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

Ignacio Franco Vega 1, MSc; Anastasia Eleftheriou 2, PhD; Cynthia Graham 3, ClinPsy, PhD

Author Affiliations

1 Department of Social & Policy Sciences, University of Bath, Bath, United Kingdom

2 TRI Technologos Research and Innovation Services Ltd, Larnaka, Cyprus

3 Department of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom

Corresponding Author

Cynthia Graham, ClinPsy, PhD Department of Psychology Faculty of Environmental and Life Sciences University of Southampton University Road, Room 44/3073 Southampton, SO17 1BJ United Kingdom Phone: 44 023 8059 3091 Email: c.a.graham@soton.ac.uk

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

Introduction

Background

Although contraceptive access and sexual education are more widely available than ever, risky sexual behavior remains an issue for people of all ages, especially younger individuals. More than 1 million sexually transmitted infections (STIs) are acquired each day worldwide among individuals aged between 15 and 49 years [1,2]. The most common STIs are chlamydia, gonorrhea, and trichomoniasis, although the diagnosis of syphilis has also increased in recent years [1]. In many countries, young people aged between 15 and 24 years have the highest rates of STIs [3,4]. Despite global and national efforts to stop the spread of STIs, the World Health Organization recently reported a “concerning lack of progress” in achieving reductions [5]. The best method for preventing the spread of STIs is the correct use of condoms [6]. However, many young people [7] engage in risky sexual behaviors such as having sex with multiple partners without the use of condoms or incorrect or incomplete condom use [8]. Many interventions have been developed to encourage consistent condom use and safer sexual behaviors; however, most of these interventions have been shown to have limited effectiveness and/or are very resource intensive [9,10]. Adolescent pregnancies are also a global concern in high-, middle-, and low-income countries. Although the past 30 years have seen a global decline in unintended pregnancy rates, a recent review of 166 low- to middle-income countries reported that approximately half of all pregnancies are unintended [11]. Furthermore, although rates of unintended pregnancies in the United States and the United Kingdom have dropped in recent decades [12], adolescent pregnancy rates remain high in many middle- to high-income countries (particularly in the United States) [13]. Despite consistent evidence that comprehensive sex education can increase protective behaviors [14], there are still many gaps in knowledge. Furthermore, access to contraceptives and sexual health services for young people remains limited in many countries [4]. Sex education, often delivered in schools as part of the national curriculum, can be a highly contested area, reflecting political, moral, and cultural debates. In the United States, school-based sex education curricula have long been criticized for being sex negative, often focusing on abstinence and omitting any mention of nonheterosexual experiences [15,16]. In many countries, traditional gatekeepers such as religious and educational authorities still powerfully restrict access, content, and materials used for sex education [4]. Therefore, for many young people, obtaining reliable information about sex and relationships can be difficult. The internet has been identified as a potentially valuable resource for comprehensive, interactive, web-based, and youth-friendly sex education [16]. Young people worldwide use the internet and social media to access information on sexual and reproductive health and rights [16,17]. Interventions delivered through digital media could particularly help reach marginalized groups such as young people in rural areas; lesbian, gay, bisexual, transgender, and intersex individuals; people with disabilities; and migrant populations [17]. It has been argued that education through games is more efficient and enjoyable than classroom teaching for several reasons [18]. First, it is predominantly the player who directs activity in games, whereas in school, it is predominantly the teacher who directs activity. This is why serious games use a learner-centered approach in which learners are involved in the process (learning through doing), in contrast to traditional education, which uses a teacher-centered approach in which learners are relatively passive. Second, children and adolescents often find it difficult to properly engage in school exercises [19], in which the challenge level is not well adjusted to their skills. In a class, there are many students with different skills, making it difficult for teachers to equally engage all students in the class. In contrast, video games engage players naturally by gradually adjusting their difficulty level as they progress in the game [20]. Game developers understand that for a game to be successful, players of varying abilities need to feel a sense of reward or achievement, often enough to retain their engagement. Third, students are sometimes discouraged by the school system as they are penalized for the mistakes they make (eg, they receive bad grades). However, in games, players are expected to make wrong decisions and do so without being discouraged (ideally, unless the game is poorly designed). In fact, games have the advantage of allowing users to train in real-life decision-making situations where the wrong choice may involve some risk without having to actually be at risk. For example, pilots often train using Microsoft Flight Simulator, whereas the military often uses battle simulators to train recruits. This allows players to make mistakes in a safe environment. Finally, an important characteristic of educational games is the constant real-time feedback provided to the user. Players almost instantly know how well a certain move or strategy works toward the goal of the game. Feedback can take the form of points, lives, levels, scores, ranks, or progress bars. Real-time feedback ensures that users are motivated throughout the game by promising that a goal is achievable. Some authors have argued that there is a strong case for integrating video games into sex education, whether by supplementing sex education classes with existing games that explore sex and sexuality or developing new games for the purpose of sex education [21]. Given the interactive nature of video games, their lack of real consequences, their capacity for privacy, and the familiarity that many adolescents already have with games, when used correctly, games could be very effective tools for students.

Aims of the Review

This review was conducted as part of a larger Erasmus+ funded project (Safe4Play) that aims to develop an innovative tool for sex and reproductive health education for young people using serious games with machine learning features. The aim of this review was to analyze the core elements and effects of video game–based interventions for improving the sexual health of young people. The findings informed the development of the intervention that was produced as part of the Safe4Play initiative.

Methods

We conducted a rapid review following the Cochrane Rapid Reviews Method Group guidelines [22,23]. A rapid review can be defined as a type of knowledge synthesis in which the usual procedures of a traditional systematic review are streamlined and accelerated such that the most crucial elements are still present, but the research time is considerably abridged [24].

Criteria for Study Selection

The criteria for selecting studies were based on the Population, Intervention, Comparison, Outcomes, and Study characteristics framework.

Population

This involved interventions aimed at working with youth (aged 15-25 years). Where studies included participants who fell both inside and outside of our target bracket (eg, aged 12-16 years), we tried, where possible, to select the appropriate results from the subset of the sample that met our age criteria; if that was not possible, we captured that specific limitation in the narrative form.

Intervention

This involved any video game–based sexual health intervention aimed at reducing risky sexual behavior. We considered a video game–based intervention as an educational intervention delivered through an electronic or digital medium that relied heavily on game mechanics, aesthetics, or game thinking (competition, cooperation, exploration, and storytelling) to engage, motivate action, promote learning, and solve problems [25].

Comparison

This criterion was not applicable.

Outcomes

As we were broadly interested in sexual health, we chose to include studies that assessed a broad range of knowledge, attitudinal, and behavioral variables. We defined primary outcomes as any of the following: decrease in unintended pregnancies and STIs, increase in contraceptive use, increase in intention to use contraceptives, acquisition of new knowledge regarding sexual health, change in the perception of risk of pregnancy, and change in the perception of risk of STIs. Secondary outcomes included changes in attitudes toward safe sex, self-efficacy toward sexual health, decrease in the number of sexual partners, increase in safe and consensual relationship practices, and increase in adherence to pre-exposure prophylaxis (PrEP). Where studies reported >1 relevant outcome, each one was captured and reported in a narrative form. When outcomes were provided at multiple follow-up points, all outcomes were reported for each follow-up point.

Study Characteristics

We included randomized controlled trials (RCTs) and quasi-RCTs (studies in which participants were allocated to different arms of the study using a method of allocation that is not truly random). Publications in either English or Spanish were considered.

Search Strategy and Search Terms

The search strategy was validated by the Safe4Play research team and an information retrieval specialist from the University of Bath. It was piloted to analyze the quality and quantity of its results; only small changes were made based on the findings. We used 5 databases to identify relevant studies: Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PsycINFO, and Scopus. Searches were conducted on April 23, 2021. In addition, we hand-searched the reference lists of the included trials for referenced articles that were not retrieved in the original search. We also contacted experts in the field for additional recent publications that the original search might not have identified. For details of the search terms used for each of the databases, see Multimedia Appendix 1.

Study Selection

A total of 2 steps were undertaken to assess the eligibility of the studies: title and abstract screening and full-text screening. A total of 2 reviewers (IFV and CG) were involved in the process. Approximately 20% (51/257) of the abstracts were independently screened by both reviewers, which served as a pilot to identify any salient issues. The remaining 80% (206/257) of the abstracts were screened by IFV. Interrater reliability was found to be moderate (weighted κ=0.53) [26]. All cases of uncertainty or discrepancy were resolved through discussions between the 2 reviewers. In the full-text screening stage, both reviewers independently screened half of the articles to confirm whether the studies identified during the title and abstract screening should be included. Reliability was found to be substantial ( κ=0.71) [26]. The same procedure was used to resolve any discrepancies between reviewers. The remaining articles were screened solely by IFV. Data extraction was performed by IFV. All pertinent data were extracted from the full text using a spreadsheet template. When an intervention was analyzed in multiple papers, data from all papers were considered during the extraction.

Results

Search Results

As shown in Figure 1, the search strategy produced 449 results, of which, after removing 132 (29.4%) duplicates, 317 (70.6%) articles remained (299/317, 94.3% of empir