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Using Video Games to Improve the Sexual Health of Young People Aged 15 to 25 Years: Rapid Review

Using Video Games to Improve the Sexual Health of Young People Aged 15 to 25 Years: Rapid Review Background: Sexually transmitted infections and unintended pregnancies among young people remain public health concerns in many countries. To date, interventions that address these concerns have had limited success. Serious games are increasingly being used as educational tools in health and professional public education. Although acknowledged as having great potential, few studies have evaluated the use of serious games in sexual health education among young people, and to date, there have been no published reviews of these studies. Objective: This study aims to assess the effects of video game–based sexual health interventions for risky sexual behavior in young people aged between 15 and 25 years. Methods: A rapid review of randomized controlled trials and quasi–randomized controlled trials was performed. The search included the following bibliographic databases: Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PsycINFO, and Scopus. A total of 2 reviewers independently screened 50% (35/70) of the retrieved articles during the full-text screening phase. Results: From a total of 459 identified citations, after removing duplicates, 327 (71.2%) articles were deemed eligible for title and abstract screening. Of the 327 articles, 70 (21.4%) full texts were screened, from which 10 (3.1%) articles (evaluating 11 different games) were included in the review. The findings highlighted the considerable diversity in video game–based interventions and assessed sexual health outcomes. Although there were some promising findings in outcome studies using game-based interventions, the results across studies were mixed. Conclusions: Although game interventions for sexual health have been in existence for almost three decades, relatively few studies have evaluated them, and the results of previous outcome studies have been mixed. Moreover, there is little clarity regarding which specific elements of a game facilitate positive outcomes. We provide recommendations for future researchers developing video game–based interventions to improve sexual health in young people. (JMIR Serious Games 2022;10(2):e33207) doi: 10.2196/33207 KEYWORDS sex education; serious games; sexually transmitted infections; rapid review; mobile phone https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al gay, bisexual, transgender, and intersex individuals; people with Introduction disabilities; and migrant populations [17]. Background It has been argued that education through games is more efficient and enjoyable than classroom teaching for several Although contraceptive access and sexual education are more reasons [18]. First, it is predominantly the player who directs widely available than ever, risky sexual behavior remains an activity in games, whereas in school, it is predominantly the issue for people of all ages, especially younger individuals. teacher who directs activity. This is why serious games use a More than 1 million sexually transmitted infections (STIs) are learner-centered approach in which learners are involved in the acquired each day worldwide among individuals aged between process (learning through doing), in contrast to traditional 15 and 49 years [1,2]. The most common STIs are chlamydia, education, which uses a teacher-centered approach in which gonorrhea, and trichomoniasis, although the diagnosis of syphilis learners are relatively passive. has also increased in recent years [1]. In many countries, young people aged between 15 and 24 years have the highest rates of Second, children and adolescents often find it difficult to STIs [3,4]. Despite global and national efforts to stop the spread properly engage in school exercises [19], in which the challenge of STIs, the World Health Organization recently reported a level is not well adjusted to their skills. In a class, there are “concerning lack of progress” in achieving reductions [5]. many students with different skills, making it difficult for teachers to equally engage all students in the class. In contrast, The best method for preventing the spread of STIs is the correct video games engage players naturally by gradually adjusting use of condoms [6]. However, many young people [7] engage their difficulty level as they progress in the game [20]. Game in risky sexual behaviors such as having sex with multiple developers understand that for a game to be successful, players partners without the use of condoms or incorrect or incomplete of varying abilities need to feel a sense of reward or condom use [8]. Many interventions have been developed to achievement, often enough to retain their engagement. encourage consistent condom use and safer sexual behaviors; however, most of these interventions have been shown to have Third, students are sometimes discouraged by the school system limited effectiveness and/or are very resource intensive [9,10]. as they are penalized for the mistakes they make (eg, they receive bad grades). However, in games, players are expected Adolescent pregnancies are also a global concern in high-, to make wrong decisions and do so without being discouraged middle-, and low-income countries. Although the past 30 years (ideally, unless the game is poorly designed). In fact, games have seen a global decline in unintended pregnancy rates, a have the advantage of allowing users to train in real-life recent review of 166 low- to middle-income countries reported decision-making situations where the wrong choice may involve that approximately half of all pregnancies are unintended [11]. some risk without having to actually be at risk. For example, Furthermore, although rates of unintended pregnancies in the pilots often train using Microsoft Flight Simulator, whereas the United States and the United Kingdom have dropped in recent military often uses battle simulators to train recruits. This allows decades [12], adolescent pregnancy rates remain high in many players to make mistakes in a safe environment. middle- to high-income countries (particularly in the United States) [13]. Finally, an important characteristic of educational games is the constant real-time feedback provided to the user. Players almost Despite consistent evidence that comprehensive sex education instantly know how well a certain move or strategy works can increase protective behaviors [14], there are still many gaps toward the goal of the game. Feedback can take the form of in knowledge. Furthermore, access to contraceptives and sexual points, lives, levels, scores, ranks, or progress bars. Real-time health services for young people remains limited in many feedback ensures that users are motivated throughout the game countries [4]. Sex education, often delivered in schools as part by promising that a goal is achievable. of the national curriculum, can be a highly contested area, reflecting political, moral, and cultural debates. In the United Some authors have argued that there is a strong case for States, school-based sex education curricula have long been integrating video games into sex education, whether by criticized for being sex negative, often focusing on abstinence supplementing sex education classes with existing games that and omitting any mention of nonheterosexual experiences explore sex and sexuality or developing new games for the [15,16]. In many countries, traditional gatekeepers such as purpose of sex education [21]. Given the interactive nature of religious and educational authorities still powerfully restrict video games, their lack of real consequences, their capacity for access, content, and materials used for sex education [4]. privacy, and the familiarity that many adolescents already have Therefore, for many young people, obtaining reliable with games, when used correctly, games could be very effective information about sex and relationships can be difficult. tools for students. The internet has been identified as a potentially valuable Aims of the Review resource for comprehensive, interactive, web-based, and This review was conducted as part of a larger Erasmus+ funded youth-friendly sex education [16]. Young people worldwide project (Safe4Play) that aims to develop an innovative tool for use the internet and social media to access information on sexual sex and reproductive health education for young people using and reproductive health and rights [16,17]. Interventions serious games with machine learning features. The aim of this delivered through digital media could particularly help reach review was to analyze the core elements and effects of video marginalized groups such as young people in rural areas; lesbian, game–based interventions for improving the sexual health of young people. The findings informed the development of the https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al intervention that was produced as part of the Safe4Play Study Characteristics initiative. We included randomized controlled trials (RCTs) and quasi-RCTs (studies in which participants were allocated to Methods different arms of the study using a method of allocation that is not truly random). Publications in either English or Spanish We conducted a rapid review following the Cochrane Rapid were considered. Reviews Method Group guidelines [22,23]. A rapid review can be defined as a type of knowledge synthesis in which the usual Search Strategy and Search Terms procedures of a traditional systematic review are streamlined The search strategy was validated by the Safe4Play research and accelerated such that the most crucial elements are still team and an information retrieval specialist from the University present, but the research time is considerably abridged [24]. of Bath. It was piloted to analyze the quality and quantity of its results; only small changes were made based on the findings. Criteria for Study Selection The criteria for selecting studies were based on the Population, We used 5 databases to identify relevant studies: Cochrane Intervention, Comparison, Outcomes, and Study characteristics Central Register of Controlled Trials, Embase, MEDLINE, framework. PsycINFO, and Scopus. Searches were conducted on April 23, 2021. In addition, we hand-searched the reference lists of the Population included trials for referenced articles that were not retrieved in This involved interventions aimed at working with youth (aged the original search. We also contacted experts in the field for 15-25 years). Where studies included participants who fell both additional recent publications that the original search might not inside and outside of our target bracket (eg, aged 12-16 years), have identified. For details of the search terms used for each of we tried, where possible, to select the appropriate results from the databases, see Multimedia Appendix 1. the subset of the sample that met our age criteria; if that was Study Selection not possible, we captured that specific limitation in the narrative form. A total of 2 steps were undertaken to assess the eligibility of the studies: title and abstract screening and full-text screening. Intervention A total of 2 reviewers (IFV and CG) were involved in the This involved any video game–based sexual health intervention process. Approximately 20% (51/257) of the abstracts were aimed at reducing risky sexual behavior. We considered a video independently screened by both reviewers, which served as a game–based intervention as an educational intervention pilot to identify any salient issues. The remaining 80% (206/257) delivered through an electronic or digital medium that relied of the abstracts were screened by IFV. Interrater reliability was heavily on game mechanics, aesthetics, or game thinking found to be moderate (weighted κ=0.53) [26]. All cases of (competition, cooperation, exploration, and storytelling) to uncertainty or discrepancy were resolved through discussions engage, motivate action, promote learning, and solve problems between the 2 reviewers. [25]. In the full-text screening stage, both reviewers independently Comparison screened half of the articles to confirm whether the studies identified during the title and abstract screening should be This criterion was not applicable. included. Reliability was found to be substantial (κ=0.71) [26]. Outcomes The same procedure was used to resolve any discrepancies between reviewers. The remaining articles were screened solely As we were broadly interested in sexual health, we chose to by IFV. include studies that assessed a broad range of knowledge, attitudinal, and behavioral variables. We defined primary Data extraction was performed by IFV. All pertinent data were outcomes as any of the following: decrease in unintended extracted from the full text using a spreadsheet template. When pregnancies and STIs, increase in contraceptive use, increase an intervention was analyzed in multiple papers, data from all in intention to use contraceptives, acquisition of new knowledge papers were considered during the extraction. regarding sexual health, change in the perception of risk of pregnancy, and change in the perception of risk of STIs. Results Secondary outcomes included changes in attitudes toward safe sex, self-efficacy toward sexual health, decrease in the number Search Results of sexual partners, increase in safe and consensual relationship As shown in Figure 1, the search strategy produced 449 results, practices, and increase in adherence to pre-exposure prophylaxis of which, after removing 132 (29.4%) duplicates, 317 (70.6%) (PrEP). articles remained (299/317, 94.3% of empirical papers, and Where studies reported >1 relevant outcome, each one was 18/317, 5.7% of reviews). All systematic reviews were scanned captured and reported in a narrative form. When outcomes were to identify additional articles to screen; 10 additional articles provided at multiple follow-up points, all outcomes were were found through this process. A total of 327 abstracts were reported for each follow-up point. deemed appropriate for screening. Overall, of the 327 articles found, 257 (78.6%) were screened at the title and abstract screening, leaving 70 (21.4%) articles https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al for full-text screening. These 70 articles were downloaded and In some cases, to obtain the information required to conduct a examined. After this final screening procedure of the 70 articles, proper analysis, additional supplementary materials had to be 60 (86%) articles were excluded, leaving 10 (14%) articles with downloaded. Most of these were in the form of protocols for suitable games to analyze. Most articles described 1 game each, trials or articles that reported preliminary results. In the although one of the articles evaluated 2 games. Thus, the final following sections, we briefly describe each of the identified search product was 11 games. games. Table 1 presents some of the key features (sample, location, and type of game) of each video game. Figure 1. Flow diagram from the article selection process. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Table 1. Key features of included studies. Game name Target population Age (years), Location and publication Console Type of game range date The Baby Game! [27] High school students 13-18 Hawaii, United States, PC Management simulator Romance [27] High school students 13-18 Hawaii, United States, PC Text adventure VODO [28] High school students 15 New Orleans, United PC Text adventure States, 1989 Choose Your Own Ad- High school sophomores 15-16 Kentucky, United States, PC Dating simulator venture [29] 2007 Men who have sex with 18-24 United States, 2013 PC 3D dating simulator SOLVE [30] men HIV risk game [31] Youth 15-19 Cape Town, South Africa, PC Quizzes Keep it up! [32-34] 18-29 Atlanta, Chicago, and PC Dating simulator and YMSM Georgia, United States, minigames BattleViro [35,36] Young patients of an- 14-26 Mississippi, United States, Smartphone (only Twin-stick shooter and tiretroviral therapy 2018 quizzes IOS ) Viral Combat [37] YMSM 18-35 Mississippi, United States, Smartphone (only Twin-stick shooter and 2021 IOS) quizzes MyPEEPS [38-40] Male youth sexually at- 13-18 United States, 2019 PC and smartphone Role-playing games tracted to men (any; usable as a web application) First-person scenario College students 17-27 Hong Kong—China, 2020 Smartphone (nonspec- First-person dating simu- ified) lator game [41,42] SOLVE: Socially Optimized Learning in Virtual Environments. YMSM: young men who have sex with men. IOS: iPhone Operating System. See Multimedia Appendix 2. sexuality and contraception, increase their skills for interaction, Identified Games and serve as a practice for responsible sexual decision-making. The Baby Game! VODO The Baby Game [27] is a management simulator in which high VODO [28] is a text adventure game in which high school school students are asked to simulate a budget and schedule students aged 15 years have to guide the main character through based on different scenarios. The students’ task is to establish a series of scenarios. The game presents the player with a how many hours they could devote to different activities (eg, detailed written description of a situation; for example, “You chores, homework, sleep, recreation, and caring for their baby). are in your room. It is a sunny room full of things that are They receive feedback, printed on a scorecard, based on how important to you. Tell the computer what you want to do?” The close their schedules are to a hidden correct time distribution. players then respond using simple English sentences; the game has an extensive vocabulary and is able to anticipate the The game aims to provide realistic information about the life responses typically provided by the students. Efforts were made changes that would occur if a student had a baby and how the so that although the player needs to make many choices, newly added responsibility might affect their lives, with the decisions are not presented overtly. This was done because the assumption that this would enhance young people’s intentions researchers wanted to convey the lesson that one has a choice, of delaying parenthood and using contraceptives. even when apparent conditions suggest otherwise. Romance An important aspect of this game is that it includes a roster of Romance [27] is a text adventure in which high school students nonplayer characters (NPCs) with whom a player can interact write down how they will deal with a set of scenarios of and even form relationships that may or may not involve sex. romantic and sexual nature. They then receive feedback in the Each of the NPCs has different names, personalities, and form of a simulated outcome. At the end of their run, players motives. In cases where the player chooses to have unprotected obtain a final scorecard based on the adequacy of their decisions. sex, the game creates a scenario in which the character has a The exercise aims to improve students’ knowledge about child. The child randomly cries for different reasons and requires https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al careful attention, creating tension between the character and in the game so that they would be different during each run. their friends. Furthermore, all in-game dialogs were recorded, and the NPCs actually spoke to the players. The other half of the module VODO was designed to improve participants’ decision-making comprised submitting an original refusal line. The researchers skills by providing a scenario in which they were able to reported that the entire module (game+refusal line submission) rehearse and obtain feedback on their choices. The topics had a completion rate of 41%. presented in the game were broad. Although they are focused on matters of sexual health (eg, contraceptive use, STIs, and Socially Optimized Learning in Virtual Environments the consequences of unwanted pregnancies), it also includes SOLVE (Socially Optimized Learning in Virtual Environments) other issues that might affect teenagers (eg, drunk driving, drug [30] is a 3D dating simulator aimed at men who have sex with use, and the ability to be alone without being lonely). Strategies men (MSM) aged 18 to 24 years who reported having engaged such as complementary quizzes were meant to increase real-life in recent unprotected anal intercourse (UAI). The settings are communication about sex within the family. constructed around different scenarios that might be faced by young MSM involving some form of sexual decision (eg, Choose Your Own Adventure meeting someone at a party and going to their apartment Choose your own adventure [29] is the name that we have afterward). In each situation, the player encounters a series of provided for 1 of the 6 modules that formed an unnamed choice points where they need to make self-regulatory decisions intervention aimed at reducing rates of unintended pregnancy (eg, accepting or refusing alcohol or offers of casual sex). After and STIs in adolescents from rural areas in the United States. choosing to engage (or not) in virtual sex, there is a customized The game comprises half of one of the modules. Players are recap sequence in which the player’s virtual behavior is shown expected to play through a virtual date and make choices that in sequence so that he can identify the different decisions that could put them in a situation where their dates want to have sex, led to a particular outcome (Figure 2). but they do not. The game finishes with different positive or The idea was that through rehearsal and feedback, players could negative outcomes and products of the in-game decisions that practice their decision-making skills. Throughout the process, were taken. To make the game more engaging and increase its they are guided by different NPCs (peers and one’s virtual future replay value, the developers built in some remarkable elements. self) who instruct them to follow a set of guidelines when faced For example, they included >150 images of various people, with risky situations. places, and STIs, which were randomly selected at various points Figure 2. SOLVE (Socially Optimized Learning in Virtual Environments) avatars [30]. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al diverse delivery methods (eg, videos, animation, and games) HIV Risk Game to improve HIV knowledge, motivate safer behaviors, teach This intervention [31], unnamed in the published article, is a skills, and increase self-efficacy for preventive behaviors. relatively simple game in which youth are expected to identify who was more likely to have HIV between 2 randomly generated BattleViro individuals. Each participant plays 10 rounds of the game. BattleViro [35] is a twin-stick shooter mobile game aimed at Instead of receiving a direct answer regarding whether they improving antiretroviral treatment adherence among young made the right choice, the participants receive information about MSM in the United States. During the game, players control an HIV and risk and construct their own learning based on their avatar that is shrunken down to fight viruses and other infections experimentation. in 6 levels of increasing challenge. Each level is set on a specific organ ranging from the lungs to the brain. Throughout the Keep it Up! different levels, the player shoots down threats to the host’s Keep it up! [32-34] is a 7-module, multi-method intervention body while picking up health points in the form of medicine (one that includes the use of >1 method of data collection in a (Figure 3). The character also receives messages from health study) aimed at improving STI prevention strategies among care personnel, encouraging them to carry on and providing young MSM in the United States. The main gaming component clues in challenging areas of the run. In addition, the player is called The Club Game. This game uses a real-life scenario might answer quizzes from clinician avatars to earn additional (going to the club) to explore decision-making around using points or powers. Wrong answers are corrected and explained. condoms; the steps to use condoms properly; and the effects of In addition to the game, participants with perfect adherence excessive alcohol consumption, drug use, and sexual arousal would receive congratulatory texts, whereas the other on decision-making. The player goes through 5 rooms and participants would receive motivational messages encouraging interacts with other patrons while completing the activities them to carry on. related to the abovementioned topics. The intervention uses Figure 3. BattleViro gameplay [35]. includes quizzes that go beyond PrEP adherence, including Viral Combat information on HIV and other STIs. Viral Combat [37] was developed by the same team that created MyPEEPS BattleViro. However, instead of targeting people already with HIV, this game attempts to promote PrEP adherence. The levels MyPEEPS [38-40] is a role-playing game in which young MSM are slightly different, as are the messages received by physicians with little to no sexual experience go through different scenarios and nurses; however, the main mechanics are similar. The game guided by 4 characters (the peeps) who teach them about sexual health care. The game comprises 4 sequential modules https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al (PEEPScapades). The completion of the different modules is intervention comprises short informative videos in which incentivized by in-app trophies. students are taught about different risks, such as sexual abuse and scams. It includes a first-person simulation game in which First-person Scenario Game the participant is presented with multiple choices when faced First-person scenario game (FPSG) is the name we have with real-life scenarios (Figure 4). The game was designed with provided for a multi-method intervention that aims to protect various algorithms that resulted in positive or adverse outcomes, university students from the risks of using dating apps. The depending on the character choices. Figure 4. First-person scenario game example screens [41] (translation available in Multimedia Appendix 2). On the basis of target population profiles, we divided the studies Results of Studies into 2 broad categories. First, there were those that were based In the following sections, we discuss the main results of our in an educational institution (high school or university), included review, structured around the findings related to the target people of all genders and sexual orientations, and focused on populations, interventions, outcomes, and study designs. contraception and STIs [27-29,41,42]. The second group was most commonly recruited from youth centers or sexual health Target Population clinics, focused exclusively on MSM, and had a clear focus on Finding games that were targeted exclusively at youth aged STI prevention and management [30,32,34,35,37,43,44]. between 15 and 25 years was not an easy task. Several identified Interventions interventions included some participants outside our selected age bracket, especially at the younger end of the age range. This Overview was likely due, in part, to the physical location where the In the following sections, we describe the elements of the 11 interventions were delivered. For example, several interventions games. However, first, it is important to note how little were conducted in high schools [27-29], including students from information about the games themselves was readily available both within and outside our age group. We did not find many in published articles. Authors often devoted little space to studies that included participants outside the upper end of our describing how the games looked and how they were played. age range. We found only 1 trial in which recruitment was done Considering that playing games is a visual activity, the inclusion in colleges; however, even in this particular setting, the number of images could have been a valuable way of providing this of students aged >25 years (our upper age limit) was small [41]. information. However, with some noteworthy exceptions Concerning gender and sexual orientation, many recent studies [27,30,35,41], this was rarely performed; most articles did not have focused on MSM and the prevention of STIs. A total of 7 include any form of visual aid to explain the game. Some articles studies had been conducted over the past 10 years; 5 of these included links to demos or webpages where the content was focused exclusively on MSM. All but one of the games targeted said to be available; however, in >1 case, the links were broken, urban youth; only 1 focused on rural populations [29]. or the page had already ceased to exist. Owing to the rapid https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al nature of this review, no author and game developers were As could be expected, these extremes in game difficulty were contacted during the process. not without their issues. A nonchallenging game can be boring and can inhibit engagement. At the same time, a too-challenging Game Age game can tire a proportion of the players out of the intervention. Regarding the age of the games themselves, we identified a In an effort to resolve these 2 positions, some game developers clear bimodal distribution; 3 games were created in the wake opted for an increasing level of difficulty; that is, instead of of the digital revolution ≥30 years ago, whereas the remaining having a flat, low-level difficulty throughout the experience or group was developed more recently. Earlier games were a series of extreme spikes every so often, these games ramp up graphically simpler but in no way less informative. We found the difficulty with every level [35,37]. it striking that from very early on, video games were seen as Expected Playthroughs and Playing Time valuable tools to promote learning and attitude change. There are 2 related elements to consider here: expected Gaming Platform playthroughs and expected contact time. In other words, how The interventions used different platforms to host the games. many times are players expected to play the game, and for how Considering the time span across which the games were long? As we will discuss in the following sections, repetition, developed, it is not surprising that the most commonly used rehearsal, and feedback play an essential role in learning through platform was that with the longest history, the PC. The changes games; therefore, it is expected that most games were designed in the games reflect the technological evolution that has affected to keep the player engaged in >1 run. Unfortunately, there is this platform. Although popular, tablets were only mentioned little information about these aspects in most of the included in one of the games [33]. As might be expected, when mobile articles. Among the games that specified an expected playing phones became widespread, the idea of using smartphones as time, we found periods of <1 hour of gaming. However, it was platforms for serious gaming became an option. Of the 4 not always clear whether these times were for single or multiple reviewed games for mobile phones, 2 (50%) were exclusively playthroughs. developed for the iPhone [35,37], whereas the other 2 (50%) Type of Game and Game Setting did not specify which operating system they worked with [38,42]. These later games used mobile connectivity to increase Game settings can be broadly divided into 2 types: realistic and participant engagement through push notifications and messages science fiction. There was a clear preference for the latter in [35,36]. However, it is noteworthy that most interventions did our sample of games. Most games were situated in locations not appear to use patches and updates to freshen their content, and environments to which the player could directly relate, such even when they were constantly connected to the internet. as hanging out with friends after school or going to a house party. The idea behind this is that a greater similarity between Accessibility and Difficulty the simulated situation and a plausible real-life event might A decision that is implicit in platform selection is accessibility. make it more likely that players will relate to the content and Most interventions aspire to be easily scalable. To achieve this, act upon what they have learned. Game developers have gone they must operate on an already popular and ubiquitous platform into great efforts to create content grounded in reality, where and use relatively little graphic processing power. We do not situations that the players have directly experienced are have access to the system requirements for any of the listed portrayed both didactically and accurately. For example, SOLVE games. However, based on their description, it appears most allowed players to personalize their avatars, and The Baby Game operated on or below the considered average computing power used actual prices when they calculated the costs of raising a at the time of their release. child. With regard to game difficulty, all interventions can be placed The types of games in the realistic group were highly diverse. on a continuum. On one end, there are games that provide an Table 1 presents a list of the different styles of games that were easy experience; that is, the game is seen as a vehicle through included. We want to highlight 3 features. First, the variety is which information can be provided in an entertaining fashion. notable; as can be seen, games ranged from management On the other end, we have games that provide a very demanding simulators to role-playing games. The second feature is the experience. The best example of this in the games we identified relative preponderance of the dating simulators. Approximately is VODO. The developers included a section of the game in 44% (4/9) of the nonfiction games were dating simulators. which the player needed to answer 2 questions about sexual However, even within this specific setting, we found different health. If either of these answers was incorrect, the game was styles (eg, text adventures, 3D, and chat simulators). Finally, over, and the player had to start all over again. This type of the role of complementary activities in each game should be failed outcome was a very common scenario of text adventures mentioned. Minigames are found in several games, particularly at the time and motivated the player to replay the game several in the form of quizzes [29,34,36,37]. This seems to have been times, learning all its intricacies. An even more challenging one of the main strategies through which game developers aspect of these questions is that the answers were not provided delivered specific sexual health knowledge. in-game. The player was meant to search elsewhere for However, not all games followed a realistic route. BattleViro information; or even better, the topic should become a and Viral Combat opted instead for science fiction in the action conversation starter for youth to discuss with their friends, setting [35,37]. In both games, the characters are shrunk down parents, or teachers. This is an example of how a severely to a microscopic scale and are meant to protect the human body challenging task was used to frustrate the players into action. from infections by shooting down viruses, bacteria, and vectors https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al of disease. Here, the developers tried to create a power fantasy Some games aim to provide knowledge, expecting that it will in which the player can take control of their actions and reach generate behavior change. For example, some games share facts a desirable healthy state. The content and settings were still about contraceptives, their efficacy, and the risks involved in related to the topic of focus (antiretroviral treatment and PrEP not using them. In such cases, one of the most critical elements adherence); however, the developers avoided making direct or is to provide a clear and easy-to-understand message. It has explicit statements about them. been noted that most interventions try to make the message grounded in a specific element or situation in the game. Many We can see that there is >1 valid strategy for promoting games focusing on providing knowledge prioritized the engagement with the material. One school of thought aims to provision of immediate and clear feedback, specifying where create easy-to-relate experiences, whereas the other uses a and when an error was made and what its potential outcomes fast-paced game to empower participants into action. might be. The same applies to decisions that have a positive Single or Multiplayer Game (Private or Social Experiences) outcome. For example, in SOLVE, when a player chose to engage (or not) in in-game sex, they were offered a quick recap An element mentioned throughout the different interventions of all the previous decisions that drove them to their current is the contrast between creating a single or multiplayer state (decisions that were not always apparent at the time they experience. In other words, was the game designed to be played were made). alone or with a group? Most of the games reviewed appear to have been designed for single-player use. However, it should The final element of knowledge is how it is constructed. We be noted that all single-player experiences can be turned into have previously stated that the message must be clearly stated. multiplayer experiences by the players themselves. Researchers However, for some interventions, this did not necessarily mean reported that, in several cases, games that were not meant to be that the message had to be explicitly delivered. For example, social experiences were transformed into a group activity when the HIV risk game had a clear message that needed to be a player spontaneously brought their friends or partner to play delivered: older people were more likely to have HIV than the game together and comment on it. younger people. Players played 10 rounds of the game in which they made a judgment about which character was more likely The decision to develop a single- or multiplayer game is affected to have HIV. As feedback, the players did not receive the correct by several factors. The first is the target population. answer; they only knew whether they were right or wrong. This Interventions focused on MSM were very keen on not outing key message was supposed to be inferred (constructed) by the their players involuntarily or having them openly disclose their participants based on their in-game experience. health information; hence, single-player games might have been preferred. Second, the game’s topic of focus is an important Two of the most frequently used strategies in games focused factor to consider. Some topics are easier to work with at the on increasing the participants’ skills and self-efficacy, which individual level than at the group level. For example, SOLVE was achieved by a mixture of relatability and rehearsal. By was a game that tried to decrease the feelings of shame that gay relatability, we mean all the different factors that can make the or bisexual men might experience regarding their sexual situation in a game similar to the ones players face or think they preferences [35]. Considering that many players had strong will face. The developers made great efforts to provide feelings of shame and were reticent to disclose information experiences grounded in those that the players have had or will about their sexual interests, they may not have been comfortable experience. The assumption is that, in general, the closer a playing a game with others. setting and its characters are to the real world, the easier it will be for the player to assimilate the lesson and put it into practice. The third influence is logistical, technological, or economic This is one of the reasons why several games designed restriction. When PCs were not ordinary household items but characters with different personalities and stories so that the specialized pieces of hardware, they were not as commonly player can easily associate 1 or several of them with their friends available as they are now. For this reason, older games tended and acquaintances. Similarly, one of the reasons why some to be a social experience; many people had to use the same avatars were customizable was to make it easier for players to computer to make it viable for enough players to play the game empathize with their in-game presence. The same can be said [27,28]. of the setting in which the interactions occur. In several cases, The final reason for choosing single- or multiplayer games the setting was very similar to that currently experienced by the relates to the learning strategy of choice. Some game developers players. One of the clearest cases of relatability is in the FPSG opted to purposely promote out-of-game discussions of sexual game. The player learns about the risks of dating apps by playing health topics [28]. The aim was to make the game a topic for a game that uses an instant messaging app as one of its primary discussion with family members, teachers, and friends. interfaces. Outcome Change Mechanisms Similarly, rehearsal and repetition also played a significant role There are several ways in which we could try to classify the in improving self-efficacy. The idea is that players will train underlying mechanisms used in video games to change specific themselves to make safe decisions in real life because they have behaviors in users. Here, we divided the mechanisms into 3 made the same correct decisions in a virtual world before. The categories: those based on knowledge, those focused on more times a player does something, the more likely it is for enhancing skills and self-efficacy, and those that motivate him or her to feel (and be) proficient in it. change through emotions. These groups are not mutually exclusive; 1 intervention might have >1 underlying mechanism. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al The final strategy relies on using emotions to generate a reaction Stakeholder Participation in the player. There are several methods in which this has been The teams in charge of designing the interventions frequently performed in different games. Some developers opted to made considerable efforts to involve different stakeholders generate negative emotions that frustrated or scared players into throughout the process. Among the stakeholders who action. For example, in Romance, if the players initiated participated in the design of games were end users [32,35,41], unprotected sex, they would have a baby that would cry members of nongovernmental organizations concerned with randomly during the game, negatively affecting their sexual health or youth well-being [34], and unspecified relationships with their friends. Other games used positive community leaders [28]. There is little to no mention of the emotions to inspire players to act. BattleViro and Viral Combat involvement of parents, teachers, or other authority figures. are good examples of this practice, having used fast action, Focus groups [34] and in-depth interviews [32,35] were used increasingly challenging shooter-style games to empower their to access stakeholders’ views. players to take control of their treatment. Finally, there were There were 3 main reasons for stakeholder involvement. The games that aimed to reduce the negative emotions that inhibit first reason was to conduct a needs assessment. This allowed players’ ability to do something. The best example of this the intervention designers to prioritize topics or behaviors that practice is SOLVE, a game whose main aim was to reduce the required specific attention. For example, in the development of feelings of shame that MSM might experience. Through a series the FPSG intervention, 4 focus groups were held by the of stories and vignettes, the intention was that the player might developer to identify key risks that caused concern among young consciously acknowledge their desires as something normal, people using dating apps in Hong Kong. The second reason to which carries no stigma. involve stakeholders was to improve the quality of the game Game Development itself. For example, Keep it up! conducted interviews with We cover 3 main topics in this section. We begin with a general stakeholders to ensure that the situations and languages they description of the development process of the games. We then used in their club games were similar to those experienced by assess the involvement of stakeholders in the creation of the young men in their everyday interactions [33]. This allowed game: who was invited, when, and in what capacity. them to generate greater engagement with the final users by presenting situations comparable with those they had Development Process experienced previously. Finally, approval from the governing The published papers provided little information on the body is needed. By involving community leaders and local development of game mechanics. There was often no data authorities, intervention designers could ensure that they would regarding how long the game design lasted, how much its budget receive support for the subsequent stages of the process. For was, who and how many people were involved, and what example, VODO involved people from 30 different local program or programs and engine or engines they used to create institutions to avoid the inclusion of content or situations that it. From conversations with researchers, we know that in some might have been perceived as unacceptable by the community cases, university-based groups were in charge of software [28]. development. However, apart from FPSG, very little additional Multi-Method Interventions information is readily available from these articles or other related publications on game development. A final element to discuss is that although all interventions relied considerably on video games to achieve their goals, it Some interventions adapted previous activities or interventions was not necessarily the only method they used. Approximately for the construction of new games. In some cases, existing 27% (3/11) of the games were meant to be played in conjunction materials and activities from previous interventions were adapted with other activities. to a video game form. The details of these interventions were usually left nebulous; however, we know that in the case of For these specific interventions, the games seem to be one of MyPEEPS, Keep it up!, and SOLVE, a considerable part of the the few activities in which the participants could take agency content of the games was taken from previous non–video and act upon the knowledge they received. For example, when game–based interventions. For example, MyPEEPS included 4 the participants are completing scales or watching videos, they characters (the titular peeps), who were a composite of are fairly passive, and the moments in which they play the games previously existing characters used during the formative phase are the only times when they really take control, make decisions, of the intervention. and see their results. Although no intervention specified the playing time, or the time used in the other modules, it appeared The development of other interventions was probably informed that the games were the activities that comprised most of the by existing games, although few articles provided much detail participants’ time. about this. The only exception to this trend was Viral Combat, heavily influenced by BattleViro [37]. The same team of Outcomes researchers developed both games, and one might even say that Overview the former is an improved version of the latter. In this section, we discuss the effectiveness of the interventions In summary, we found that interventions have either been in achieving their goals, organized by the outcomes adopted in developed entirely from scratch or based on a previous in-person our search criteria. Multimedia Appendix 3 provides a summary intervention. Explicit references to previously existing games of the results. were unusual in the reviewed studies. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Decrease in Unintended Pregnancies between intervention and data collection in Viral Combat, compounded by attrition of 32% of the original sample, might Rather unexpectedly, none of the studies assessed the number have biased the intervention results. However, one would also of pregnancies. There are 2 possible explanations for this. First, expect that participants who stayed longer would be more almost half of the chosen games were not marketed to women engaged, would have clocked in more hours in the game, and but to MSM. Second, the sample sizes were too small, and the would have a better overall performance. follow-up periods were too short, for the relatively low occurrence of pregnancy to become a viable measure of the In conclusion, we do not have enough evidence to clearly state success of an intervention. that games have a significant effect on increasing knowledge of sexual health topics. The variety of topics assessed, the Decrease in STIs limited amount of information regarding the content of the tests, Only Keep it up! used STI biomarkers to assess changes in STI and the large variability in the time between intervention and incidence. The researchers tested for chlamydia and gonorrhea postintervention assessment precludes our ability to establish through self-collection of rectal swabs. Through matched odds a clear causal relationship between playing and learning. ratios, the control group showed a 55% increase in STI incidence, whereas the treatment group showed a decrease of Changes in Perceived Risk of Pregnancy 51%. These results were significant; however, we must be Only 2 games assessed this variable. Romance asked participants mindful that this intervention had multiple components, and the to assess the odds of becoming pregnant when having video game was only one of them. unprotected sex. Improvements in favor of the treatment group immediately after they finished playing the game were reported. Increased Contraceptive Use Unexpectedly, a study on Choose Your Own Adventure found Approximately 27% (3/11) of interventions measured changes significant differences in favor of the control group. However, in reported contraceptive use. Unfortunately, they did so in very the researchers measured a construct called susceptibility, which different ways, which limited our ability to compare them. merged the perceived risk of pregnancy with the perceived risk Choose Your Own Adventure asked about condom use at the of STIs; thus, there might have been some cross-contamination last intercourse and found no effect of the intervention. The in the assessment. The authors speculated that their results might other 2 studies assessed the frequency of UAI with nonprimary be related to the fact that fewer people initiated sexual activities partners during the past 3 months. Although SOLVE was unable in the treatment group (ie, they were abstinent) than in the to show significant differences between the treatment and control group; hence, they did not feel at risk of any adverse control groups, Keep it up! reported a significant decrease in outcomes related to having sex. They also considered that as the number of UAI events 1 year after the start of the the treatment group was more aware of the risks and the intervention. measures they could take against them, they felt better able to In summary, studies on the effects of video game interventions protect themselves. on contraceptive use have shown inconsistent results. Changes in Perceived Risk of STIs Acquisition of New Knowledge Regarding Sexual Health Approximately 36% (4/11) of games addressed this topic. We The acquisition of new knowledge was one of the most have already discussed the findings of Choose Your Own commonly measured outcomes; however, the topics and Adventure. The entire intervention of the HIV risk game was measures varied significantly among the different interventions. centered on assessing the risk of someone having HIV based Frequently, ad hoc questionnaires were created to assess on their age and gender. Positive results were obtained for both differences between the treatment and control groups. The Baby men and women. The assessment was performed immediately Game quizzed participants on the costs (both time and money) after the intervention and 3 months later (the last time only for involved in taking care of a baby. Romance used the same male participants). methodology but compared knowledge about the efficacy of BattleViro and MyPEEPS also assessed the perceived risk of different contraceptive methods. Studies on both of these STIs but in an indirect fashion by asking about STI testing. interventions suggested improved knowledge in the treatment BattleViro measured the types of sexual behavior, frequency of group compared with the control group. However, we should sex, and number and gender of partners reported in the past 3 keep in mind that knowledge was assessed only immediately months. The authors found no differences between the control after the game ended and that no effect size measure was and treatment groups. MyPEEPS measured the frequency of presented. Other interventions also relied on ad hoc tests; STI testing and found that after the intervention, those in the however, it was unclear exactly what topics they explored. treatment group were more likely to get tested than those in the Choose Your Own Adventure showed positive results (of control group. medium effect size); however, VODO failed to do so. Both interventions followed a pretest-posttest design. Attitudinal Change Toward Safe Sex Approximately 18% (2/11) of interventions targeted attitudinal A comparable example is that of BattleViro and Viral Combat. changes toward safe sex. VODO measured participants’ attitudes They both tested their participants’ HIV knowledge, and toward sex on 2 axes: liberal versus conservative and positive although they were very similar games, only BattleViro showed versus negative. Both the control and treatment groups shifted positive results. It should be noted that BattleViro tested their to a more liberal position; however, the change was greater in participants 16 weeks after the intervention started, whereas the treatment group. The change in this group was sufficient Viral Combat did so at weeks 12 and 24. The extended period https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al for it to move, on average, from a conservative perspective weeks and 24 weeks after the beginning of the intervention; toward a liberal one. No significant changes were observed in however, these findings were not statistically significant. the positive and negative axes. Treatment adherence, measured by self-report in Viral Combat and by self-report plus electronic device records in BattleViro, Choose Your Own Adventure assessed the predisposition toward showed similar results. In this regard, no intervention showed waiting to have sex and found a significant effect of their better results than the usual treatment. MyPEEPS also measured intervention among students aged between 15 and 16 years. PrEP and postexposure prophylaxis adherence using After completing ≥1 of its modules, participants were more self-reported measures and found no significant differences likely than those in the control group to postpone sexual between the treatment and control groups. initiation. Study Designs Self-efficacy Toward Sexual Health Bearing in mind that our search criteria only allowed for RCTs Self-efficacy, be it general or specific to sexuality, was one of and quasi-RCTs, we identified 2 main study designs. Studies the most frequently chosen outcome variables across the were either posttest-only trials [31,37,43] or pretest-posttest different games. Choose Your Own Adventure considered 4 trials [27-30,33,35,36,42]. domains of sexual self-efficacy: condom negotiation self-efficacy, condom use self-efficacy, situational self-efficacy Depending on the study, the control group received different (the ability to control a situation that might be conducive to treatments. Waiting-list control was one of the most sex), and refusal self-efficacy (the ability to say no to sexual straightforward control designs. A more complex one was intercourse). However, the findings were mixed. The treatment as usual (TAU), where the usual or standard was given intervention increased participants’ self-efficacy toward condom to a group of participants. negotiation and situational self-efficacy; however, no effects For example, for The Baby Game, researchers compared their were found regarding condom use or refusal. It is not surprising game with a regular sexual health education class for that that condom use self-efficacy did not change considerably specific age group [28]. A similar option was TAU+. Here, the between groups as the intervention did not include any participants received TAU and an additional component that components that directly taught students how to apply and use was functionally similar but thematically different from the a condom. However, it did have 1 activity specifically focused experimental group. For example, as BattleViro provided on improving refusal skills, which was tightly tied to the game smartphones so that participants could play the game, they also itself. The fact that this activity failed to produce the desired provided smartphones to the control group. However, these results for this variable is noteworthy. iPhones did not have the specific game installed but another BattleViro and Viral Combat assessed a similar domain of non–HIV-related game [35]. Another form of control group self-efficacy: participants’ belief that they would be able to provided more or less the same content as the game but in a adhere to a treatment regime. Both interventions found no delivery mode that had no ludic or interactive elements. For significant change in either the short (12 weeks) or long-term example, Keep it up! provided an internet-based experience (16 weeks and 24 weeks) assessments. MyPEEPS reported with the same information as their intervention but using static positive results when assessing HIV self-efficacy in the short slides instead of the more dynamic approach taken with the term (3 months). Researchers have yet to publish their results treatment group. for the long-term assessments (6 months). Finally, in reviewing whether the studies had adequate sample We consider that the results on self-efficacy are mixed. sizes, we found that the sample sizes were generally large Considering that the interventions are varied in methodology enough to detect expected differences. Most studies, especially and topics and that they have worked on different domains of the more recent ones, determined their sample size based on a self-efficacy, this is not a particularly surprising result. power analysis (although this analysis was usually constructed around educated guesses). Even if the sample size in the Decrease in the Number of Sexual Partners reviewed studies was usually large enough, one of the main Approximately 27% (3/11) of interventions aimed at reducing threats to statistical power was a relatively large attrition rate, the number of sexual partners, all of them for MSM—Keep it especially among studies with multiple or long follow-ups. The up!, Viral Combat, and MyPEEPS—and none resulted in a most extreme case was in the HIV risk game study, which reduction in the number of sexual partners in their samples. reported an attrition rate of 66.8%. In the remaining studies, the attrition rate was approximately 30%. Increase in Adherence to Prophylaxis or Treatment Approximately 27% (3/11) of interventions focused on Discussion increasing adherence to either treatment or PrEP. BattleViro and Viral Combat used a mixture of bioindicators, self-reported Principal Findings behavior, and electronic device follow-ups to assess this The findings of our review yielded important conclusions and outcome. A total of 2 bioindicators were used: HIV-1 viral load implications for future research and game development. First, in BattleViro and 1ARV (activator protein 1) levels in Viral the findings highlighted considerable diversity in video Combat. BattleViro produced equivalent decreases in HIV-1 game–based interventions. Although all of them addressed viral load in both treatment and control groups. Viral Combat similar topics, they did so in fairly distinct ways. The outcomes reported results that favored the treatment group at both 12 assessed in studies evaluating games were also very diverse https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al and, even when similar, were measured differently in each study. on any of these games being picked up for broad distribution. Second, we found that game developers have made great efforts In fact, only BattleViro was readily available for download. to elicit experiences tailored to the specific needs of the targeted Moreover, although the interventions were very varied, almost population, most often achieving this through regular all of them targeted people living in urban areas of the United stakeholder participation activities throughout the game States. There were no interventions developed with populations development process. from lower-income countries in mind, and almost no interventions were aimed at rural populations. Finally, very few One of the most surprising findings was the age of the identified interventions were informed by a behavioral theory or model. games. The fact that the games were developed over such an extended period suggests that even when the graphical Strengths and Limitations complexity and the interface changed considerably, learning Our review had some notable strengths. We followed the through gaming is and has been seen as a viable and successful Cochrane Rapid Reviews Method Group guidelines [22,24] to strategy. conduct the review and searched several key literature databases. A second reviewer was involved in screening 20% (51/257) of However, although game interventions for sexual health have the articles at the title and abstract screening stage and 50% been in existence for almost three decades, relatively few studies (35/70) of the articles at the full-text screening stage. have evaluated them, and the results of previous studies have been mixed. Moreover, there is little clarity regarding which Some limitations of our review should also be acknowledged. specific elements of a game facilitate a positive outcome. This As this review was rapid, our search used 5 databases; thus, we is partly because of the diversity of the behavior change may not have identified all the relevant literature. We restricted mechanisms underlying interventions, the variety of the games our age range to 15 to 25 years and, in the screening process, themselves, the populations they target, the outcomes measured, noticed that some interesting game-based interventions focused and how these are measured. All these differences make it on younger adolescents and children. A final limitation was that challenging to identify a clear causal link between playing a we did not exclude studies based on quality. game and improving an aspect of sexual health. However, Conclusions and Recommendations although the impact on sexual health is not always clear, the fact that video game–based interventions are of interest to most In conclusion, we do not have enough evidence to clearly state young people is well-established. that games have a significant effect on sexual health among young people. The interventions and how they were evaluated Nevertheless, there are other less positive aspects of research were too diverse to reach a clear conclusion. However, based in this area that we need to acknowledge. First, there is a lack on the original authors’ criteria for success, we have compiled of information available in published reports on different games, a set of recommendations for developing game-based especially in the gameplay aspect. This ties to another interventions to improve sexual health in young people (Textbox unexpected finding of our review. Although video game–based 1). interventions are meant to be easily scalable, there are no reports https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Textbox 1. Recommendations for developing game-based interventions to improve sexual health in young people. Recommendations for developing game-based interventions to improve sexual health Stakeholders should be involved in different stages of the game development process. Most successful strategies used qualitative participatory methods involving multiple stakeholders. A pilot phase in the development of games is strongly encouraged. This enables specific elements that could otherwise jeopardize the success of the initiative to be identified and modified. One of the most crucial decisions during the game development process is whether intervention participants are expected to go through the game once or multiple times. This affects the length, difficulty setting, and the main mechanics of the game. There are several viable ways in which a game can try to change someone’s behavior. None have proven to be markedly better than the others. However, some recommendations are as follows: Knowledge-based interventions should aim to provide a clear message, and this message does not need to be explicit. In fact, some researchers recommend that the message is not explicitly stated but constructed by the players themselves. Self-efficacy and skill-building interventions aim to provide easily relatable experiences and those that feel proximal to the player. The closer the player feels a game experience is to their own experience, the more likely it is that they will act upon it. The game serves as a rehearsal for the decisions they will make in real life. Disregarding the mechanisms chosen by developers, some common elements are shared by most strategies: Feedback is better if it is clear, detailed, and immediate. When playing, it is encouraged that users recap their decisions and learn which actions drove them to their current stage (whether positive or negative). Repetition (as long as it does not transform into tediousness) is usually favorable, especially for skill building and knowledge acquisition. There are 3 common threats that plague these interventions: Lack of technical support, especially after the game development phase ends, is a common threat. Another threat is the stagnation of the content; that is, no updates are provided, and no new content is delivered. The games are not easily found when someone wants to use them in other contexts. The created game should be openly available on the web if possible. Game quality indicators (including playing time) were registered using self-reported measures. A suitable workaround using in-game data collection is recommended to bypass social desirability and recall issues that affect purely self-reported information. A plan for the implementation of the intervention should be made at the early stage of the project. Acknowledgments This study was funded by an Erasmus+ grant (project number 2020-2-UK01-KA205-079645). Conflicts of Interest None declared. Multimedia Appendix 1 Search strategy. [PDF File (Adobe PDF File), 117 KB-Multimedia Appendix 1] Multimedia Appendix 2 First-person scenario game example—English translation. [PDF File (Adobe PDF File), 240 KB-Multimedia Appendix 2] Multimedia Appendix 3 Summary of results per intervention. [DOCX File , 16 KB-Multimedia Appendix 3] References https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al 1. Rowley J, Vander Hoorn S, Korenromp E, Low N, Unemo M, Abu-Raddad LJ, et al. Chlamydia, gonorrhoea, trichomoniasis and syphilis: global prevalence and incidence estimates, 2016. Bull World Health Organ 2019 Aug 01;97(8):548-62P [FREE Full text] [doi: 10.2471/BLT.18.228486] [Medline: 31384073] 2. 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J Clin Epidemiol 2021 Feb;130:13-22 [FREE Full text] [doi: 10.1016/j.jclinepi.2020.10.007] [Medline: 33068715] 23. Garritty C, Gartlehner G, Kamel C, King VJ, Nussbaumer-Streit B, Stevens A, et al. Cochrane Rapid Reviews: Interim Guidance from the Cochrane Rapid Reviews Methods Group. Cochrane Methods Rapid Reviews. 2020 Mar. URL: http:/ /methods.cochrane.org/sites/methods.cochrane.org.rapidreviews/files/uploads/cochrane_rr_-_guidance-23mar2020-final. pdf [accessed 2022-05-13] https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al 24. Ganann R, Ciliska D, Thomas H. Expediting systematic reviews: methods and implications of rapid reviews. Implement Sci 2010 Jul 19;5:56 [FREE Full text] [doi: 10.1186/1748-5908-5-56] [Medline: 20642853] 25. Kapp KM. The Gamification of Learning and Instruction: Game-based Methods and Strategies for Training and Education. San Francisco, CA, USA: Pfeiffer; 2012. 26. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977 Mar;33(1):159-174. [Medline: 843571] 27. Paperny DM, Starn JR. Adolescent pregnancy prevention by health education computer games: computer-assisted instruction of knowledge and attitudes. Pediatrics 1989 May;83(5):742-752. [Medline: 2654867] 28. Alemi F, Cherry F, Meffert G. Rehearsing decisions may help teenagers: an evaluation of a simulation game. Comput Biol Med 1989;19(4):283-290. [doi: 10.1016/0010-4825(89)90015-2] [Medline: 2680255] 29. Roberto AJ, Zimmerman RS, Carlyle KE, Abner EL. A computer-based approach to preventing pregnancy, STD, and HIV in rural adolescents. J Health Commun 2007;12(1):53-76. [doi: 10.1080/10810730601096622] [Medline: 17365349] 30. Christensen JL, Miller LC, Appleby PR, Corsbie-Massay C, Godoy CG, Marsella SC, et al. Reducing shame in a game that predicts HIV risk reduction for young adult MSM: a randomized trial delivered nationally over the Web. J Int AIDS Soc 2013 Nov 13;16(3 Suppl 2):18716 [FREE Full text] [doi: 10.7448/IAS.16.3.18716] [Medline: 24242264] 31. Datta S, Burns J, Maughan-Brown B, Darling M, Eyal K. Risking it all for love? Resetting beliefs about HIV risk among low-income South African teens. J Econ Behav Organ 2015 Oct;118:184-198. [doi: 10.1016/j.jebo.2015.02.020] 32. Motley DN, Hammond S, Mustanski B. Strategies chosen by YMSM during goal setting to reduce risk for HIV and other sexually transmitted infections: results from the Keep It Up! 2.0 prevention trial. AIDS Educ Prev 2017 Feb;29(1):1-13 [FREE Full text] [doi: 10.1521/aeap.2017.29.1.1] [Medline: 28195780] 33. Mustanski B, Madkins K, Greene GJ, Parsons JT, Johnson BA, Sullivan P, et al. Internet-based HIV prevention with at-home sexually transmitted infection testing for young men having sex with men: study protocol of a randomized controlled trial of Keep It Up! 2.0. JMIR Res Protoc 2017 Jan 07;6(1):e1 [FREE Full text] [doi: 10.2196/resprot.5740] [Medline: 28062389] 34. Mustanski B, Parsons JT, Sullivan PS, Madkins K, Rosenberg E, Swann G. Biomedical and behavioral outcomes of Keep It Up!: an eHealth HIV prevention program RCT. Am J Prev Med 2018 Aug;55(2):151-158 [FREE Full text] [doi: 10.1016/j.amepre.2018.04.026] [Medline: 29937115] 35. Whiteley L, Brown LK, Mena L, Craker L, Arnold T. Enhancing health among youth living with HIV using an iPhone game. AIDS Care 2018;30(sup4):21-33 [FREE Full text] [doi: 10.1080/09540121.2018.1503224] [Medline: 30626196] 36. Whiteley L, Mena L, Craker LK, Healy MG, Brown LK. Creating a theoretically grounded gaming app to increase adherence to pre-exposure prophylaxis: lessons from the development of the viral combat mobile phone game. JMIR Serious Games 2019 Mar 27;7(1):e11861 [FREE Full text] [doi: 10.2196/11861] [Medline: 30916652] 37. Whiteley L, Craker L, Haubrick KK, Arnold T, Mena L, Olsen E, et al. The impact of a mobile gaming intervention to increase adherence to pre-exposure prophylaxis. AIDS Behav 2021 Jun;25(6):1884-1889. [doi: 10.1007/s10461-020-03118-3] [Medline: 33483897] 38. Kuhns LM, Garofalo R, Hidalgo M, Hirshfield S, Pearson C, Bruce J, et al. A randomized controlled efficacy trial of an mHealth HIV prevention intervention for sexual minority young men: MyPEEPS mobile study protocol. BMC Public Health 2020 Jan 15;20(1):65 [FREE Full text] [doi: 10.1186/s12889-020-8180-4] [Medline: 31941475] 39. Schnall R, Kuhns L, Pearson C, Bruce J, Batey DS, Radix A, et al. Preliminary results from a pragmatic clinical trial of MYPEEPS mobile to improve HIV prevention behaviors in young men. Stud Health Technol Inform 2020 Jun 16;270:1365-1366 [FREE Full text] [doi: 10.3233/SHTI200444] [Medline: 32570661] 40. Ignacio M, Garofalo R, Pearson C, Kuhns LM, Bruce J, Scott Batey DS, et al. Pilot feasibility trial of the MyPEEPS mobile app to reduce sexual risk among young men in 4 cities. JAMIA Open 2019 Jul;2(2):272-279 [FREE Full text] [doi: 10.1093/jamiaopen/ooz008] [Medline: 31294422] 41. Wong WC, Song L, See C, Lau ST, Sun WH, Choi KW, et al. Using crowdsourcing to develop a peer-led intervention for safer dating app use: pilot study. JMIR Form Res 2020 Apr 21;4(4):e12098 [FREE Full text] [doi: 10.2196/12098] [Medline: 32314975] 42. Wong WC, Sun WH, Chia SM, Tucker JD, Mak WP, Song L, et al. Effectiveness of a peer-led Web-based intervention to improve general self-efficacy in using dating apps among young adults: randomized clustered trial. J Med Internet Res 2020 Oct 30;22(10):e16378 [FREE Full text] [doi: 10.2196/16378] [Medline: 33124987] 43. Hidalgo MA, Kuhns LM, Hotton AL, Johnson AK, Mustanski B, Garofalo R. The MyPEEPS randomized controlled trial: a pilot of preliminary efficacy, feasibility, and acceptability of a group-level, HIV risk reduction intervention for young men who have sex with men. Arch Sex Behav 2015 Feb;44(2):475-485 [FREE Full text] [doi: 10.1007/s10508-014-0347-6] [Medline: 25135064] 44. Gordián-Arroyo A, Garofalo R, Kuhns LM, Pearson C, Bruce J, Batey DS, et al. Awareness, willingness, and perceived efficacy of pre-exposure prophylaxis among adolescent sexual minority males. J Urban Health 2020 Oct;97(5):749-757 [FREE Full text] [doi: 10.1007/s11524-020-00447-5] [Medline: 32789625] https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Abbreviations FPSG: first-person scenario game MSM: men who have sex with men NPC: nonplayer character PrEP: pre-exposure prophylaxis RCT: randomized controlled trial SOLVE: Socially Optimized Learning in Virtual Environments STI: sexually transmitted infection TAU: treatment as usual UAI: unprotected anal intercourse Edited by N Zary; submitted 27.08.21; peer-reviewed by E Olsen, E Rahmani; comments to author 05.03.22; revised version received 19.03.22; accepted 07.04.22; published 19.05.22 Please cite as: Franco Vega I, Eleftheriou A, Graham C JMIR Serious Games 2022;10(2):e33207 URL: https://games.jmir.org/2022/2/e33207 doi: 10.2196/33207 PMID: ©Ignacio Franco Vega, Anastasia Eleftheriou, Cynthia Graham. Originally published in JMIR Serious Games (https://games.jmir.org), 19.05.2022. 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 https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 18 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Using Video Games to Improve the Sexual Health of Young People Aged 15 to 25 Years: Rapid Review

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JMIR Publications
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2291-9279
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10.2196/33207
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Abstract

Background: Sexually transmitted infections and unintended pregnancies among young people remain public health concerns in many countries. To date, interventions that address these concerns have had limited success. Serious games are increasingly being used as educational tools in health and professional public education. Although acknowledged as having great potential, few studies have evaluated the use of serious games in sexual health education among young people, and to date, there have been no published reviews of these studies. Objective: This study aims to assess the effects of video game–based sexual health interventions for risky sexual behavior in young people aged between 15 and 25 years. Methods: A rapid review of randomized controlled trials and quasi–randomized controlled trials was performed. The search included the following bibliographic databases: Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PsycINFO, and Scopus. A total of 2 reviewers independently screened 50% (35/70) of the retrieved articles during the full-text screening phase. Results: From a total of 459 identified citations, after removing duplicates, 327 (71.2%) articles were deemed eligible for title and abstract screening. Of the 327 articles, 70 (21.4%) full texts were screened, from which 10 (3.1%) articles (evaluating 11 different games) were included in the review. The findings highlighted the considerable diversity in video game–based interventions and assessed sexual health outcomes. Although there were some promising findings in outcome studies using game-based interventions, the results across studies were mixed. Conclusions: Although game interventions for sexual health have been in existence for almost three decades, relatively few studies have evaluated them, and the results of previous outcome studies have been mixed. Moreover, there is little clarity regarding which specific elements of a game facilitate positive outcomes. We provide recommendations for future researchers developing video game–based interventions to improve sexual health in young people. (JMIR Serious Games 2022;10(2):e33207) doi: 10.2196/33207 KEYWORDS sex education; serious games; sexually transmitted infections; rapid review; mobile phone https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al gay, bisexual, transgender, and intersex individuals; people with Introduction disabilities; and migrant populations [17]. Background It has been argued that education through games is more efficient and enjoyable than classroom teaching for several Although contraceptive access and sexual education are more reasons [18]. First, it is predominantly the player who directs widely available than ever, risky sexual behavior remains an activity in games, whereas in school, it is predominantly the issue for people of all ages, especially younger individuals. teacher who directs activity. This is why serious games use a More than 1 million sexually transmitted infections (STIs) are learner-centered approach in which learners are involved in the acquired each day worldwide among individuals aged between process (learning through doing), in contrast to traditional 15 and 49 years [1,2]. The most common STIs are chlamydia, education, which uses a teacher-centered approach in which gonorrhea, and trichomoniasis, although the diagnosis of syphilis learners are relatively passive. has also increased in recent years [1]. In many countries, young people aged between 15 and 24 years have the highest rates of Second, children and adolescents often find it difficult to STIs [3,4]. Despite global and national efforts to stop the spread properly engage in school exercises [19], in which the challenge of STIs, the World Health Organization recently reported a level is not well adjusted to their skills. In a class, there are “concerning lack of progress” in achieving reductions [5]. many students with different skills, making it difficult for teachers to equally engage all students in the class. In contrast, The best method for preventing the spread of STIs is the correct video games engage players naturally by gradually adjusting use of condoms [6]. However, many young people [7] engage their difficulty level as they progress in the game [20]. Game in risky sexual behaviors such as having sex with multiple developers understand that for a game to be successful, players partners without the use of condoms or incorrect or incomplete of varying abilities need to feel a sense of reward or condom use [8]. Many interventions have been developed to achievement, often enough to retain their engagement. encourage consistent condom use and safer sexual behaviors; however, most of these interventions have been shown to have Third, students are sometimes discouraged by the school system limited effectiveness and/or are very resource intensive [9,10]. as they are penalized for the mistakes they make (eg, they receive bad grades). However, in games, players are expected Adolescent pregnancies are also a global concern in high-, to make wrong decisions and do so without being discouraged middle-, and low-income countries. Although the past 30 years (ideally, unless the game is poorly designed). In fact, games have seen a global decline in unintended pregnancy rates, a have the advantage of allowing users to train in real-life recent review of 166 low- to middle-income countries reported decision-making situations where the wrong choice may involve that approximately half of all pregnancies are unintended [11]. some risk without having to actually be at risk. For example, Furthermore, although rates of unintended pregnancies in the pilots often train using Microsoft Flight Simulator, whereas the United States and the United Kingdom have dropped in recent military often uses battle simulators to train recruits. This allows decades [12], adolescent pregnancy rates remain high in many players to make mistakes in a safe environment. middle- to high-income countries (particularly in the United States) [13]. Finally, an important characteristic of educational games is the constant real-time feedback provided to the user. Players almost Despite consistent evidence that comprehensive sex education instantly know how well a certain move or strategy works can increase protective behaviors [14], there are still many gaps toward the goal of the game. Feedback can take the form of in knowledge. Furthermore, access to contraceptives and sexual points, lives, levels, scores, ranks, or progress bars. Real-time health services for young people remains limited in many feedback ensures that users are motivated throughout the game countries [4]. Sex education, often delivered in schools as part by promising that a goal is achievable. of the national curriculum, can be a highly contested area, reflecting political, moral, and cultural debates. In the United Some authors have argued that there is a strong case for States, school-based sex education curricula have long been integrating video games into sex education, whether by criticized for being sex negative, often focusing on abstinence supplementing sex education classes with existing games that and omitting any mention of nonheterosexual experiences explore sex and sexuality or developing new games for the [15,16]. In many countries, traditional gatekeepers such as purpose of sex education [21]. Given the interactive nature of religious and educational authorities still powerfully restrict video games, their lack of real consequences, their capacity for access, content, and materials used for sex education [4]. privacy, and the familiarity that many adolescents already have Therefore, for many young people, obtaining reliable with games, when used correctly, games could be very effective information about sex and relationships can be difficult. tools for students. The internet has been identified as a potentially valuable Aims of the Review resource for comprehensive, interactive, web-based, and This review was conducted as part of a larger Erasmus+ funded youth-friendly sex education [16]. Young people worldwide project (Safe4Play) that aims to develop an innovative tool for use the internet and social media to access information on sexual sex and reproductive health education for young people using and reproductive health and rights [16,17]. Interventions serious games with machine learning features. The aim of this delivered through digital media could particularly help reach review was to analyze the core elements and effects of video marginalized groups such as young people in rural areas; lesbian, game–based interventions for improving the sexual health of young people. The findings informed the development of the https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al intervention that was produced as part of the Safe4Play Study Characteristics initiative. We included randomized controlled trials (RCTs) and quasi-RCTs (studies in which participants were allocated to Methods different arms of the study using a method of allocation that is not truly random). Publications in either English or Spanish We conducted a rapid review following the Cochrane Rapid were considered. Reviews Method Group guidelines [22,23]. A rapid review can be defined as a type of knowledge synthesis in which the usual Search Strategy and Search Terms procedures of a traditional systematic review are streamlined The search strategy was validated by the Safe4Play research and accelerated such that the most crucial elements are still team and an information retrieval specialist from the University present, but the research time is considerably abridged [24]. of Bath. It was piloted to analyze the quality and quantity of its results; only small changes were made based on the findings. Criteria for Study Selection The criteria for selecting studies were based on the Population, We used 5 databases to identify relevant studies: Cochrane Intervention, Comparison, Outcomes, and Study characteristics Central Register of Controlled Trials, Embase, MEDLINE, framework. PsycINFO, and Scopus. Searches were conducted on April 23, 2021. In addition, we hand-searched the reference lists of the Population included trials for referenced articles that were not retrieved in This involved interventions aimed at working with youth (aged the original search. We also contacted experts in the field for 15-25 years). Where studies included participants who fell both additional recent publications that the original search might not inside and outside of our target bracket (eg, aged 12-16 years), have identified. For details of the search terms used for each of we tried, where possible, to select the appropriate results from the databases, see Multimedia Appendix 1. the subset of the sample that met our age criteria; if that was Study Selection not possible, we captured that specific limitation in the narrative form. A total of 2 steps were undertaken to assess the eligibility of the studies: title and abstract screening and full-text screening. Intervention A total of 2 reviewers (IFV and CG) were involved in the This involved any video game–based sexual health intervention process. Approximately 20% (51/257) of the abstracts were aimed at reducing risky sexual behavior. We considered a video independently screened by both reviewers, which served as a game–based intervention as an educational intervention pilot to identify any salient issues. The remaining 80% (206/257) delivered through an electronic or digital medium that relied of the abstracts were screened by IFV. Interrater reliability was heavily on game mechanics, aesthetics, or game thinking found to be moderate (weighted κ=0.53) [26]. All cases of (competition, cooperation, exploration, and storytelling) to uncertainty or discrepancy were resolved through discussions engage, motivate action, promote learning, and solve problems between the 2 reviewers. [25]. In the full-text screening stage, both reviewers independently Comparison screened half of the articles to confirm whether the studies identified during the title and abstract screening should be This criterion was not applicable. included. Reliability was found to be substantial (κ=0.71) [26]. Outcomes The same procedure was used to resolve any discrepancies between reviewers. The remaining articles were screened solely As we were broadly interested in sexual health, we chose to by IFV. include studies that assessed a broad range of knowledge, attitudinal, and behavioral variables. We defined primary Data extraction was performed by IFV. All pertinent data were outcomes as any of the following: decrease in unintended extracted from the full text using a spreadsheet template. When pregnancies and STIs, increase in contraceptive use, increase an intervention was analyzed in multiple papers, data from all in intention to use contraceptives, acquisition of new knowledge papers were considered during the extraction. regarding sexual health, change in the perception of risk of pregnancy, and change in the perception of risk of STIs. Results Secondary outcomes included changes in attitudes toward safe sex, self-efficacy toward sexual health, decrease in the number Search Results of sexual partners, increase in safe and consensual relationship As shown in Figure 1, the search strategy produced 449 results, practices, and increase in adherence to pre-exposure prophylaxis of which, after removing 132 (29.4%) duplicates, 317 (70.6%) (PrEP). articles remained (299/317, 94.3% of empirical papers, and Where studies reported >1 relevant outcome, each one was 18/317, 5.7% of reviews). All systematic reviews were scanned captured and reported in a narrative form. When outcomes were to identify additional articles to screen; 10 additional articles provided at multiple follow-up points, all outcomes were were found through this process. A total of 327 abstracts were reported for each follow-up point. deemed appropriate for screening. Overall, of the 327 articles found, 257 (78.6%) were screened at the title and abstract screening, leaving 70 (21.4%) articles https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al for full-text screening. These 70 articles were downloaded and In some cases, to obtain the information required to conduct a examined. After this final screening procedure of the 70 articles, proper analysis, additional supplementary materials had to be 60 (86%) articles were excluded, leaving 10 (14%) articles with downloaded. Most of these were in the form of protocols for suitable games to analyze. Most articles described 1 game each, trials or articles that reported preliminary results. In the although one of the articles evaluated 2 games. Thus, the final following sections, we briefly describe each of the identified search product was 11 games. games. Table 1 presents some of the key features (sample, location, and type of game) of each video game. Figure 1. Flow diagram from the article selection process. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Table 1. Key features of included studies. Game name Target population Age (years), Location and publication Console Type of game range date The Baby Game! [27] High school students 13-18 Hawaii, United States, PC Management simulator Romance [27] High school students 13-18 Hawaii, United States, PC Text adventure VODO [28] High school students 15 New Orleans, United PC Text adventure States, 1989 Choose Your Own Ad- High school sophomores 15-16 Kentucky, United States, PC Dating simulator venture [29] 2007 Men who have sex with 18-24 United States, 2013 PC 3D dating simulator SOLVE [30] men HIV risk game [31] Youth 15-19 Cape Town, South Africa, PC Quizzes Keep it up! [32-34] 18-29 Atlanta, Chicago, and PC Dating simulator and YMSM Georgia, United States, minigames BattleViro [35,36] Young patients of an- 14-26 Mississippi, United States, Smartphone (only Twin-stick shooter and tiretroviral therapy 2018 quizzes IOS ) Viral Combat [37] YMSM 18-35 Mississippi, United States, Smartphone (only Twin-stick shooter and 2021 IOS) quizzes MyPEEPS [38-40] Male youth sexually at- 13-18 United States, 2019 PC and smartphone Role-playing games tracted to men (any; usable as a web application) First-person scenario College students 17-27 Hong Kong—China, 2020 Smartphone (nonspec- First-person dating simu- ified) lator game [41,42] SOLVE: Socially Optimized Learning in Virtual Environments. YMSM: young men who have sex with men. IOS: iPhone Operating System. See Multimedia Appendix 2. sexuality and contraception, increase their skills for interaction, Identified Games and serve as a practice for responsible sexual decision-making. The Baby Game! VODO The Baby Game [27] is a management simulator in which high VODO [28] is a text adventure game in which high school school students are asked to simulate a budget and schedule students aged 15 years have to guide the main character through based on different scenarios. The students’ task is to establish a series of scenarios. The game presents the player with a how many hours they could devote to different activities (eg, detailed written description of a situation; for example, “You chores, homework, sleep, recreation, and caring for their baby). are in your room. It is a sunny room full of things that are They receive feedback, printed on a scorecard, based on how important to you. Tell the computer what you want to do?” The close their schedules are to a hidden correct time distribution. players then respond using simple English sentences; the game has an extensive vocabulary and is able to anticipate the The game aims to provide realistic information about the life responses typically provided by the students. Efforts were made changes that would occur if a student had a baby and how the so that although the player needs to make many choices, newly added responsibility might affect their lives, with the decisions are not presented overtly. This was done because the assumption that this would enhance young people’s intentions researchers wanted to convey the lesson that one has a choice, of delaying parenthood and using contraceptives. even when apparent conditions suggest otherwise. Romance An important aspect of this game is that it includes a roster of Romance [27] is a text adventure in which high school students nonplayer characters (NPCs) with whom a player can interact write down how they will deal with a set of scenarios of and even form relationships that may or may not involve sex. romantic and sexual nature. They then receive feedback in the Each of the NPCs has different names, personalities, and form of a simulated outcome. At the end of their run, players motives. In cases where the player chooses to have unprotected obtain a final scorecard based on the adequacy of their decisions. sex, the game creates a scenario in which the character has a The exercise aims to improve students’ knowledge about child. The child randomly cries for different reasons and requires https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al careful attention, creating tension between the character and in the game so that they would be different during each run. their friends. Furthermore, all in-game dialogs were recorded, and the NPCs actually spoke to the players. The other half of the module VODO was designed to improve participants’ decision-making comprised submitting an original refusal line. The researchers skills by providing a scenario in which they were able to reported that the entire module (game+refusal line submission) rehearse and obtain feedback on their choices. The topics had a completion rate of 41%. presented in the game were broad. Although they are focused on matters of sexual health (eg, contraceptive use, STIs, and Socially Optimized Learning in Virtual Environments the consequences of unwanted pregnancies), it also includes SOLVE (Socially Optimized Learning in Virtual Environments) other issues that might affect teenagers (eg, drunk driving, drug [30] is a 3D dating simulator aimed at men who have sex with use, and the ability to be alone without being lonely). Strategies men (MSM) aged 18 to 24 years who reported having engaged such as complementary quizzes were meant to increase real-life in recent unprotected anal intercourse (UAI). The settings are communication about sex within the family. constructed around different scenarios that might be faced by young MSM involving some form of sexual decision (eg, Choose Your Own Adventure meeting someone at a party and going to their apartment Choose your own adventure [29] is the name that we have afterward). In each situation, the player encounters a series of provided for 1 of the 6 modules that formed an unnamed choice points where they need to make self-regulatory decisions intervention aimed at reducing rates of unintended pregnancy (eg, accepting or refusing alcohol or offers of casual sex). After and STIs in adolescents from rural areas in the United States. choosing to engage (or not) in virtual sex, there is a customized The game comprises half of one of the modules. Players are recap sequence in which the player’s virtual behavior is shown expected to play through a virtual date and make choices that in sequence so that he can identify the different decisions that could put them in a situation where their dates want to have sex, led to a particular outcome (Figure 2). but they do not. The game finishes with different positive or The idea was that through rehearsal and feedback, players could negative outcomes and products of the in-game decisions that practice their decision-making skills. Throughout the process, were taken. To make the game more engaging and increase its they are guided by different NPCs (peers and one’s virtual future replay value, the developers built in some remarkable elements. self) who instruct them to follow a set of guidelines when faced For example, they included >150 images of various people, with risky situations. places, and STIs, which were randomly selected at various points Figure 2. SOLVE (Socially Optimized Learning in Virtual Environments) avatars [30]. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al diverse delivery methods (eg, videos, animation, and games) HIV Risk Game to improve HIV knowledge, motivate safer behaviors, teach This intervention [31], unnamed in the published article, is a skills, and increase self-efficacy for preventive behaviors. relatively simple game in which youth are expected to identify who was more likely to have HIV between 2 randomly generated BattleViro individuals. Each participant plays 10 rounds of the game. BattleViro [35] is a twin-stick shooter mobile game aimed at Instead of receiving a direct answer regarding whether they improving antiretroviral treatment adherence among young made the right choice, the participants receive information about MSM in the United States. During the game, players control an HIV and risk and construct their own learning based on their avatar that is shrunken down to fight viruses and other infections experimentation. in 6 levels of increasing challenge. Each level is set on a specific organ ranging from the lungs to the brain. Throughout the Keep it Up! different levels, the player shoots down threats to the host’s Keep it up! [32-34] is a 7-module, multi-method intervention body while picking up health points in the form of medicine (one that includes the use of >1 method of data collection in a (Figure 3). The character also receives messages from health study) aimed at improving STI prevention strategies among care personnel, encouraging them to carry on and providing young MSM in the United States. The main gaming component clues in challenging areas of the run. In addition, the player is called The Club Game. This game uses a real-life scenario might answer quizzes from clinician avatars to earn additional (going to the club) to explore decision-making around using points or powers. Wrong answers are corrected and explained. condoms; the steps to use condoms properly; and the effects of In addition to the game, participants with perfect adherence excessive alcohol consumption, drug use, and sexual arousal would receive congratulatory texts, whereas the other on decision-making. The player goes through 5 rooms and participants would receive motivational messages encouraging interacts with other patrons while completing the activities them to carry on. related to the abovementioned topics. The intervention uses Figure 3. BattleViro gameplay [35]. includes quizzes that go beyond PrEP adherence, including Viral Combat information on HIV and other STIs. Viral Combat [37] was developed by the same team that created MyPEEPS BattleViro. However, instead of targeting people already with HIV, this game attempts to promote PrEP adherence. The levels MyPEEPS [38-40] is a role-playing game in which young MSM are slightly different, as are the messages received by physicians with little to no sexual experience go through different scenarios and nurses; however, the main mechanics are similar. The game guided by 4 characters (the peeps) who teach them about sexual health care. The game comprises 4 sequential modules https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al (PEEPScapades). The completion of the different modules is intervention comprises short informative videos in which incentivized by in-app trophies. students are taught about different risks, such as sexual abuse and scams. It includes a first-person simulation game in which First-person Scenario Game the participant is presented with multiple choices when faced First-person scenario game (FPSG) is the name we have with real-life scenarios (Figure 4). The game was designed with provided for a multi-method intervention that aims to protect various algorithms that resulted in positive or adverse outcomes, university students from the risks of using dating apps. The depending on the character choices. Figure 4. First-person scenario game example screens [41] (translation available in Multimedia Appendix 2). On the basis of target population profiles, we divided the studies Results of Studies into 2 broad categories. First, there were those that were based In the following sections, we discuss the main results of our in an educational institution (high school or university), included review, structured around the findings related to the target people of all genders and sexual orientations, and focused on populations, interventions, outcomes, and study designs. contraception and STIs [27-29,41,42]. The second group was most commonly recruited from youth centers or sexual health Target Population clinics, focused exclusively on MSM, and had a clear focus on Finding games that were targeted exclusively at youth aged STI prevention and management [30,32,34,35,37,43,44]. between 15 and 25 years was not an easy task. Several identified Interventions interventions included some participants outside our selected age bracket, especially at the younger end of the age range. This Overview was likely due, in part, to the physical location where the In the following sections, we describe the elements of the 11 interventions were delivered. For example, several interventions games. However, first, it is important to note how little were conducted in high schools [27-29], including students from information about the games themselves was readily available both within and outside our age group. We did not find many in published articles. Authors often devoted little space to studies that included participants outside the upper end of our describing how the games looked and how they were played. age range. We found only 1 trial in which recruitment was done Considering that playing games is a visual activity, the inclusion in colleges; however, even in this particular setting, the number of images could have been a valuable way of providing this of students aged >25 years (our upper age limit) was small [41]. information. However, with some noteworthy exceptions Concerning gender and sexual orientation, many recent studies [27,30,35,41], this was rarely performed; most articles did not have focused on MSM and the prevention of STIs. A total of 7 include any form of visual aid to explain the game. Some articles studies had been conducted over the past 10 years; 5 of these included links to demos or webpages where the content was focused exclusively on MSM. All but one of the games targeted said to be available; however, in >1 case, the links were broken, urban youth; only 1 focused on rural populations [29]. or the page had already ceased to exist. Owing to the rapid https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al nature of this review, no author and game developers were As could be expected, these extremes in game difficulty were contacted during the process. not without their issues. A nonchallenging game can be boring and can inhibit engagement. At the same time, a too-challenging Game Age game can tire a proportion of the players out of the intervention. Regarding the age of the games themselves, we identified a In an effort to resolve these 2 positions, some game developers clear bimodal distribution; 3 games were created in the wake opted for an increasing level of difficulty; that is, instead of of the digital revolution ≥30 years ago, whereas the remaining having a flat, low-level difficulty throughout the experience or group was developed more recently. Earlier games were a series of extreme spikes every so often, these games ramp up graphically simpler but in no way less informative. We found the difficulty with every level [35,37]. it striking that from very early on, video games were seen as Expected Playthroughs and Playing Time valuable tools to promote learning and attitude change. There are 2 related elements to consider here: expected Gaming Platform playthroughs and expected contact time. In other words, how The interventions used different platforms to host the games. many times are players expected to play the game, and for how Considering the time span across which the games were long? As we will discuss in the following sections, repetition, developed, it is not surprising that the most commonly used rehearsal, and feedback play an essential role in learning through platform was that with the longest history, the PC. The changes games; therefore, it is expected that most games were designed in the games reflect the technological evolution that has affected to keep the player engaged in >1 run. Unfortunately, there is this platform. Although popular, tablets were only mentioned little information about these aspects in most of the included in one of the games [33]. As might be expected, when mobile articles. Among the games that specified an expected playing phones became widespread, the idea of using smartphones as time, we found periods of <1 hour of gaming. However, it was platforms for serious gaming became an option. Of the 4 not always clear whether these times were for single or multiple reviewed games for mobile phones, 2 (50%) were exclusively playthroughs. developed for the iPhone [35,37], whereas the other 2 (50%) Type of Game and Game Setting did not specify which operating system they worked with [38,42]. These later games used mobile connectivity to increase Game settings can be broadly divided into 2 types: realistic and participant engagement through push notifications and messages science fiction. There was a clear preference for the latter in [35,36]. However, it is noteworthy that most interventions did our sample of games. Most games were situated in locations not appear to use patches and updates to freshen their content, and environments to which the player could directly relate, such even when they were constantly connected to the internet. as hanging out with friends after school or going to a house party. The idea behind this is that a greater similarity between Accessibility and Difficulty the simulated situation and a plausible real-life event might A decision that is implicit in platform selection is accessibility. make it more likely that players will relate to the content and Most interventions aspire to be easily scalable. To achieve this, act upon what they have learned. Game developers have gone they must operate on an already popular and ubiquitous platform into great efforts to create content grounded in reality, where and use relatively little graphic processing power. We do not situations that the players have directly experienced are have access to the system requirements for any of the listed portrayed both didactically and accurately. For example, SOLVE games. However, based on their description, it appears most allowed players to personalize their avatars, and The Baby Game operated on or below the considered average computing power used actual prices when they calculated the costs of raising a at the time of their release. child. With regard to game difficulty, all interventions can be placed The types of games in the realistic group were highly diverse. on a continuum. On one end, there are games that provide an Table 1 presents a list of the different styles of games that were easy experience; that is, the game is seen as a vehicle through included. We want to highlight 3 features. First, the variety is which information can be provided in an entertaining fashion. notable; as can be seen, games ranged from management On the other end, we have games that provide a very demanding simulators to role-playing games. The second feature is the experience. The best example of this in the games we identified relative preponderance of the dating simulators. Approximately is VODO. The developers included a section of the game in 44% (4/9) of the nonfiction games were dating simulators. which the player needed to answer 2 questions about sexual However, even within this specific setting, we found different health. If either of these answers was incorrect, the game was styles (eg, text adventures, 3D, and chat simulators). Finally, over, and the player had to start all over again. This type of the role of complementary activities in each game should be failed outcome was a very common scenario of text adventures mentioned. Minigames are found in several games, particularly at the time and motivated the player to replay the game several in the form of quizzes [29,34,36,37]. This seems to have been times, learning all its intricacies. An even more challenging one of the main strategies through which game developers aspect of these questions is that the answers were not provided delivered specific sexual health knowledge. in-game. The player was meant to search elsewhere for However, not all games followed a realistic route. BattleViro information; or even better, the topic should become a and Viral Combat opted instead for science fiction in the action conversation starter for youth to discuss with their friends, setting [35,37]. In both games, the characters are shrunk down parents, or teachers. This is an example of how a severely to a microscopic scale and are meant to protect the human body challenging task was used to frustrate the players into action. from infections by shooting down viruses, bacteria, and vectors https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al of disease. Here, the developers tried to create a power fantasy Some games aim to provide knowledge, expecting that it will in which the player can take control of their actions and reach generate behavior change. For example, some games share facts a desirable healthy state. The content and settings were still about contraceptives, their efficacy, and the risks involved in related to the topic of focus (antiretroviral treatment and PrEP not using them. In such cases, one of the most critical elements adherence); however, the developers avoided making direct or is to provide a clear and easy-to-understand message. It has explicit statements about them. been noted that most interventions try to make the message grounded in a specific element or situation in the game. Many We can see that there is >1 valid strategy for promoting games focusing on providing knowledge prioritized the engagement with the material. One school of thought aims to provision of immediate and clear feedback, specifying where create easy-to-relate experiences, whereas the other uses a and when an error was made and what its potential outcomes fast-paced game to empower participants into action. might be. The same applies to decisions that have a positive Single or Multiplayer Game (Private or Social Experiences) outcome. For example, in SOLVE, when a player chose to engage (or not) in in-game sex, they were offered a quick recap An element mentioned throughout the different interventions of all the previous decisions that drove them to their current is the contrast between creating a single or multiplayer state (decisions that were not always apparent at the time they experience. In other words, was the game designed to be played were made). alone or with a group? Most of the games reviewed appear to have been designed for single-player use. However, it should The final element of knowledge is how it is constructed. We be noted that all single-player experiences can be turned into have previously stated that the message must be clearly stated. multiplayer experiences by the players themselves. Researchers However, for some interventions, this did not necessarily mean reported that, in several cases, games that were not meant to be that the message had to be explicitly delivered. For example, social experiences were transformed into a group activity when the HIV risk game had a clear message that needed to be a player spontaneously brought their friends or partner to play delivered: older people were more likely to have HIV than the game together and comment on it. younger people. Players played 10 rounds of the game in which they made a judgment about which character was more likely The decision to develop a single- or multiplayer game is affected to have HIV. As feedback, the players did not receive the correct by several factors. The first is the target population. answer; they only knew whether they were right or wrong. This Interventions focused on MSM were very keen on not outing key message was supposed to be inferred (constructed) by the their players involuntarily or having them openly disclose their participants based on their in-game experience. health information; hence, single-player games might have been preferred. Second, the game’s topic of focus is an important Two of the most frequently used strategies in games focused factor to consider. Some topics are easier to work with at the on increasing the participants’ skills and self-efficacy, which individual level than at the group level. For example, SOLVE was achieved by a mixture of relatability and rehearsal. By was a game that tried to decrease the feelings of shame that gay relatability, we mean all the different factors that can make the or bisexual men might experience regarding their sexual situation in a game similar to the ones players face or think they preferences [35]. Considering that many players had strong will face. The developers made great efforts to provide feelings of shame and were reticent to disclose information experiences grounded in those that the players have had or will about their sexual interests, they may not have been comfortable experience. The assumption is that, in general, the closer a playing a game with others. setting and its characters are to the real world, the easier it will be for the player to assimilate the lesson and put it into practice. The third influence is logistical, technological, or economic This is one of the reasons why several games designed restriction. When PCs were not ordinary household items but characters with different personalities and stories so that the specialized pieces of hardware, they were not as commonly player can easily associate 1 or several of them with their friends available as they are now. For this reason, older games tended and acquaintances. Similarly, one of the reasons why some to be a social experience; many people had to use the same avatars were customizable was to make it easier for players to computer to make it viable for enough players to play the game empathize with their in-game presence. The same can be said [27,28]. of the setting in which the interactions occur. In several cases, The final reason for choosing single- or multiplayer games the setting was very similar to that currently experienced by the relates to the learning strategy of choice. Some game developers players. One of the clearest cases of relatability is in the FPSG opted to purposely promote out-of-game discussions of sexual game. The player learns about the risks of dating apps by playing health topics [28]. The aim was to make the game a topic for a game that uses an instant messaging app as one of its primary discussion with family members, teachers, and friends. interfaces. Outcome Change Mechanisms Similarly, rehearsal and repetition also played a significant role There are several ways in which we could try to classify the in improving self-efficacy. The idea is that players will train underlying mechanisms used in video games to change specific themselves to make safe decisions in real life because they have behaviors in users. Here, we divided the mechanisms into 3 made the same correct decisions in a virtual world before. The categories: those based on knowledge, those focused on more times a player does something, the more likely it is for enhancing skills and self-efficacy, and those that motivate him or her to feel (and be) proficient in it. change through emotions. These groups are not mutually exclusive; 1 intervention might have >1 underlying mechanism. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al The final strategy relies on using emotions to generate a reaction Stakeholder Participation in the player. There are several methods in which this has been The teams in charge of designing the interventions frequently performed in different games. Some developers opted to made considerable efforts to involve different stakeholders generate negative emotions that frustrated or scared players into throughout the process. Among the stakeholders who action. For example, in Romance, if the players initiated participated in the design of games were end users [32,35,41], unprotected sex, they would have a baby that would cry members of nongovernmental organizations concerned with randomly during the game, negatively affecting their sexual health or youth well-being [34], and unspecified relationships with their friends. Other games used positive community leaders [28]. There is little to no mention of the emotions to inspire players to act. BattleViro and Viral Combat involvement of parents, teachers, or other authority figures. are good examples of this practice, having used fast action, Focus groups [34] and in-depth interviews [32,35] were used increasingly challenging shooter-style games to empower their to access stakeholders’ views. players to take control of their treatment. Finally, there were There were 3 main reasons for stakeholder involvement. The games that aimed to reduce the negative emotions that inhibit first reason was to conduct a needs assessment. This allowed players’ ability to do something. The best example of this the intervention designers to prioritize topics or behaviors that practice is SOLVE, a game whose main aim was to reduce the required specific attention. For example, in the development of feelings of shame that MSM might experience. Through a series the FPSG intervention, 4 focus groups were held by the of stories and vignettes, the intention was that the player might developer to identify key risks that caused concern among young consciously acknowledge their desires as something normal, people using dating apps in Hong Kong. The second reason to which carries no stigma. involve stakeholders was to improve the quality of the game Game Development itself. For example, Keep it up! conducted interviews with We cover 3 main topics in this section. We begin with a general stakeholders to ensure that the situations and languages they description of the development process of the games. We then used in their club games were similar to those experienced by assess the involvement of stakeholders in the creation of the young men in their everyday interactions [33]. This allowed game: who was invited, when, and in what capacity. them to generate greater engagement with the final users by presenting situations comparable with those they had Development Process experienced previously. Finally, approval from the governing The published papers provided little information on the body is needed. By involving community leaders and local development of game mechanics. There was often no data authorities, intervention designers could ensure that they would regarding how long the game design lasted, how much its budget receive support for the subsequent stages of the process. For was, who and how many people were involved, and what example, VODO involved people from 30 different local program or programs and engine or engines they used to create institutions to avoid the inclusion of content or situations that it. From conversations with researchers, we know that in some might have been perceived as unacceptable by the community cases, university-based groups were in charge of software [28]. development. However, apart from FPSG, very little additional Multi-Method Interventions information is readily available from these articles or other related publications on game development. A final element to discuss is that although all interventions relied considerably on video games to achieve their goals, it Some interventions adapted previous activities or interventions was not necessarily the only method they used. Approximately for the construction of new games. In some cases, existing 27% (3/11) of the games were meant to be played in conjunction materials and activities from previous interventions were adapted with other activities. to a video game form. The details of these interventions were usually left nebulous; however, we know that in the case of For these specific interventions, the games seem to be one of MyPEEPS, Keep it up!, and SOLVE, a considerable part of the the few activities in which the participants could take agency content of the games was taken from previous non–video and act upon the knowledge they received. For example, when game–based interventions. For example, MyPEEPS included 4 the participants are completing scales or watching videos, they characters (the titular peeps), who were a composite of are fairly passive, and the moments in which they play the games previously existing characters used during the formative phase are the only times when they really take control, make decisions, of the intervention. and see their results. Although no intervention specified the playing time, or the time used in the other modules, it appeared The development of other interventions was probably informed that the games were the activities that comprised most of the by existing games, although few articles provided much detail participants’ time. about this. The only exception to this trend was Viral Combat, heavily influenced by BattleViro [37]. The same team of Outcomes researchers developed both games, and one might even say that Overview the former is an improved version of the latter. In this section, we discuss the effectiveness of the interventions In summary, we found that interventions have either been in achieving their goals, organized by the outcomes adopted in developed entirely from scratch or based on a previous in-person our search criteria. Multimedia Appendix 3 provides a summary intervention. Explicit references to previously existing games of the results. were unusual in the reviewed studies. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Decrease in Unintended Pregnancies between intervention and data collection in Viral Combat, compounded by attrition of 32% of the original sample, might Rather unexpectedly, none of the studies assessed the number have biased the intervention results. However, one would also of pregnancies. There are 2 possible explanations for this. First, expect that participants who stayed longer would be more almost half of the chosen games were not marketed to women engaged, would have clocked in more hours in the game, and but to MSM. Second, the sample sizes were too small, and the would have a better overall performance. follow-up periods were too short, for the relatively low occurrence of pregnancy to become a viable measure of the In conclusion, we do not have enough evidence to clearly state success of an intervention. that games have a significant effect on increasing knowledge of sexual health topics. The variety of topics assessed, the Decrease in STIs limited amount of information regarding the content of the tests, Only Keep it up! used STI biomarkers to assess changes in STI and the large variability in the time between intervention and incidence. The researchers tested for chlamydia and gonorrhea postintervention assessment precludes our ability to establish through self-collection of rectal swabs. Through matched odds a clear causal relationship between playing and learning. ratios, the control group showed a 55% increase in STI incidence, whereas the treatment group showed a decrease of Changes in Perceived Risk of Pregnancy 51%. These results were significant; however, we must be Only 2 games assessed this variable. Romance asked participants mindful that this intervention had multiple components, and the to assess the odds of becoming pregnant when having video game was only one of them. unprotected sex. Improvements in favor of the treatment group immediately after they finished playing the game were reported. Increased Contraceptive Use Unexpectedly, a study on Choose Your Own Adventure found Approximately 27% (3/11) of interventions measured changes significant differences in favor of the control group. However, in reported contraceptive use. Unfortunately, they did so in very the researchers measured a construct called susceptibility, which different ways, which limited our ability to compare them. merged the perceived risk of pregnancy with the perceived risk Choose Your Own Adventure asked about condom use at the of STIs; thus, there might have been some cross-contamination last intercourse and found no effect of the intervention. The in the assessment. The authors speculated that their results might other 2 studies assessed the frequency of UAI with nonprimary be related to the fact that fewer people initiated sexual activities partners during the past 3 months. Although SOLVE was unable in the treatment group (ie, they were abstinent) than in the to show significant differences between the treatment and control group; hence, they did not feel at risk of any adverse control groups, Keep it up! reported a significant decrease in outcomes related to having sex. They also considered that as the number of UAI events 1 year after the start of the the treatment group was more aware of the risks and the intervention. measures they could take against them, they felt better able to In summary, studies on the effects of video game interventions protect themselves. on contraceptive use have shown inconsistent results. Changes in Perceived Risk of STIs Acquisition of New Knowledge Regarding Sexual Health Approximately 36% (4/11) of games addressed this topic. We The acquisition of new knowledge was one of the most have already discussed the findings of Choose Your Own commonly measured outcomes; however, the topics and Adventure. The entire intervention of the HIV risk game was measures varied significantly among the different interventions. centered on assessing the risk of someone having HIV based Frequently, ad hoc questionnaires were created to assess on their age and gender. Positive results were obtained for both differences between the treatment and control groups. The Baby men and women. The assessment was performed immediately Game quizzed participants on the costs (both time and money) after the intervention and 3 months later (the last time only for involved in taking care of a baby. Romance used the same male participants). methodology but compared knowledge about the efficacy of BattleViro and MyPEEPS also assessed the perceived risk of different contraceptive methods. Studies on both of these STIs but in an indirect fashion by asking about STI testing. interventions suggested improved knowledge in the treatment BattleViro measured the types of sexual behavior, frequency of group compared with the control group. However, we should sex, and number and gender of partners reported in the past 3 keep in mind that knowledge was assessed only immediately months. The authors found no differences between the control after the game ended and that no effect size measure was and treatment groups. MyPEEPS measured the frequency of presented. Other interventions also relied on ad hoc tests; STI testing and found that after the intervention, those in the however, it was unclear exactly what topics they explored. treatment group were more likely to get tested than those in the Choose Your Own Adventure showed positive results (of control group. medium effect size); however, VODO failed to do so. Both interventions followed a pretest-posttest design. Attitudinal Change Toward Safe Sex Approximately 18% (2/11) of interventions targeted attitudinal A comparable example is that of BattleViro and Viral Combat. changes toward safe sex. VODO measured participants’ attitudes They both tested their participants’ HIV knowledge, and toward sex on 2 axes: liberal versus conservative and positive although they were very similar games, only BattleViro showed versus negative. Both the control and treatment groups shifted positive results. It should be noted that BattleViro tested their to a more liberal position; however, the change was greater in participants 16 weeks after the intervention started, whereas the treatment group. The change in this group was sufficient Viral Combat did so at weeks 12 and 24. The extended period https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al for it to move, on average, from a conservative perspective weeks and 24 weeks after the beginning of the intervention; toward a liberal one. No significant changes were observed in however, these findings were not statistically significant. the positive and negative axes. Treatment adherence, measured by self-report in Viral Combat and by self-report plus electronic device records in BattleViro, Choose Your Own Adventure assessed the predisposition toward showed similar results. In this regard, no intervention showed waiting to have sex and found a significant effect of their better results than the usual treatment. MyPEEPS also measured intervention among students aged between 15 and 16 years. PrEP and postexposure prophylaxis adherence using After completing ≥1 of its modules, participants were more self-reported measures and found no significant differences likely than those in the control group to postpone sexual between the treatment and control groups. initiation. Study Designs Self-efficacy Toward Sexual Health Bearing in mind that our search criteria only allowed for RCTs Self-efficacy, be it general or specific to sexuality, was one of and quasi-RCTs, we identified 2 main study designs. Studies the most frequently chosen outcome variables across the were either posttest-only trials [31,37,43] or pretest-posttest different games. Choose Your Own Adventure considered 4 trials [27-30,33,35,36,42]. domains of sexual self-efficacy: condom negotiation self-efficacy, condom use self-efficacy, situational self-efficacy Depending on the study, the control group received different (the ability to control a situation that might be conducive to treatments. Waiting-list control was one of the most sex), and refusal self-efficacy (the ability to say no to sexual straightforward control designs. A more complex one was intercourse). However, the findings were mixed. The treatment as usual (TAU), where the usual or standard was given intervention increased participants’ self-efficacy toward condom to a group of participants. negotiation and situational self-efficacy; however, no effects For example, for The Baby Game, researchers compared their were found regarding condom use or refusal. It is not surprising game with a regular sexual health education class for that that condom use self-efficacy did not change considerably specific age group [28]. A similar option was TAU+. Here, the between groups as the intervention did not include any participants received TAU and an additional component that components that directly taught students how to apply and use was functionally similar but thematically different from the a condom. However, it did have 1 activity specifically focused experimental group. For example, as BattleViro provided on improving refusal skills, which was tightly tied to the game smartphones so that participants could play the game, they also itself. The fact that this activity failed to produce the desired provided smartphones to the control group. However, these results for this variable is noteworthy. iPhones did not have the specific game installed but another BattleViro and Viral Combat assessed a similar domain of non–HIV-related game [35]. Another form of control group self-efficacy: participants’ belief that they would be able to provided more or less the same content as the game but in a adhere to a treatment regime. Both interventions found no delivery mode that had no ludic or interactive elements. For significant change in either the short (12 weeks) or long-term example, Keep it up! provided an internet-based experience (16 weeks and 24 weeks) assessments. MyPEEPS reported with the same information as their intervention but using static positive results when assessing HIV self-efficacy in the short slides instead of the more dynamic approach taken with the term (3 months). Researchers have yet to publish their results treatment group. for the long-term assessments (6 months). Finally, in reviewing whether the studies had adequate sample We consider that the results on self-efficacy are mixed. sizes, we found that the sample sizes were generally large Considering that the interventions are varied in methodology enough to detect expected differences. Most studies, especially and topics and that they have worked on different domains of the more recent ones, determined their sample size based on a self-efficacy, this is not a particularly surprising result. power analysis (although this analysis was usually constructed around educated guesses). Even if the sample size in the Decrease in the Number of Sexual Partners reviewed studies was usually large enough, one of the main Approximately 27% (3/11) of interventions aimed at reducing threats to statistical power was a relatively large attrition rate, the number of sexual partners, all of them for MSM—Keep it especially among studies with multiple or long follow-ups. The up!, Viral Combat, and MyPEEPS—and none resulted in a most extreme case was in the HIV risk game study, which reduction in the number of sexual partners in their samples. reported an attrition rate of 66.8%. In the remaining studies, the attrition rate was approximately 30%. Increase in Adherence to Prophylaxis or Treatment Approximately 27% (3/11) of interventions focused on Discussion increasing adherence to either treatment or PrEP. BattleViro and Viral Combat used a mixture of bioindicators, self-reported Principal Findings behavior, and electronic device follow-ups to assess this The findings of our review yielded important conclusions and outcome. A total of 2 bioindicators were used: HIV-1 viral load implications for future research and game development. First, in BattleViro and 1ARV (activator protein 1) levels in Viral the findings highlighted considerable diversity in video Combat. BattleViro produced equivalent decreases in HIV-1 game–based interventions. Although all of them addressed viral load in both treatment and control groups. Viral Combat similar topics, they did so in fairly distinct ways. The outcomes reported results that favored the treatment group at both 12 assessed in studies evaluating games were also very diverse https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al and, even when similar, were measured differently in each study. on any of these games being picked up for broad distribution. Second, we found that game developers have made great efforts In fact, only BattleViro was readily available for download. to elicit experiences tailored to the specific needs of the targeted Moreover, although the interventions were very varied, almost population, most often achieving this through regular all of them targeted people living in urban areas of the United stakeholder participation activities throughout the game States. There were no interventions developed with populations development process. from lower-income countries in mind, and almost no interventions were aimed at rural populations. Finally, very few One of the most surprising findings was the age of the identified interventions were informed by a behavioral theory or model. games. The fact that the games were developed over such an extended period suggests that even when the graphical Strengths and Limitations complexity and the interface changed considerably, learning Our review had some notable strengths. We followed the through gaming is and has been seen as a viable and successful Cochrane Rapid Reviews Method Group guidelines [22,24] to strategy. conduct the review and searched several key literature databases. A second reviewer was involved in screening 20% (51/257) of However, although game interventions for sexual health have the articles at the title and abstract screening stage and 50% been in existence for almost three decades, relatively few studies (35/70) of the articles at the full-text screening stage. have evaluated them, and the results of previous studies have been mixed. Moreover, there is little clarity regarding which Some limitations of our review should also be acknowledged. specific elements of a game facilitate a positive outcome. This As this review was rapid, our search used 5 databases; thus, we is partly because of the diversity of the behavior change may not have identified all the relevant literature. We restricted mechanisms underlying interventions, the variety of the games our age range to 15 to 25 years and, in the screening process, themselves, the populations they target, the outcomes measured, noticed that some interesting game-based interventions focused and how these are measured. All these differences make it on younger adolescents and children. A final limitation was that challenging to identify a clear causal link between playing a we did not exclude studies based on quality. game and improving an aspect of sexual health. However, Conclusions and Recommendations although the impact on sexual health is not always clear, the fact that video game–based interventions are of interest to most In conclusion, we do not have enough evidence to clearly state young people is well-established. that games have a significant effect on sexual health among young people. The interventions and how they were evaluated Nevertheless, there are other less positive aspects of research were too diverse to reach a clear conclusion. However, based in this area that we need to acknowledge. First, there is a lack on the original authors’ criteria for success, we have compiled of information available in published reports on different games, a set of recommendations for developing game-based especially in the gameplay aspect. This ties to another interventions to improve sexual health in young people (Textbox unexpected finding of our review. Although video game–based 1). interventions are meant to be easily scalable, there are no reports https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Textbox 1. Recommendations for developing game-based interventions to improve sexual health in young people. Recommendations for developing game-based interventions to improve sexual health Stakeholders should be involved in different stages of the game development process. Most successful strategies used qualitative participatory methods involving multiple stakeholders. A pilot phase in the development of games is strongly encouraged. This enables specific elements that could otherwise jeopardize the success of the initiative to be identified and modified. One of the most crucial decisions during the game development process is whether intervention participants are expected to go through the game once or multiple times. This affects the length, difficulty setting, and the main mechanics of the game. There are several viable ways in which a game can try to change someone’s behavior. None have proven to be markedly better than the others. However, some recommendations are as follows: Knowledge-based interventions should aim to provide a clear message, and this message does not need to be explicit. In fact, some researchers recommend that the message is not explicitly stated but constructed by the players themselves. Self-efficacy and skill-building interventions aim to provide easily relatable experiences and those that feel proximal to the player. The closer the player feels a game experience is to their own experience, the more likely it is that they will act upon it. The game serves as a rehearsal for the decisions they will make in real life. Disregarding the mechanisms chosen by developers, some common elements are shared by most strategies: Feedback is better if it is clear, detailed, and immediate. When playing, it is encouraged that users recap their decisions and learn which actions drove them to their current stage (whether positive or negative). Repetition (as long as it does not transform into tediousness) is usually favorable, especially for skill building and knowledge acquisition. There are 3 common threats that plague these interventions: Lack of technical support, especially after the game development phase ends, is a common threat. Another threat is the stagnation of the content; that is, no updates are provided, and no new content is delivered. The games are not easily found when someone wants to use them in other contexts. The created game should be openly available on the web if possible. Game quality indicators (including playing time) were registered using self-reported measures. A suitable workaround using in-game data collection is recommended to bypass social desirability and recall issues that affect purely self-reported information. A plan for the implementation of the intervention should be made at the early stage of the project. Acknowledgments This study was funded by an Erasmus+ grant (project number 2020-2-UK01-KA205-079645). Conflicts of Interest None declared. Multimedia Appendix 1 Search strategy. [PDF File (Adobe PDF File), 117 KB-Multimedia Appendix 1] Multimedia Appendix 2 First-person scenario game example—English translation. [PDF File (Adobe PDF File), 240 KB-Multimedia Appendix 2] Multimedia Appendix 3 Summary of results per intervention. [DOCX File , 16 KB-Multimedia Appendix 3] References https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al 1. Rowley J, Vander Hoorn S, Korenromp E, Low N, Unemo M, Abu-Raddad LJ, et al. Chlamydia, gonorrhoea, trichomoniasis and syphilis: global prevalence and incidence estimates, 2016. Bull World Health Organ 2019 Aug 01;97(8):548-62P [FREE Full text] [doi: 10.2471/BLT.18.228486] [Medline: 31384073] 2. 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J Urban Health 2020 Oct;97(5):749-757 [FREE Full text] [doi: 10.1007/s11524-020-00447-5] [Medline: 32789625] https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Franco Vega et al Abbreviations FPSG: first-person scenario game MSM: men who have sex with men NPC: nonplayer character PrEP: pre-exposure prophylaxis RCT: randomized controlled trial SOLVE: Socially Optimized Learning in Virtual Environments STI: sexually transmitted infection TAU: treatment as usual UAI: unprotected anal intercourse Edited by N Zary; submitted 27.08.21; peer-reviewed by E Olsen, E Rahmani; comments to author 05.03.22; revised version received 19.03.22; accepted 07.04.22; published 19.05.22 Please cite as: Franco Vega I, Eleftheriou A, Graham C JMIR Serious Games 2022;10(2):e33207 URL: https://games.jmir.org/2022/2/e33207 doi: 10.2196/33207 PMID: ©Ignacio Franco Vega, Anastasia Eleftheriou, Cynthia Graham. Originally published in JMIR Serious Games (https://games.jmir.org), 19.05.2022. 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 https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/2/e33207 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e33207 | p. 18 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious GamesJMIR Publications

Published: May 19, 2022

Keywords: sex education; serious games; sexually transmitted infections; rapid review; mobile phone

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