This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included.
Sexually transmitted infections (STIs) are ongoing concerns. The best method for preventing the transmission of these infections is the correct and consistent use of condoms. Few studies have explored the use of games in interventions for increasing condom use by challenging the false sense of security associated with judging the presence of an STI based on attractiveness.
The primary purpose of this study was to explore the potential use of computer simulation as a serious game for sex education. Specific aims were to (1) study the influence of a newly designed serious game on self-rated confidence for assessing STI risk and (2) examine whether this varied by gender, age, and scores on sexuality-related personality trait measures.
This paper undertook a Web-based questionnaire study employing between and within subject analyses. A Web-based platform hosted in the United Kingdom was used to deliver male and female stimuli (facial photographs) and collect data. A convenience sample group of 66 participants (64%, 42/66) male, mean age 22.5 years) completed the
The overall confidence of participants to evaluate sexual risks reduced after playing the game (
This study extends the literature by investigating the potential of computer simulations as a serious game for sex education. Engaging in the
Sexually transmitted infections (STI), including human immunodeficiency virus (HIV) are ongoing concerns. Rates of new STI diagnoses are increasing in most countries of the world, particularly among young people [
There are several reasons for variation in the impact of interventions. First, a “one-size-fits-all” approach is unlikely to be effective with all the intended recipients, given that they will vary in age, sexual preferences, sexual experience, and sexual attitudes [
In addition to SSS, another measure that might be relevant is Sexual Inhibition (SI), particularly a subscale from the
Second, some people feel less vulnerable to STIs based on their belief that they can ascertain whether a potential partner is likely to be infected or not on the basis of the way that they look or some other superficial characteristic. It has been shown that men feel that they would be able to make judgments about other people’s sexual health status based on perceived attractiveness [
Third, many sex education programs have been described, particularly by young people, as being “boring” or “irrelevant” to their needs [
Bearing in mind these three issues, one direction in which sexual health interventions could profitably develop involves the use of serious games. As young people are very familiar with computer and video game playing [
There has been some previous research exploring the use of games for sex education.
Verran et al [
Shegog et al [
Although previous studies have suggested potential positive benefits of serious games in health education, very little research has been carried out to investigate the influence of computer simulations for sex education specifically. As it is possible that the benefits of such games will vary according to age [
The primary purpose of this study was to explore the potential of computer simulation as a serious game for sex education and how the effects of a serious game might be moderated by personality traits, age, and gender. The research questions were (1) Do gender, age, and personality traits influence levels of confidence in evaluating sexual risk? (2) Does a simulation in the form of a serious game influence participants’ confidence regarding the assessment of sexual risk? and (3) Do gender, age, and personality traits influence the impact of the serious game in altering participants’ confidence in evaluating sexual risks?
Men and women in Southampton and surrounding areas were recruited via social media (Facebook, Twitter), posters at the University, and community advertisement boards. Potential participants were informed that data would be collected using an electronic quiz in order to investigate the use of a serious game in the form of a computer simulation for sex education. The posters contained the following information: “I would like to see how you will perform in a game we have developed for sex education.” Inclusion criteria were 18-30 years of age and English speaking. A total of 42 men, 22 women, and 2 participants who chose “other” for the question on gender were screened and all met the inclusion criteria.
Data were collected in May 2016. In total, 22 participants completed the experiment online at home, with a further 44 doing so in the lab. All participants were provided with a study information sheet and indicated electronic informed consent. The study took approximately 25 min.
This was a Web-based questionnaire study (that used between and within subject analyses). The study employed a quiz to collect data. A draft quiz was initially trialed on 6 pilot study participants and was then refined on the basis of their feedback during individual “think aloud” sessions. “Think aloud” is a commonly used protocol for usability testing of an intervention [
The final questionnaire comprised four sections: (1) demographic information, (2) the participant’s sexual risk evaluations, (3 personality trait questionnaires (SSS [
Participants were asked about their age, ethnicity, gender, and sexual orientation. Ethnicity options included white, black, Asian, mixed, and other. Gender options were “male,” “female,” “other,” and “prefer not to say,” and for sexual orientation (preference), “men,” “women,” “both,” or “none.”
The SSS [
The SIS2 assesses individual propensity to inhibit arousal because of threat of performance consequences (such as contracting an STI) [
Participants were asked to respond to the following statement: “Risks taken during unprotected sex are easy to evaluate.” Response options ranged from 1 (
Participants also rated their level of agreement with this statement: “The risk that someone takes when they have unprotected sex depends on the risk taking behavior of the other people in the sexual population.” Response options ranged from 1 (
Both items were completed before (
The quiz concerns a cruise called
The storyboard was introduced with the following: “You embarked on a singles love cruise sailing from Mykonos down to Ibiza. The ship is full of heterosexual single men and women who are looking for easy, no-strings attached sexual encounters with each other. Passengers have not been medically examined and therefore are unaware of whether are carrying a sexually transmitted disease or not. The journey time to your destination is 1 week. The ship is fully prepared for any lengthy journey and it is well-stocked with food and supplies including an inexhaustive supply of condoms. Due to the nature of the cruise, everyone is unconcerned with forming a relationship. So whether they will choose to have sex with someone, with or without a condom, is purely based on physical appearance.” The main task of the participants was to give the right answer to 10 questions or scenarios regarding the sexual health status of certain people on the cruise.
The scenarios presented in the questions were based on the responses of male participants in a previous study [
A summary of attractiveness ratings given by each man in the previous study to each woman was shown to the users throughout the game (
Male profiles in the computer simulation. Each type has two symbols to describe his personality. For the top one, a “+” indicates that a person uses condoms more with women that they find attractive, a “−” indicates that a person uses condoms less with women that they find attractive, and an “=” indicates that condom use is not affected by attractiveness. The bottom symbol represents the belief of a person with regards to the relationship between sexually transmitted infection (STI) risk and attractiveness: “+” means the person believes that attractive women are more likely to have an STI, “−” means that they believe attractive women are less likely to have an STI, and “=” means that the person believes that attractiveness is not related to STI.
Attractiveness table. A “+” indicates that the specified man is attracted to the specified woman, a “−” indicates that the man specified is not attracted to the specified woman, and an “=” means that the man does not find the woman either attractive or unattractive.
There were various different framings used and each one of them clearly specified the precise situation of the people in the simulation. For example, in one, the user is asked to predict the outcome of an encounter between a man of Type A and a Type 4 woman versus an encounter between a man of Type A and a Type 7 woman (see
The final stage of the game was the feedback provided to the users. Users watched a series of encounters between men and women in the simulated population, and they received information on how well they managed to estimate risk in each scenario, by receiving an overall score for the quiz and appropriate feedback to each question (see
In order to determine the correct answers to the questions, the computer simulation makes use of the attractiveness and condom use intentions of each person on the cruise. At the beginning of each simulation, infections are allocated to the population at random. People have the chance to meet each other and decide (1) whether to have sex or not, and, if they decide to have sex, (2) whether to have sex with or without a condom, based on the variables of attractiveness and condom use intentions specified for their type. There is a very high chance of an STI transmission when someone has condomless sex with another person who carries an infection. An average over 100 simulations was used for this quiz.
In order to account for possible biases stemming from the appearance of the images used for each type of person in the game, a random selection of pictures was allocated at the beginning of the game, from a selection of three different versions (white, black, and Asian faces).
After providing informed consent, each participant completed the self-administered questionnaires followed by the quiz. A £100 Amazon voucher was offered as an incentive to the person with the highest score on the quiz. The Ethics Committee of the University of Southampton approved the study.
To identify factors influencing the confidence ratings and the levels of change of confidence of evaluating sexual risk, a series of bivariate associations (Pearson correlation coefficients) and independent
Example question: Is a type A man more likely to get an infection from a Type 4 woman or a Type 7 woman?
Feedback given to the participants.
A total of 66 participants (42 men, 22 women, and 2 “other”) had a mean age of 22.5 years (SD 3.3, min 18, max 29). The majority of participants were identified as white (80%, 53/66) and as heterosexual (approximately 88% [58/66]; see
On the SSS, the mean score for men was 23.1 and for women was 22.5. Higher scores indicated greater sexual sensation seeking. There was no significant gender difference in this measure (
Sample demographics.
Variable | n | |
White | 53 | |
Black | 3 | |
Asian | 7 | |
Mixed | 1 | |
Other | 2 | |
Men | 42 | |
Women | 22 | |
Prefer not to say | 2 | |
18-24 | 46 | |
25-30 | 20 |
On the SIS2, the higher a participant scored, the higher the propensity for sexual arousal to be reduced in the face of threats of performance consequences. The mean SIS2 score for women (12.9) was significantly higher than that for men (11.2) (
At
Age showed no significant correlations with participants’ confidence in evaluating risk (
At
In response to the statement “Risks taken during unprotected sex are easy to evaluate,” the mean score before the game was 3.47, and after the game it was 2.98. A matched pairs
In response to the statement “The risk that someone takes when they have unprotected sex depends on the risk taking behavior of the other people in the sexual population,” the mean score before the game was 3.74, and after the game it was 3.77. A matched pairs
There was a significant gender difference in the impact of the game on confidence ratings; women had a greater reduction in confidence regarding their perceived ability to evaluate sexual risk than did men (mean change scores for men 0.30 and 0.82 for women;
Similarly, there was no correlation between the changes in confidence ratings concerning assessment of sexual risk before and after the game, and scores on SSS or SIS2 (
The average score on the quiz across the 66 participants was 5 out of 10 (min=2, max=8; the mean for men was 5.1, and 4.8 for women;
No significant correlation was found between scores on the quiz and confidence in evaluating sexual risk at
This study sheds some light on the use of computer simulations as a serious game for sex education. There was a significant change in participants’ confidence in evaluating sexual risk in the
Age and the personality trait variables—SSS and SIS2—were not correlated with the confidence of evaluating risk or with the level of change in confidence before and after the game. Gender, however, did have an effect, as women demonstrated a bigger shift in confidence of evaluating sexual risk than men. This finding agrees with a previous study on
Previous studies have shown that the difficulty of a game is a major determinant of the influence that it has on users, mainly because users get discouraged if the game is very difficult or they get bored if it is too easy [
Future research should investigate the effect of age on the influence of a sex education game using a bigger sample, as there were not enough older participants in this study to report findings regarding this variable with confidence. Additionally, the relationship status and relationship power of the participants should be investigated, as this might significantly change the way they associate with the characters of the game and therefore their evaluation of sexual risk [
This study is a step toward the design of tailored and relevant sex education interventions, as called for by DeSmet [
Some limitations of the study need to be acknowledged. Participants were not asked systematically about the difficulty of the game and therefore we only have anecdotal information about this variable. Also, we used a relatively small convenience sample and no behavioral outcomes or behavioral theory were assessed. Notwithstanding these limitations, this study is the first to explore the influence of computer simulations in the form of a serious game for sex education in relation to risk perception, and to investigate the impact that individual difference variables (age, gender, and personality) may have on the outcome. The results would be particularly useful for serious games designers for sex education as they provide some limited but promising insight into which aspects of games-tailoring could be beneficial and worth investigating further.
Computer simulations, presented in the form of a serious game, had an impact on participants’ confidence in evaluating sexual risk, especially for women. This suggests that serious games developed for use in this setting should be further investigated and perhaps gender-tailored. Working toward these goals might contribute to a reduction in STI rates. Personality traits and age were not related to the change in participants’ confidence in evaluating sexual risks before and after engaging in the game.
human immunodeficiency virus
It’s Your Game
Sexual Excitation Scale
Sexual Inhibition
Sexual Inhibition Subscale 2
Sensation Seeking
Sexual Sensation Seeking Scale
sexually transmitted infection
This work was supported by an EPSRC Doctoral Training Centre grant (EP/G03690X/1).
AE led the study design, game development, conducted the research, and prepared early drafts of the article. SB, CG, and RI helped with the design of the study and the game development. RI and AE carried out the analyses. All authors read and commented on drafts of the article, and approved the final version.
None declared.