GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications

Volume 4, Number 3, 2015

ª Mary Ann Liebert, Inc.
DOI: 10.1089/g4h.2014.0059

Promoting Sex Education Among Teenagers

Through an Interactive Game:
Reasons for Success and Implications

Samuel Kai Wah Chu, PhD,1 Alvin C.M. Kwan, PhD,1 Rebecca Reynolds, PhD,2 Robin R. Mellecker, PhD,3
Frankie Tam, MSc,4 Grace Lee, MSocSc,5 Athena Hong, PhD,6 and Ching Yin Leung, MA1

Abstract

Objectives: A game application, ‘‘Making Smart Choices’’, was developed to fill the gap of limited easy-to-
access resources available on sex education in Hong Kong and to disseminate correct knowledge and positive
attitudes toward sex to teenagers using popular platforms such as tablets, Facebook, and the Web.
Subjects and Methods: Three versions of the game (iPAD, Facebook, and Web-based) were developed using
HTML5. A theoretical framework that involved game-based learning and participatory design approach was
used to design, develop, modify, and optimize the game for use with secondary school students (n = 1176) 12–
16 years of age. Pre- and post-test scores of students’ safer sex knowledge were compared to test the effec-
tiveness of the game. Students’ survey and interviews were analyzed to assess participant feelings and attitudes
toward the game.
Results: The Wilcoxon Signed-Rank test indicated that students’ sex knowledge (n = 788) improved with a
medium effect size (0.477) after playing the game. Increases in positive attitudes toward sex and relationship
and in awareness of making smart sexual choices were reported from student surveys and interviews. Students
described the game as ‘‘interesting,’’ ‘‘interactive,’’ ‘‘informative,’’ and ‘‘real-to-life.’’
Conclusions: We advocate that the participatory design approach, which supports collaborative efforts of
different stakeholders, is an effective framework for developing game-based learning tools for sex education.
Our work provides preliminary findings that suggest game-based learning, preferably delivered through popular
interactive platforms, can be effective in promoting sex education to teenagers.

Introduction grams in schools.2 The lack of sex education is further con-

S ex education in Hong Kong has been integrated into
primary and secondary educational curriculum for many
years, yet efforts to provide quality sex education have been
limited and largely unsuccessful.1 A recent survey conducted
by the Hong Kong government with 134 secondary schools
indicated that sex education at the junior secondary school
level (12–16 years of age) is limited to an average of 3–4
school hours. Limited time and space for sex education
programs, coupled with the lack of documented policy,
learning, and teaching resources as well as ill-equipped
teachers, are constraints for successful sex education pro-
founded by traditional Chinese values that limit discussions
about sexual behaviors in the home environment.3,4
Engagement in underage sexual intercourse, unprotected
sex, and limited knowledge of contraceptive methods have
become increasingly apparent among youths in Hong
Kong.5,6 According to a recent report published by the Family
Planning Association of Hong Kong including the views of
2934 adolescents, 7 percent of teenage girls and 10 percent of
teenage boys (average age, 16.2 years) have experienced
sexual intercourse.7 It is remarkable that the mean age of
first sex experience for boys and girls was reported to be
at the ages of 14.6 and 15.3 years, respectively.7 Among

1
Faculty of Education, The University of Hong Kong, Hong Kong SAR, China.
2
School of Communication and Information, Rutgers, The State University of New Jersey, New Brunswick, New Jersey.
3
Institute of Human Performance, The University of Hong Kong, Hong Kong SAR, China.
4
FifthWisdom Technology Ltd., Hong Kong SAR, China.
5
The Family Planning Association of Hong Kong, Hong Kong SAR, China.
6
School of Nursing, The University of Hong Kong, Hong Kong SAR, China.

168
PROMOTING SEX EDUCATION AMONG TEENAGERS
the adolescents reporting sexual intercourse experiences, 22.5
percent had not used contraceptive measures. These sexual
behaviors could increase health risks such as the spread of
sexually transmitted infections and unwanted pregnancy.
Although educational resources for sex education are
available, attractive and easily accessible materials specif-
ically tailored for young Hong Kong adolescents remain
scarce. Since ‘‘Net Generation’’ adolescents are drawn to
technology and videogaming, promoting sex education
through a game-based learning approach seems promising.
In a conservative culture where topics relating to sex are not
openly discussed or taught by parents,3,4 the game-based
approach may also provide a risk-free, nonthreatening, and
highly engaging environment in which students can learn,
explore, experiment, and make decisions in stimulated sit-
uations.8,9 Through this interactive game-based medium,
learning potential is maximized.10
The primary aims of the development of the interactive
game, ‘‘Making Smart Choices’’ (MSC) are: (1) to elicit
adolescents’ greater knowledge and awareness about sexu-
ally transmitted infection prevention, and (2) to promote
knowledgeable decision-making regarding healthy sexual
practices in a fun and interactive way. This article describes
the development of MSC utilizing game-based learning and
the participatory design approach, the application of MSC,
and the effectiveness of the game in helping students to ac-
quire safer sex knowledge and to establish healthy attitudes
in handling relationships.
Methodology of ‘‘MSC’’ Development Strategy: Game-
Based Approach with Participatory Design
In order to increase uptake and learning, sex education
should be delivered in a manner that is engaging as well
as culturally and socially relevant to the targeted population.
As social networking has become an increasingly popular
activity for Hong Kong adolescents, smart devices and plat-
forms present vast potential in attracting the attention of Hong
Kong adolescents. We developed MSC for use on the iPad
(Apple, Cupertino, CA) tablet, the social networking site
Facebook, and the Web to enable wide dissemination of the
game through social networking and smart devices commonly
used by adolescents. Although the Web and iPad (school)
versions require registration with a student account to a local
educational website, the Facebook and iPad (International)
versions are made widely available for all interested adolescents
at https://apps.facebook.com/fpasmartchoices and https://itunes
.apple.com/us/app/jue-xing-shi-ke-guo-ji-ban/id774628862?mt=8
Acceptability, usability, and utility are three critical di-
mensions for effective use of technologies in education
contexts. Acceptability refers to users’ views on the value of
technology (or a game) in fostering learning (e.g., whether
the game content is relevant and the cost is reasonable),
whereas usability relates to the user-friendliness and effec-
tiveness of the technology (or game interface) in a given
learning context. Utility, on the other hand, is relevance of
the tasks in relation to the target outcomes.11 These three
dimensions can be recognized through the application of
participatory design approach, a methodology emphasizing
the active role of users in the design process12 as well as
expertise of different stakeholders to design, develop, and
refine the targeted product.13 The theoretical framework that
169
guided the development of the game along with its targeted
learning outcomes is presented in Figure 1.
As indicated in Figure 1, the game content was designed by
experts from the Family Planning Association of Hong Kong
with experience in developing and disseminating multime-
dia resources on sex education. Academics with extensive
expertise in education and health science were responsible for
aligning the game content with targeted learning outcomes.
Computer and information science experts provided sugges-
tions on the game framework, game structure, and mecha-
nism, thereby contributing to the acceptability and utility of
the game. The game was developed with target learning out-
comes adopted from the International Technical Guidance
on Sexuality Education.14 Overall, the information and values
embedded into the game messages fall in line with the learn-
ing points related to sex education in the curriculum of the
Life and Society subject prepared by the Curriculum Devel-
opment Council15 in Hong Kong. Advanced graphics in
the game were created by a software vendor, Fifthwisdom
Technology Ltd., specialized in education game develop-
ment. Usability tests16,17 with the target users (adolescents)
were conducted during different phrases of game develop-
ment. Heuristic evaluation18 conducted by computer science
experts and experienced Web users was also included.
Game structure
The application consists of five mini-games offering dif-
ferent scenarios for participants to make decisions using
chosen virtual characters. All the mini-games share a similar
structure (Fig. 2). Each mini-game begins with an intro-
duction to the aims and instructions, followed by one or more
scenarios with each of them styled in comic strip–like ani-
mations. In each scenario, the player is given a few choices
and is required to choose his or her desired response to the
specific scenario. Educational messages relevant to the sce-
narios and in response to the students’ choices are shown
after all scenarios of a mini-game are completed.
The descriptions of mini-games are provided below:
 Mini-game 1: ‘‘Love Q&A.’’ The goal is to gain a
better self-understanding for establishing a healthy love
relationship.
Description: The player (virtual character) is required to
choose his or her desired response from different scenar-
ios, which involve conflicts with love and relationships.
 Mini-game 2: ‘‘Intimacy Photo.’’ The goal is to set and
maintain intimate boundaries and respect the feelings
of others.
Description: The player is asked to set the maturity of a
relationship (e.g., beginning with courtship for a few
days) for the virtual characters of opposite sexes. The
player then selects a gesture and the physical distance
between the two characters. The player takes a photo-
graph by clicking a camera icon. An educational
message is displayed and explains the impact and
feelings of the virtual characters with respect to the
gestures and physical distance set by the player.
 Mini-game 3: ‘‘Escape from Sexual Impulse.’’ The
goal is to understand sexual impulse and considerations
prior to engaging in sexual behavior.
Description: Two virtual adolescents in courtship want
to watch a DVD movie at home. In the search for the
170
FIG. 1. A theoretical framework of game-based approach with participatory design for designing a sex education game.
Color images available online at www.liebertonline.com/g4h
misplaced DVD, the player is required to click on
different objects in the living room and bathroom.
When the objects are selected by the player, the
character’s impulse for sex increases or decreases de-
pending on what kind of object is chosen. For example,
the entertainment magazine with photos of sexy im-
ages on the bathroom floor increases the impulse,
whereas watermelon in the living room decreases
the desire for sex. The objective of the mini-game is
for the player to maintain a medium level of sexual
impulse.
 Mini-game 4: ‘‘Sorting Out Safer Sex Knowledge.’’ The
goal is to acquire safer sex knowledge, including con-
traceptives, prevention of sexually transmissible infec-
tions, and awareness of self-protection.
Description: In this mini-game, the player is required
to identify correct sex knowledge or advice suggested
by his or her Internet friends by clicking the ‘‘like’’
icon. If the player liked advice that was incorrect, an
instant message is displayed with an explanation of
why the advice is incorrect.
 Mini-game 5: ‘‘Rank Your Options.’’ The goal is to be
aware of available support services and options in the
event of unwanted pregnancies
Description: This mini-game begins with the player’s
friend carrying an unwanted pregnancy. The player is
required to identify various information sources, help,
and appropriate options for his or her friend by
CHU ET AL.
choosing the icons associated with different sources of
assistance such as Family Planning Association, social
workers, parents, etc.
Figure 3 shows screenshots of the five mini-games.
Architectural design
LimeJS, an HTML5 game framework used for building
games for modern touchscreens and desktop browsers, was
chosen as the basis for the development of MSC. A single
code base was used for all three different versions of the
game: iPAD, Facebook, and Web-based. MySQL database
was used for keeping track of the players’ data and behavior
in the game. To minimize workload on the user account
management for the iPAD and Web-based versions of the
game, a single sign-on solution was integrated into EdCon-
nect from Hong Kong Education City (www.hkedcity.net/
english/).
Game evaluation
To evaluate the effectiveness and acceptance of the game
among teenagers, a series of game sessions for 1176 sec-
ondary school students (12–16 years of age) in six co-ed
schools were conducted. Prior to data collection and analysis,
informed consents were sought from both the parents and
students, and the institutional board granted ethics approval.
Schools were recruited through convenience sampling.
Each game session lasted for approximately an hour, and
PROMOTING SEX EDUCATION AMONG TEENAGERS
FIG. 2. Key screen shots of the mini-games. Color images available online at www.liebertonline.com/g4h
participation was voluntary. Students were allowed to play as
many times as they liked in the game session. Pre-test and
post-test were embedded at the beginning and at the end of
the game. Each test consisted of six identical multiple choice
questions drawn from a pool of 12 questions related to safer
sex knowledge that are covered in the mini-game ‘‘Sorting
Out Safer Sex Knowledge.’’ The pre-test was accessible only
once for each student account. The post-test appeared once
the player completed all five mini-games. Once the tests
were complete, the test scores were automatically recorded
into the database. For students who played the game more
than once, their highest post-test scores were used for anal-
ysis. In total, 788 sets of pre-test and post-test scores were
collected. The total number is smaller than the actual number
of students who played the game because data from students
who did not submit their consent forms were excluded in the
analysis, and some students did not complete the post-test at
the end of the game.
Students’ feedback on the value and effectiveness of the
game was collected through questionnaires and focus group
interviews. In total, 1123 questionnaires were collected. For
the purpose of our analysis, a mean score of 3.5 was con-
sidered neutral. Mean scores that were higher than 4 were
regarded as edging toward positive, whereas mean scores
lower than 3 were regarded as edging toward negative
feedback. Ten focus group semistructured interviews in-
volving a total of 57 students were conducted. The interview
data were transcribed, and common themes and quotes were
recorded.
171
Data analysis
Means and standard deviations were calculated and re-
ported for all variables. Data were analyzed using SPSS
version 20 software (IBM, Armonk, NY). To examine the
effectiveness of the interactive game in enhancing students’
safer sex knowledge, we first conducted normality tests, the
Shapiro–Wilk test and the Kolmogorov–Smirnov test, on the
game score data (n = 788) and followed up the analysis with
the Wilcoxon Signed–Rank test, a nonparametric test, as
questionable normality of data was found. We calculated the
effect size by dividing the Z score by the square root of the
sample size: r = Z/sqrt(N). We used the standard values for
r = 0.1, 0.3, and 0.519 to substantiate our results.
Results
The results of the Wilcoxon Signed-Rank test, the means
and standard deviations, and effect sizes for pre- and post-
test are summarized in Table 1.
Among the 788 participants, 711 students played the game
once, and 77 played more than once. The difference between
pre- and post-test scores for the whole group (the group that
played once & the group that played more than once) was
significant (P < 0.001) with a medium effect size of 0.477.
The result indicates that a relatively larger improvement in
the mean scores was found for students who played the game
more than once. The mean difference for the two groups was
0.63 and 1.27, respectively. A larger effect size (0.679) was
also noted for students who played the game more than once.
172 CHU ET AL.

FIG. 3. Screen shots of the five mini-games. Color images available online at www.liebertonline.com/g4h
Key results of the survey supplemented with quotes from For instance, a student said, ‘‘I find out that there are a lot to
the student interviews are shown below. On average, stu- be considered before having a decision on having sex, for
dents agreed that the game was fun and interesting (mean = example, my family.and many other factors,’’ and another
4.36). After playing the game, students believed that their student reported, ‘‘I’ve learned that I shouldn’t be affected
ability to make smart choices in relation to love and sex by others easily. I have to think carefully before taking any
improved (Section 3: mean scores ranged from 4.54 to 4.66). actions, even though friends around me have had sex be-
fore.’’ A relatively high agreement was also observed on
Table 1. Pre-Test and Post-Test Scores items related to a better understanding of the risk of sexual
on Safer Sex Knowledge of Students behaviors (Item 2.9; mean = 4.89), the importance of coming
Using the Wilcoxon Signed-Rank Test up with a consensus with their partners when seeking solu-
Mean score tions for their problems (Item 2.8; mean = 4.79), and the
Effect importance of having the awareness and knowledge to pro-
Student group n Pre-test Post-test P size tect themselves (Item 2.6; mean = 4.76). Corresponding
quotes from students include the following: ‘‘I have learned
Played once 711 3.00 3.63 < 0.001 0.449 how to protect myself and how to have safer sex in order to
More than once 77 3.42 4.69 < 0.001 0.688
All 788 3.04 3.74 < 0.001 0.477 reduce the chance of getting sexually-transmitted infec-
tions,’’ ‘‘Through this game, I have learned how to response/
PROMOTING SEX EDUCATION AMONG TEENAGERS
reject others’ [sexual] requests. We can solve problems or
reject others through better communication,’’ ‘‘Lots of fun
and it can enhance my knowledge of self-protection,’’ and
‘‘It is good to learn by going through different scenarios in
the game so that we know what we should do if we encounter
similar situations in the future.’’
Discussion
The participatory design, which emphasizes the active role
and collaboration of key stakeholders, used in this study en-
hanced acceptability, usability, and utility of the MSC game.
These components of the theoretical framework are critical for
effective application of technologies in education contexts.
Collaboration of stakeholders has been shown to be useful
in promoting health communication interventions20,21 and
effective in handling forceful or threatening actions, thus
limiting the chances of sexual coercion.22 For this project,
collaborators included an interdisciplinary team of researchers,
experts, and community partners with varied expertise in
education, health and wellness, sex education, and game
development. This collaboration of a wide range of experts,
stakeholders, and partners facilitated important design im-
provements on the game interface, mechanism, and game
instruction for students. The preliminary findings indicate
that many students discussed the game experience in positive
terms. Students’ favorable perception of the game, as well as
an increase in positive attitudes toward sex and relationships
and an awareness of having safer sex practices and making
smart sexual choices reported in the surveys and interviews,
suggested that participation in the game session could result
in positive influences over future decision-making.
Games provide a safe, risk-free simulated environment in
which students can experiment, play, practice decision-
making, and test scenarios, with minimal deleterious con-
sequences. MSC is a self-paced learning tool that helps
students gain correct knowledge and positive attitudes to-
ward sex in a fun and interactive way. This innovative ap-
proach is attractive in a conservative culture, which avoids
discussions and topics in reference to sex.4 The results are
particularly significant to the population studied given the
limited knowledge on healthy sexual behavior among ado-
lescents in Hong Kong and the lack of appealing tools to
teach sex education in this vulnerable population.
Conclusions
The game application MSC was developed to fill the gap of
limited easy-to-access resources available on sex education in
Hong Kong and to disseminate correct knowledge and posi-
tive attitudes toward sex to teenagers using popular platforms
such as the iPad, Facebook, and the Web. This pioneer Chi-
nese language interactive game on sex education has been
well received among Hong Kong adolescents since its intro-
duction. The game-based affordances of this game have led to
positive changes in students’ safer sex knowledge (particu-
larly in those who repeat gameplay), with student responses
indicating a link between gameplay and potential for behavior
change. Given that discussions on sex are still taboo in much
of the Asian regions and among families with Chinese origins,
there is great potential for the MSC game in promoting sex
education for teenagers in Mainland China, Macau, and Tai-
wan and other Chinese-speaking teenagers worldwide.
173
A limitation of our study is that we only collected self-
report measures on students’ perceived usefulness of the
game for sex education as assessing sex behavior change
using objective assessment tools is outside the scope of our
current study and is noted to be challenging.23 Examining the
extent to which MSC can lead to actual behavior changes
can be a future research direction. Future educational game
developers may consider adopting the participatory design
approach involving end users, experts, and stakeholders in the
game development process. The current version of MSC was
developed for the Hong Kong population. Translation into
other languages and adaption of the game content according to
the laws and culture of particular countries would widen the
outreach into non–Chinese-speaking countries/regions.
Acknowledgments
We are grateful to the participants and schools for assist-
ing us with this research project. We would also like to ac-
knowledge the government’s Health Care and Promotion
Fund for providing the financial support for this project.
Author Disclosure Statement
F.T. is an employee of FifthWisdom Technology Ltd. No
competing financial interests exist for C.K.W.C., A.C.M.K.,
R.R., R.R.M., G.L., A.H., and C.Y.L.
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Address correspondence to:
Samuel Kai Wah Chu, PhD
Division of Information & Technology Studies
Centre for Information Technology in Education
Faculty of Education
The University of Hong Kong
Pokfulam Road
Hong Kong SAR, China
E-mail: samchu@hku.hk