuhn, F Mckay, J Salisbury; comments to author 27.04.19; revised version received 18.06.19; accepted 19.08.19; published 20.12.19 Please cite as: Hemingway C, Baja ES, Dalmacion GV, Medina PMB, Guevara EG, Sy TR, Dacombe R, Dormann C, Taegtmeyer M Development of a Mobile Game to Influence Behavior Determinants of HIV Service Uptake Among Key Populations in the Philippines: User-Centered Design Process JMIR Serious Games 2019;7(4):e13695 URL: http://games.jmir.org/2019/4/e13695/ doi: 10.2196/13695 PMID: 31859673 ©Charlotte Devon Hemingway, Emmanuel S Baja, Godafreda V Dalmacion, Paul Mark B Medina, Ernest Genesis Guevara, Tyrone Reden Sy, Russell Dacombe, Claire Dormann, Miriam Taegtmeyer. Originally published in JMIR Serious Games (http://games.jmir.org), 20.12.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2019/4/e13695/ JMIR Serious Games 2019 | vol. 7 | iss. 4 | e13695 | p. 15 (page number not for citation purposes) XSL FO RenderX
Journal
JMIR Serious Games – JMIR Publications
Published: Dec 20, 2019
Keywords: HIV; video games; health communication; persuasive communication; games; experimental; user-centered design