Gamifying sexual health education in Tanzania

Results of a randomised control trial provide new evidence that gamification and game-based learning (GBL) are both highly effective tools for increasing sexual health knowledge among adolescents in Tanzania and, importantly, are something adolescents both enjoy and are motivated to do.

Adolescents are affected by HIV in unique ways. During this time, they go through physical, mental and emotional changes that mean they may be more likely to engage in unhealthy sexual behaviours such as underage sex, concurrent relationships and unprotected sex.

Across sub-Saharan Africa, traditional teaching methods are the predominant means of delivering sexual health education. These are focused on lecturing, with little to no room for discussion. The result is poor knowledge about sexual health and HIV across the region among adolescents. It’s been estimated that adolescents aged 15–19 years in sub-Saharan Africa account for 37% of all new global HIV infections.

Studies elsewhere have confirmed that innovative, game-derived techniques are a highly effective way to deliver comprehensive sexual health education. But there is little-known research on their effectiveness in schools in sub-Saharan Africa, where young people are most affected by sexual health issues such as HIV and human papillomavirus (HPV).

In a randomised control trial conducted in Tanzania, 120 students were assigned to one of three teaching conditions for sexual health education. Traditional teaching was used as the control condition and was compared to two experimental teaching methods: game-based learning (GBL) and gamification. It was hoped that digital game technology could be used as a potentially powerful way to engage today's digitally-orientated adolescents in a low-resource context, also providing confidentiality in a culturally and socially conservative context.

In the gamification methodology, sexual health information was ‘gamified’ through elements such as badges, leadership and a points system. This construct was used to promote competition and give students the desire to learn more content.

In the GBL approach, a game was developed in collaboration with researchers, reproductive health specialists, computer and information scientists, community members, teachers, and students. It was scenario-driven and digital characters and stories were woven into the learning content, which was then interactively embedded into a game.

For both of these interventions, students completed the game at their own pace, individually, and performed various activities such as quizzes and completing exercises relating to sexual education.

Demographic, socio-economic and use of digital technologies data was collected from the students. The mean age for the students was 14.2 for the males and 13.9 for the females, making up 52.5% and 47.5% of the cohort respectively. Most (66.7%) of the students lived with both parents while 17.5% lived with their mother only. Most (51.7%) of the students described themselves as not rich, but managing to live well, 20% of them described themselves as among the well-off in the area, and the rest described themselves as ‘average’.

In this cohort, around a third did not have access to a computer at home or at school, just under half had access to a smartphone at school or at home, and over a third reported not playing computer or mobile games. Despite these low levels of technology use compared to studies outside of sub-Saharan Africa, the adolescents responded well to GBL and gamification.

The researchers used a mixed-methods approach to determine the effectiveness of the interventions. An Adolescent Sexual Health Literacy Test (ASHLT) was conducted to assess knowledge acquisition covering five topic areas, conducted pre- and post-intervention. All three interventions yielded statistically significant improvements, however, GBL and gamification final test results were markedly higher than the control. Mean test scores were 79.94 and 79.23 respectively, and 51.93 for the traditional delivery. This was up from 29.26 across all interventions at the beginning.

They also evaluated the teaching methods using the ‘MAKE’ framework. This involved a questionnaire post-intervention measuring Motivation, Attitude, Knowledge and Engagement of all three study arms. 21 students were then selected for more in-depth focus group interviews on each of the teaching methods. This allowed for the students to express their opinions and the researchers to gain more insight into the efficacy of each method – based also on the MAKE framework.

The researchers found that students were much more motivated in both the experiment arms – saying that learning was more fun and friendlier, while those in the control arm said they weren’t free to learn, with some students fearing being beaten if they got things wrong.

Student attitudes towards both the teaching methods and content was, again, very positive in the experiment arms. One student commented, “My participation to the course was very high due to this teaching approach,” while those in the control arm commented, “I feel shy, embarrassed, and awkward to ask questions in sexual health matters in the class.”

Overall students felt like all three approaches improved knowledge but felt that the experiment arms were much more effective because students could go at their own pace and catch-up where appropriate, something the traditional approach could not offer.

Students also felt that the traditional approach ended up being less engaging. “The way we were taught this subject is too personal and teacher-centred and but it is supposed to be more engaging, involving, and attractive,” commented one student in the control arm. In stark contrast, those in the experiment arms were highly engaged and enjoyed the learning. Another student commented, “I always am the last students to leave the computer lab and sometimes I was reluctant to shut off my computer.”

This study provides interesting insight into a relatively novel approach to comprehensive sexual health education in schools. The study authors conclude, “The study confirms that if used in a positive way, games can be powerful educational tools in low resource settings and regions where discussions about sexual issues are taboo for adolescents vulnerable to high-risk sexual behaviour.”