Behavior

This Video Game Can Prevent Risky Sexual Behavior in Teens

The growing field of "serious games" is trying to tap the unique power of gaming to boost sexual IQ and encourage smart choices in real life.

PlayForward is a serious role-playing video game that engages youth with a variety of challenges and choices in fictional yet realistic life situations. | Lynn Fiellin, MD, Yale School of Medicine
PlayForward is a serious role-playing video game that engages youth with a variety of challenges and choices in fictional yet realistic life situations. | Lynn Fiellin, MD, Yale School of Medicine

What if we could help teens make smarter decisions by turning their real-life drama into a video game? That’s exactly what a team of researchers at the Yale School of Medicine set out to do, developing an immersive first-person video game that aims to raise the sexual health IQ of at-risk youth. A year later, kids who played the game displayed much healthier attitudes towards sex and significantly greater knowledge than their peers, according to a paper published in the Journal of Medical Internet Research.

Lynn Fiellin is the director of the play2PREVENT Lab at the Yale Center for Health and Learning Games, where the video game was created with funding from the National Institutes of Health. The original NIH grant focused on HIV prevention in minority youth between 11 and 14 years old, but Fiellin and her team wanted to develop a game that addressed the “entire landscape of adolescence,” including drug use, alcohol, smoking, opioids, cheating, bullying, unsafe driving, friend relationships, and more.

The result was PlayForward: Elm Street Stories, a 2D adventure game for the iPad where players navigate their avatar through a realistic, graphic-novel world while learning how to negotiate and defuse potentially dangerous situations. The hardest part, Fiellin told Seeker, was creating a game that didn’t feel like a public service announcement.

“It just couldn’t be one more ‘sex ed’ intervention,” explained Fiellin. “It had to be something that they got so engaged in and pulled into that everything they learned and processed was just part of the game play.”

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To get it right, Fiellin not only assembled a team of professional game designers, but her lab also spent countless hours consulting with the true experts: young teens themselves.

“One thing about kids is that they tell you exactly what they think,” said Fiellin. “‘No one has hair like that. His pants are too short. No one says stuff like that.’ The result is that the game is really in their voice and from their heads.”

This isn’t the first time that a video game has been used in a health education setting. Starting almost a decade ago, so-called “serious” games were developed to teach kids and young teens about managing conditions like asthma, depression, and even cancer. The problem, explained Fiellin, is that previous studies on the impact of serious games were either too small or not scientifically rigorous. The goal of the Yale project was not only to impact the lives of at-risk youth, but to determine if such an impact can even be measured.

To test the PayForward game, Fiellin’s lab recruited 333 kids ages 11 through 14 from schools and after-school programs in New Haven, Connecticut. Nearly all the kids were from racial or ethnic minorities, since health data shows that minority kids, particularly boys, are far more likely to contract HIV than the general population. The kids were randomly assigned to either a control group that played non-educational games like Angry Birds for six weeks, or the experimental group, which exclusively played PlayForward.

To play the game, kids followed the story of their avatar from seventh grade through twelfth grade. Along the way, they had to use skills like “people sense” to determine who to trust and who was “bad news.” Players had to win five mini-games that test skills like “refusal power” — how to recognize and diffuse “pressure attacks” involving sex, smoking, or substance abuse.

The game also included “epilogues,” a vision of where the avatar ends up at 30 years old based on the decisions he or she made as a teen. Without a fully developed prefrontal cortex, teens and young adults are more susceptible to risk-taking behavior and are often blind to long-term consequences. The epilogue feature, which is continuously updated with each in-game decision, was designed to encourage “future orientation” or big-picture thinking.

PlayForward takes an average of 16 hours of gameplay to complete. Fiellin admitted that at first, some kids wanted to play Angry Birds instead of PlayForward, but that they quickly got hooked on the storylines, all culled from real teen experiences. By the end of the six weeks, even the Angry Bird kids were asking where they could download PlayForward.

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But the Yale researchers wanted to find out more than if kids “liked” the video game. It needed to prove whether PlayForward had a measurable impact on teens’ attitudes and behaviors. Fiellin and her team administered standardized risk assessments at six weeks — when the game was first completed — and again at three, six and 12 months.

The results were conclusive. The kids who played the game had healthier attitudes around sexual health and simply knew more about the risks of sex than the control group. For example, they knew that it was a myth that a girl can’t get pregnant the first time she has sex.

What the experiment didn’t prove was that a video game intervention like PlayForward delays the initiation of sexual activity. The majority of both the control and experimental groups were not sexually active during the 12-month testing period. That’s good news for the kids, but makes it harder for researchers like Fiellin to make the case that virtual behaviors influence real-life choices. The plan is to check again at 24 months when the group is a little older.  

Meanwhile, Fiellin’s lab has received more funding from the NIH and a private foundation to build the game out even further and to make it available for free download on all device platforms as well as a browser-based version.

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