Abstract

This study aims to map educational games related to the sexuality of adolescents/young people, based on publications that occurred over the last decade (2011 to 2020). An integrative review was performed in the Web of Science, SCOPUS, MEDLINE/PubMed, and LILACS databases in September 2020, with the final inclusion of 16 studies. Games developed on four continents were identified, predominantly in high-income countries, with the United States of America and Brazil being those that published the most. The tools consisted mostly of videogames and digital games, with the adoption of simulated scenarios and plots. Regarding development, there was a preference for the participatory construction mode, while some also underwent a validation process. The tools addressed several areas of human sexuality and demonstrated a positive potential for use, with educational gains and changes in habits, but their results need to be carefully considered. Only the effects of three games were evaluated by randomized controlled trials.

Key words:
Sexuality; Adolescent; Health education; Play and playthings

Introduction

Sexuality is a multifactorial phenomenon observed not only in sexual behavior and practices, but also in feelings, desires, and affectionate bonds. Despite being expressed from birth, it is during adolescence and youth, a transitional phase that extends from 10 to 24 years of age, that it becomes evident¹1 Brasil. Ministério da Saúde (MS). Proteger e cuidar da saúde de adolescentes na atenção básica. 2. ed. Brasília: MS; 2018..

Motivated by desires, passions, and curiosity, experiences specific to this phase put boys and girls in vulnerable conditions that are capable of having repercussions throughout their lives. Violence, teenage pregnancy, and diseases are some examples of these experiences. Therefore, it is necessary to make room for discussion to promote sexual and reproductive health, focusing on recognizing one’s own body, providing guidance on protective and risky behaviors, breaking through prejudices, and talking about realities²2 Beserra EP, Sousa, LB, Cardoso VP, Alves MDS. Percepção de adolescentes acerca da atividade de vida "exprimir sexualidade". RPCFO 2017; 9(2):340-346..

Although relevant, discussions about sexuality with the adolescent population are surrounded by taboos that interfere, directly or indirectly, in the healthy experience and exercise of sexuality. Within the nuclear family, these discussions are often not discussed between parents and children, are seen as a source of discomfort, and are almost never treated as naturally as they should be. At school, the subject is approached superficially and shows low transformative potential in promoting health³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20..

Thus, there is an clear need to expand opportunities to discuss sexuality with young people, favoring innovative and attractive approaches to ensure greater adherence and effectiveness of actions. As an option, educational-care technologies are intended to take advantage of the technological potential to engage individuals in their own health care⁴4 Leopardi MT, Paim LMD, Nietsche EA. Empoderamento da enfermagem e o uso de tecnologias do cuidado. In: Nietsche EA, Teixeira E, Medeiros HP, organizadores. Tecnologias cuidativo-educacionais: uma possibilidade para o empoderamento do(a) enfermeiro(a)? Porto Alegre: Moriá; 2014. p. 75-95..

Among the technologies applied to health, educational games with content and purpose, also known as serious games, play an important role. Conceptually, they represent games that go beyond entertainment, promoting health, contributing to the discussion of sensitive topics, as well as educating, guiding, and encouraging healthy habits and behaviors⁵5 Desmet A, Shegogo R, Ryckeghem DV, Crombez G, Bouedeaudhuij ID. A systematic review and meta-analysis of interventions for sexual health promotion involving serious digital games. Games Health J 2015; 4(2):78-90..

Evidence shows that games about sexuality help to better understand the subject, encourage attitude change, and promote safe sexual practices⁶6 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295.^,77 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742.. In addition, they foster critical thinking and guide decision-making and problem-solving, while creating a sense of responsibility⁸8 Winskell K, Sabben G, Obongo'O C. Interactive narrative in a mobile health behavioral intervention (Tumaini): theoretical grounding and structure of a smartphone game to prevent HIV among young Africans. JMIR Serious Games 2019; 7(2):e13037..

It should be noted that, until 2013, based on an analysis of the literature, there were very few games on sexual health, as opposed to what was observed in other health-promoting contexts. Furthermore, studies were concentrated in high-income countries, with no record in low- and middle-income countries⁵5 Desmet A, Shegogo R, Ryckeghem DV, Crombez G, Bouedeaudhuij ID. A systematic review and meta-analysis of interventions for sexual health promotion involving serious digital games. Games Health J 2015; 4(2):78-90.. In this light, there is an identifiable need to analyze the spatial and theoretical-methodological behavior of the study of this topic in recent literature, recommending current options of games to be used by educators to approach the subject with young people.

Based on the foregoing information, considering the adolescent/young population as being adept at using technologies, recognizing the importance of sexuality in their lives, and identifying the need to situate the current state of knowledge on the subject, especially with regard to Brazilian data, this study aimed to map educational games related to sexuality in adolescence and youth from publications over the last ten years (2011-2020).

Method

This is an integrative literature review involving six steps: 1^st - the identification of the topic and formulation of the research question; 2^nd - the establishment of the inclusion and exclusion criteria and literature search; 3^rd - the definition of the information to be extracted and its categorization; 4^th - the evaluation of the articles included; 5^th - the interpretation of results; and 6^th - the synthesis of knowledge⁹9 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764..

To construct the core question of the study and set up the search strategy, the terms were organized according to the PICOT strategy (P - problem, I - interest, CO - context, T- time)¹⁰10 Stern C, Jordan Z, McArthur A. Developing the review question and inclusion criteria. AJN 2014; 114(4):53-56.. Educational games represented the study problem; the interest was sexuality in the context of adolescence/youth, and the reference time was the last ten years (2011-2020). It was then possible to formulate the research question: “What is the current state of the art on educational games related to sexuality in adolescence and youth produced between 2011 and 2020?”

All terms belonging to the same element of the PICOT strategy were combined with the Boolean operator “OR”, and the expressions for each element were combined with the “AND” connector. The organization of controlled and uncontrolled descriptors generated the following general search expression: (“Play and Playthings” OR Technology OR “Game” OR “Pedagogical Device”) AND (Sexuality OR “Sex Education” OR “Sexual Development” OR “Reproductive Health” OR “Sexual Health” OR “Sexual Behavior” OR “Pregnancy in Adolescence”) AND (Adolescent OR “Adolescent Health” OR Youth). Organizing the terms and formulating the search strategy followed the specific recommendations for each database.

The search was conducted in September 2020 in the following databases: Web of Science - Main Collection (Thomson Reuters Scientific), SCOPUS (Elsevier), MEDLINE/PubMed (via National Library of Medicine), and LILACS (via Biblioteca Virtual em Saúde - BVS). The primary findings were filtered by time period (2011-2020) and type of publication (excluding book chapters, theses, and dissertations; texts published in conference proceedings; editorials; and letters/notes).

The time frame is justified by the lack of consolidated data on recent literature on the subject. It is important to note that, despite the existence of a review of the literature on games published until July 2013, this study does not include research bases from Latin America⁵5 Desmet A, Shegogo R, Ryckeghem DV, Crombez G, Bouedeaudhuij ID. A systematic review and meta-analysis of interventions for sexual health promotion involving serious digital games. Games Health J 2015; 4(2):78-90.. For that reason, the present review chose to extend the coverage period to the last decade.

Original articles (methodological and interventional) that presented a serious game on sexuality, aimed at the adolescent/young population, were included. The following exclusion criteria were adopted: studies that presented other educational interventions (curricular programs, mobile applications, and multimedia interventions), articles that did not include enough details to characterize the educational game (type, focus, and dynamics), and those that presented repeated games that were already included in the review.

The studies were selected by two researchers from the health area in order to reduce the risk of bias. A third evaluator was consulted in case of disagreement. Initially, titles and abstracts were analyzed. The texts included in the second stage were read in full to define the final sample (16 articles). The search flowchart is shown in Figure 1.

The final sample was characterized by having the researchers fill out a form extracting the following variables: title, authors, year, country, target audience, game characterization (type, name, and focus), methodology, results, conclusions, and limitations.

Results

This review resulted in the identification of 16 serious games that focused on the sexuality of adolescents and young people and were published between 2011 and 2020. The characteristics of the studies will be described in Chart 1 and the methodological paths and main findings in Chart 2. The limitations and implications for future studies are also highlighted.

Serious games for sex education over the last decade (2011-2020): study characterization

The development of educational games focused on the sex education of adolescents were predominantly developed in high-income countries, such as the United States of America⁶6 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295.^,1111 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254

12 Gariepy AM, Hieftje K, Pendergrass T, Miller E, Dziura JD, Fiellin LE. Development and feasibility testing of a videogame intervention to reduce high-risk sexual behavior in black and Hispanic adolescents. Games Health J 2018; 7(6):393-400.

13 Fiellin LE, Kyriakides TC, Hieftje KD, Pendergrass TM, Duncan LR, Dziura JD, Sawyer BG, Fiellin DA. The design and implementation of a randomized controlled trial of a risk reduction and human immunodeficiency virus prevention videogame intervention in minority adolescents: PlayForward: Elm City Stories. Clin Trials 2016; 13(4):400-408.

14 Gilliam M, Jagoda P, Heathcock S, Sutherland A. InFection Four: development of a youth-informed sexual health card game. Am J Sex Educ 2014; 9(4):485-498.

15 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35.^-1616 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404., England¹⁷17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30., and Hong Kong¹⁸18 Chu SKW, Kwan ACM, Reynolds R, Mellecker RR, Tam F, Lee G, Hong A, Leung CY. Promoting sex education among teenagers through an interactive game: reasons for success and implications. Games Health J 2015; 4(3):168-174.. Interestingly, studies were also identified in low- and middle-income countries, such as Brazil¹⁹19 Conceição C, Silva JVA, Pereira MCSS. Construção de um jogo lúdico para educação sexual de adolescentes com o transtorno do espectro autista. Adolesc Saude 2019; 16(3):111-120.

20 Monteiro RJS, Oliveira MPCA, Belian RB, Lima LS, Santiago ME, Gontijo DT. DECIDIX: encontro da pedagogia Paulo Freire com os serious games no campo da educação em saúde com adolescentes. Cien Saude Colet 2018; 23(9):2951-2962.

21 Sousa MG, Oliveira EML, Coelho MMF, Miranda KCL, Henriques ACPT, Cabral RL. Validação de jogo educativo sobre sexualidade para adolescentes. RPCFO 2018; 10(1):203-209.^-2222 Souza V, Gazzinelli MF, Soares AN, Fernandes MM, Oliveira RNG, Fonseca RMGS. O jogo como estratégia para abordagem da sexualidade com adolescentes: reflexões teórico-metodológicas. Rev Bras Enferm 2017; 70(2):394-401., India³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20., Kenya⁸8 Winskell K, Sabben G, Obongo'O C. Interactive narrative in a mobile health behavioral intervention (Tumaini): theoretical grounding and structure of a smartphone game to prevent HIV among young Africans. JMIR Serious Games 2019; 7(2):e13037., and Tanzania⁷7 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742..

Regarding the types of games, there was a predominance of video games and digital games. Only three games broke the rule, two card games (Contando bem que mal tem?²¹21 Sousa MG, Oliveira EML, Coelho MMF, Miranda KCL, Henriques ACPT, Cabral RL. Validação de jogo educativo sobre sexualidade para adolescentes. RPCFO 2018; 10(1):203-209. and InFection Four¹⁶16 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404.) and a board game (A aventura do adolescente com TEA: descobrindo a sexualidade¹⁹19 Conceição C, Silva JVA, Pereira MCSS. Construção de um jogo lúdico para educação sexual de adolescentes com o transtorno do espectro autista. Adolesc Saude 2019; 16(3):111-120.). Most authors chose to restrict the age group of the technology’s target audience, with games recommended for the early⁷7 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742.^,88 Winskell K, Sabben G, Obongo'O C. Interactive narrative in a mobile health behavioral intervention (Tumaini): theoretical grounding and structure of a smartphone game to prevent HIV among young Africans. JMIR Serious Games 2019; 7(2):e13037.^,1515 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35.^,1717 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30. or later years of youth³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20.^,1111 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254^,1212 Gariepy AM, Hieftje K, Pendergrass T, Miller E, Dziura JD, Fiellin LE. Development and feasibility testing of a videogame intervention to reduce high-risk sexual behavior in black and Hispanic adolescents. Games Health J 2018; 7(6):393-400.^,2222 Souza V, Gazzinelli MF, Soares AN, Fernandes MM, Oliveira RNG, Fonseca RMGS. O jogo como estratégia para abordagem da sexualidade com adolescentes: reflexões teórico-metodológicas. Rev Bras Enferm 2017; 70(2):394-401..

In terms of focus, serious games encompass several areas of human sexuality. Among them, it is possible to mention: Making Smart Choices¹⁸18 Chu SKW, Kwan ACM, Reynolds R, Mellecker RR, Tam F, Lee G, Hong A, Leung CY. Promoting sex education among teenagers through an interactive game: reasons for success and implications. Games Health J 2015; 4(3):168-174., focusing on knowledge and attitudes about sex among adolescents; Contando bem que mal tem?²¹21 Sousa MG, Oliveira EML, Coelho MMF, Miranda KCL, Henriques ACPT, Cabral RL. Validação de jogo educativo sobre sexualidade para adolescentes. RPCFO 2018; 10(1):203-209., about sexually transmitted infections and preventive methods; and Lucidity¹⁴14 Gilliam M, Jagoda P, Heathcock S, Sutherland A. InFection Four: development of a youth-informed sexual health card game. Am J Sex Educ 2014; 9(4):485-498. and PREPARE¹⁷17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30., dealing with violence and sexual coercion. In addition, some specific population groups were prioritized, such as adolescents with autism (A aventura do adolescente com TEA: descobrindo a sexualidade¹⁹19 Conceição C, Silva JVA, Pereira MCSS. Construção de um jogo lúdico para educação sexual de adolescentes com o transtorno do espectro autista. Adolesc Saude 2019; 16(3):111-120.), females (DRAMA-RAMA¹⁵15 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35.), Latin Americans (Sexpert High School⁶6 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295.), and residents of low-tech areas in sub-Saharan Africa (My Future Begins Today⁷7 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742.).

Sex education through games: what do the studies say?

Most serious games were developed in a participatory way by multidisciplinary groups³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20.^,77 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742.^,1313 Fiellin LE, Kyriakides TC, Hieftje KD, Pendergrass TM, Duncan LR, Dziura JD, Sawyer BG, Fiellin DA. The design and implementation of a randomized controlled trial of a risk reduction and human immunodeficiency virus prevention videogame intervention in minority adolescents: PlayForward: Elm City Stories. Clin Trials 2016; 13(4):400-408.^,1414 Gilliam M, Jagoda P, Heathcock S, Sutherland A. InFection Four: development of a youth-informed sexual health card game. Am J Sex Educ 2014; 9(4):485-498.^,1616 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404.

17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30.^-1818 Chu SKW, Kwan ACM, Reynolds R, Mellecker RR, Tam F, Lee G, Hong A, Leung CY. Promoting sex education among teenagers through an interactive game: reasons for success and implications. Games Health J 2015; 4(3):168-174., while some underwent a systematic validation process¹¹11 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254^,1818 Chu SKW, Kwan ACM, Reynolds R, Mellecker RR, Tam F, Lee G, Hong A, Leung CY. Promoting sex education among teenagers through an interactive game: reasons for success and implications. Games Health J 2015; 4(3):168-174.^,2020 Monteiro RJS, Oliveira MPCA, Belian RB, Lima LS, Santiago ME, Gontijo DT. DECIDIX: encontro da pedagogia Paulo Freire com os serious games no campo da educação em saúde com adolescentes. Cien Saude Colet 2018; 23(9):2951-2962. or were evaluated by means of intervention studies to measure the tool’s effect on the target population²2 Beserra EP, Sousa, LB, Cardoso VP, Alves MDS. Percepção de adolescentes acerca da atividade de vida "exprimir sexualidade". RPCFO 2017; 9(2):340-346.^,33 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20.^,66 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295.^,88 Winskell K, Sabben G, Obongo'O C. Interactive narrative in a mobile health behavioral intervention (Tumaini): theoretical grounding and structure of a smartphone game to prevent HIV among young Africans. JMIR Serious Games 2019; 7(2):e13037.^,1515 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35.^,1616 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404.^,1717 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30.. Chart 2 presents the methodological paths and main results of the studies included in this review.

As mentioned, there was a predominance of digital games, with most of them using simulated scenarios, including plots, characters, and interactive dialogues through which adolescents are encouraged to build relationships, make choices, and experience their consequences. Nine of the identified games were designed from this perspective⁶6 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295.

7 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742.^-88 Winskell K, Sabben G, Obongo'O C. Interactive narrative in a mobile health behavioral intervention (Tumaini): theoretical grounding and structure of a smartphone game to prevent HIV among young Africans. JMIR Serious Games 2019; 7(2):e13037.^,1111 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254

12 Gariepy AM, Hieftje K, Pendergrass T, Miller E, Dziura JD, Fiellin LE. Development and feasibility testing of a videogame intervention to reduce high-risk sexual behavior in black and Hispanic adolescents. Games Health J 2018; 7(6):393-400.^-1313 Fiellin LE, Kyriakides TC, Hieftje KD, Pendergrass TM, Duncan LR, Dziura JD, Sawyer BG, Fiellin DA. The design and implementation of a randomized controlled trial of a risk reduction and human immunodeficiency virus prevention videogame intervention in minority adolescents: PlayForward: Elm City Stories. Clin Trials 2016; 13(4):400-408.^,1515 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35.^,1818 Chu SKW, Kwan ACM, Reynolds R, Mellecker RR, Tam F, Lee G, Hong A, Leung CY. Promoting sex education among teenagers through an interactive game: reasons for success and implications. Games Health J 2015; 4(3):168-174.^,2222 Souza V, Gazzinelli MF, Soares AN, Fernandes MM, Oliveira RNG, Fonseca RMGS. O jogo como estratégia para abordagem da sexualidade com adolescentes: reflexões teórico-metodológicas. Rev Bras Enferm 2017; 70(2):394-401..

Digital games also made use of other plots. DECIDIX²⁰20 Monteiro RJS, Oliveira MPCA, Belian RB, Lima LS, Santiago ME, Gontijo DT. DECIDIX: encontro da pedagogia Paulo Freire com os serious games no campo da educação em saúde com adolescentes. Cien Saude Colet 2018; 23(9):2951-2962. simulates the interface of an instant messaging application, while PREPARE¹⁷17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30. uses the backdrop of a game show. Furthermore, two games chose to present a narrative about the different developmental milestones (My Future Family³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20.) or phases of the characters’ lives (Lucidity¹⁴14 Gilliam M, Jagoda P, Heathcock S, Sutherland A. InFection Four: development of a youth-informed sexual health card game. Am J Sex Educ 2014; 9(4):485-498.).

Other methodologies were used in addition to digital games. A Aventura do Adolescente com TEA: Descobrindo a Sexualidade is a board game that contains 17 illustrated houses, three pawns, a single die, an illustrated book, and a puzzle whose main plot takes place in a camp¹⁹19 Conceição C, Silva JVA, Pereira MCSS. Construção de um jogo lúdico para educação sexual de adolescentes com o transtorno do espectro autista. Adolesc Saude 2019; 16(3):111-120.. Two card games were identified as well. Contando bem que mal tem? consists of the shared construction of a story based on picture cards that are intentionally or randomly presented by the facilitator²¹21 Sousa MG, Oliveira EML, Coelho MMF, Miranda KCL, Henriques ACPT, Cabral RL. Validação de jogo educativo sobre sexualidade para adolescentes. RPCFO 2018; 10(1):203-209.. Infection Four is a collaborative, multiplayer card game that features a fictional storyline about heroes and villains¹⁶16 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404..

The way the games are presented and their degree of interactivity have much to say about their acceptance by the target audience. Strategies that promote engagement, such as the possibility of being customized¹¹11 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254, the unlocking of new functions¹²12 Gariepy AM, Hieftje K, Pendergrass T, Miller E, Dziura JD, Fiellin LE. Development and feasibility testing of a videogame intervention to reduce high-risk sexual behavior in black and Hispanic adolescents. Games Health J 2018; 7(6):393-400., and reward systems that reward correct answers and positive actions⁸8 Winskell K, Sabben G, Obongo'O C. Interactive narrative in a mobile health behavioral intervention (Tumaini): theoretical grounding and structure of a smartphone game to prevent HIV among young Africans. JMIR Serious Games 2019; 7(2):e13037., make them more entertaining and stimulating. Moreover, these criteria favor their effectiveness through the development of social skills¹⁵15 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35.^,1919 Conceição C, Silva JVA, Pereira MCSS. Construção de um jogo lúdico para educação sexual de adolescentes com o transtorno do espectro autista. Adolesc Saude 2019; 16(3):111-120..

An analysis of the studies affirmed that sexuality in adolescence is still treated as a social taboo, and the use of games to approach the subject reveals an innovative potential since, through playfulness and the interactive approach, it results in educational benefits. In addition to facilitating the acquisition of information³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20.^,66 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295.^,77 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742., these games boost self-efficacy and risk perception¹²12 Gariepy AM, Hieftje K, Pendergrass T, Miller E, Dziura JD, Fiellin LE. Development and feasibility testing of a videogame intervention to reduce high-risk sexual behavior in black and Hispanic adolescents. Games Health J 2018; 7(6):393-400.^,1515 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35., encourage behavioral change, and promote conscious decision-making¹⁷17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30.. In this sense, educational technologies demonstrate high acceptability, utility, and usability, while promoting the sharing of ideas, experiences, reflections, and discussions⁷7 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742.^,2020 Monteiro RJS, Oliveira MPCA, Belian RB, Lima LS, Santiago ME, Gontijo DT. DECIDIX: encontro da pedagogia Paulo Freire com os serious games no campo da educação em saúde com adolescentes. Cien Saude Colet 2018; 23(9):2951-2962..

The following limitations and challenges were observed: the complexity of the games makes them hard to understand¹⁴14 Gilliam M, Jagoda P, Heathcock S, Sutherland A. InFection Four: development of a youth-informed sexual health card game. Am J Sex Educ 2014; 9(4):485-498., the use of a fictional plot generates low engagement, technical language interferes with understanding, and playing them in large groups generates confusion¹⁶16 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404.. Furthermore, it is important to point out the lack of low-cost technologies capable of integrating educational practices in unfavorable socioeconomic contexts⁷7 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742..

As such, some basic criteria need to be observed when developing educational technologies for the adolescent population, namely: using simple and direct language, clear rules and low complexity, free from judgment/embarrassment and respect for privacy; demonstrating an approximation with reality, adapted to age group and sociocultural characteristics; inserting a professional mediator to direct the application of the game; and adopting the participatory design method.

Finally, it should be noted that, although most of the studies acknowledge positive signs of using games for sex education, measuring the effect is still limited. Only three of the sixteen studies presented a randomized controlled trial¹³13 Fiellin LE, Kyriakides TC, Hieftje KD, Pendergrass TM, Duncan LR, Dziura JD, Sawyer BG, Fiellin DA. The design and implementation of a randomized controlled trial of a risk reduction and human immunodeficiency virus prevention videogame intervention in minority adolescents: PlayForward: Elm City Stories. Clin Trials 2016; 13(4):400-408.^,1515 Norris AE, Hughes C, Hecht M, Peragallo N, Nickerson D. A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA(tm). Nurs Res 2013; 62(1):25-35.^,1717 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30., the gold standard for assessing intervention effects, involving 45 to 505 participants. There was a predominance of pilot tests without randomization of the participants and the control group, as well as an insufficient number of participants and a lack of sample diversity.

Discussion

This study presents sixteen educational games focusing on the sexuality of adolescents and young people, published over the last decade (2011-2020). Regarding geographic distribution, studies published in America (North and South), Africa, Europe, and Asia were identified. There was a predominance of digital games. The games discussed various topics within the scope of sexuality, such as corporeality and relationships, diseases, contraceptive methods, and sexual violence. The results are promising; however, there is a methodological deficiency, namely the small number of controlled and randomized intervention studies.

There is a growing trend in the use of serious games for health education purposes. A scope review conducted in the PubMed and Science Direct databases identified studies published between 1985 and 2018, with considerable growth since 2011 and a peak from 2015. A total of 161 studies were identified, focusing on health professionals (26.1%), patients (23.6%), and the general population (46.6%). The topics varied considerably, and only eight of the games focused on sexuality²³23 Sharifzadeh N, Kharrazi H, Nazari E, Tabesh H, Khodabandeh ME, Heidari S, Tara M. Health education serious games targeting health care providers, patients, and public health users: scoping review. JMIR Serious Games 2020; 8(1):e13459..

Contrary to what has been observed in other contexts, the use of serious games in sex education is still limited. A systematic review with meta-analysis developed in PubMed, Web of Science, CINAHL, and PsycINFO identified only seven studies published on the subject until July 2013.

In addition to being scarce, especially in middle/low-income countries, there was a lack of rigor in assessing the effectiveness of these games, especially in relation to measuring their long-term effects⁵5 Desmet A, Shegogo R, Ryckeghem DV, Crombez G, Bouedeaudhuij ID. A systematic review and meta-analysis of interventions for sexual health promotion involving serious digital games. Games Health J 2015; 4(2):78-90..

The development of games has shown significant importance in promoting educational and health actions. Traditional pedagogical models are gradually losing ground, and the use of games as a pedagogical tool is increasingly present in the context of health. In that respect, serious games use playfulness to teach while entertaining, facilitating adherence and the effectiveness of these actions²⁴24 Ferreira SC. A gamificação na área da saúde: um mapeamento sistemático. XIII Seminário de Jogos Eletrônicos, Educação e Comunicação 2019 mai 22-24; Alagoas, Brasil. [acessado 2020 nov 10]. Disponível em: https://revistas.uneb.br/index.php/sjec/article/view /6328
https://revistas.uneb.br/index.php/sjec/... .

Faced with the trend of change in pedagogical posture, the use of new methodologies also raises concerns and requires caution in the educational setting. Immersion in playful fantasies, especially in relation to digital formats, can lead to dependence/addiction, interfering with sleep quality, nutritional and hygiene standards, and social interaction, setting the stage for anxious, aggressive, and compulsive situations among young people. Therefore, the support network needs to be attentive to any changes in behavior, and educators are encouraged to use games rationally so that the risks do not outweigh the expected benefits²⁵25 Ferreira EZ, Zimmer E, Oliveira AMN, Brum AN, Silva MRS, Lourenção LG. Gamification: educational expectation, impact on health. Sustinere 2021; 9(Supl. 2):383-395..

It is recommended that educational games be adapted to the reality of the target audience to ensure a balance between education and entertainment and as a way to boost engagement¹¹11 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254. The young population shows greater adherence to low-complexity and easy-to-understand games⁶6 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295., which should be appropriate for the age group¹¹11 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254 and the sociocultural characteristics⁷7 Haruna H, Zainuddin Z, Mellecker RR, Chu SKW, Hu X. "An iterative process for developing digital gamified sexual health education for adolescent students in low-tech settings". Inf Learn Sci 2019; 120(11/12):723-742. of the target audience. Strategies involving competition and cooperation are other ways to bolster young people’s engagement¹⁶16 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404., as well as the use of gamification, using rewards and penalties¹¹11 Patchen L, Ellis L, Ma TX, Ott C, Chang KHK, Araya B, Atreyapurapu S, Alyusuf A, Lanzi RG. Engaging African American youth in the development of a serious mobile game for sexual health education: mixed methods study. JMIR Serious Games 2020; 8(1):e16254.

In addition to promoting communication about sexuality with young people, these games encourage discussions on topics considered taboo, especially when they are played in groups¹⁴14 Gilliam M, Jagoda P, Heathcock S, Sutherland A. InFection Four: development of a youth-informed sexual health card game. Am J Sex Educ 2014; 9(4):485-498.. From this perspective, using group games benefits from the presence of an instructor (health or education professional) who mediates discussions and raises the quality of the players’ experiences. It should be noted that smaller groups perform better¹⁶16 Gilliam M, Jagoda P, Jaworski E, Hebert LE, Lyman P, Wilson MC. "Because if we don't talk about it, how are we going to prevent it?": Lucidity, a narrative-based digital game about sexual violence. Sex Educ 2015; 16(4):391-404. and favor the exchange of opinions¹⁷17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30..

It is important to prioritize interactivity during discussions. Making room for pauses for further discussion of situations and issues that have arisen encourages active reflection, including the possibility of changing attitudes¹⁷17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30.. This is because the kind of interaction that occurs during the game intensifies learning and reflections about the situations, fortifying the development and maturation that make up the psychological basis of adolescents²¹21 Sousa MG, Oliveira EML, Coelho MMF, Miranda KCL, Henriques ACPT, Cabral RL. Validação de jogo educativo sobre sexualidade para adolescentes. RPCFO 2018; 10(1):203-209..

The reflections mediated by games reveal a protective role, encourage the acquisition of life skills, and present high acceptability. Teenagers classify them as fun and interesting because of their innovation and interactivity, while acknowledging their pedagogical benefits¹⁸18 Chu SKW, Kwan ACM, Reynolds R, Mellecker RR, Tam F, Lee G, Hong A, Leung CY. Promoting sex education among teenagers through an interactive game: reasons for success and implications. Games Health J 2015; 4(3):168-174.. In addition to being widely accepted by the target audience, the authors call attention to the parents’ positive evaluation on the use of educational games as a way for their preteen and teenage children to learn about sexuality³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20..

Educational games prove to be beneficial to adolescent sex education as they promote information, knowledge, and behaviorial change⁶6 Pensak MJ, Lundsberg LS, Stanwood NL, Cluster AS, Gariepy AM. Development and feasibility testing of a video game to reduce high-risk heterosexual behavior in Spanish-speaking Latinx adolescents: mixed methods study. JMIR Serious Games 2020; 8(2):e17295.. By reflecting on real-life situations, games sharpen critical thinking skills, encourage decision-making and problem-solving, and instill a sense of responsibility⁸8 Winskell K, Sabben G, Obongo'O C. Interactive narrative in a mobile health behavioral intervention (Tumaini): theoretical grounding and structure of a smartphone game to prevent HIV among young Africans. JMIR Serious Games 2019; 7(2):e13037..

Despite the benefits suggested by the studies, the real effects of games on the target population deserve further investigation. Future studies should invest in methodological designs that contribute to a better assessment of the effect of the intervention in the short, medium, and long term³3 Bertozzi E, Bertozzi-Villa A, Kulkarni P, Sridhar A. Collecting family planning intentions and providing reproductive health information using a tablet-based video game in India. Gates Open Res 2018; 2:20.. There is also an interest in expanding the number of participants and adopting diversified samples in terms of socioeconomic and cultural characteristics²¹21 Sousa MG, Oliveira EML, Coelho MMF, Miranda KCL, Henriques ACPT, Cabral RL. Validação de jogo educativo sobre sexualidade para adolescentes. RPCFO 2018; 10(1):203-209..

Despite the limitations and the impossibility of making generalizations, the results indicate that public health policies aimed at the adolescent population should involve playful, innovative, and attractive strategies, especially when mediating sensitive issues that are difficult to approach. Within this framework, serious games emerge as valid and promising options that provide rich, engaging experiences for young people¹⁷17 Arnab S, Brown K, Clarke S, Dunwell I, Lim T, Suttie N, Louchart S, Hendrix M, Freitas S. The development approach of a pedagogically-driven serious game to support Relationship and Sex Education (RSE) within a classroom setting. Comput Educ 2013; 69:15-30..

Final considerations

The development of serious games aimed at the sexuality of adolescents and young people is an expanding area of knowledge, which has undergone a greater geographic distribution over the last decade (2011-2020). However, the number of investigations on the subject is still limited.

The public’s preference for digital games was observed, covering a spectrum of different approaches and topics. Most of the studies involved participatory construction methods and/or systematic validation processes. Although the results are promising, there is a methodological deficiency in the evaluation of the impact of these games on the knowledge and attitudes of adolescents and young people with few controlled and randomized studies.

This study maps and disseminates game options about sexuality to the academic and professional communities, and identifies trends observed over the last decade (2011-2020). The limited number of investigations justifies the need for further development, especially in the design of more robust studies that investigate the real effect of games on the sexual health of adolescents and young people.

References

Publication Dates

History