A smartphone game to prevent HIV among young Kenyans: local perceptions of mechanisms of effect

Abstract

Electronic games delivered via smartphones have the potential to become valuable tools in HIV prevention in high-prevalence and low-resource international settings. To ground theoretical elaboration around novel mHealth interventions in contextual realities, it is important to understand the mechanisms of their effects as perceived by local populations. Such perspectives are particularly important when working cross-culturally. ‘Tumaini’ is an interactive narrative-based smartphone game that uses a ‘choose-your-own-adventure’ format. It is designed to prevent HIV among young African adolescents (aged 11–14) by increasing age and condom use at first sex. It was developed with a US-based commercial game developer and is grounded in social behavioral theory, evidence-based practice and contextually relevant scenarios. In a 2017 randomized pilot study (n = 60) in Western Kenya, ‘Tumaini’ showed promising effects on behavioral mediators of sexual debut. In subsequent focus group discussions, adolescent participants and their parents shared their perceptions of the game’s mechanisms of effect, which included motivation to play, future orientation, decision-making, relationship to a diverse range of characters and a bridging of the virtual and real worlds. These findings align with our theoretical framework, confirm its successful translation into the intervention and will inform mediation analyses in an upcoming efficacy trial.

Introduction

Despite substantial progress in the response to HIV over the past decade and a half, 1.8 million people were newly infected in 2017. Young people continue to make up a large proportion of those becoming infected [1] and there are fears of a resurgence in the epidemic if HIV incidence is not further reduced as the largest ever generation of young Africans enters adolescence and adulthood [2]. This age group moreover suffers disproportionately high levels of HIV-related morbidity and mortality [3].

Youth need information and skills prior to sexual debut to protect themselves from HIV. Reaching pre-adolescents with pre-risk prevention interventions may help establish long-term patterns of safer sexual behavior and avert high-risk behaviors in the future [4, 5]. Early interventions can also nurture attitudes and norms supportive of people—including adolescents—living with HIV and an environment supportive of access to HIV services and ART adherence. Interventions must promote skills for understanding and managing the risks of HIV infection that are relevant to the prevailing sociocultural context, addressing important contextual drivers of adolescent risk [6–10], and grounded in scenarios which young people perceive as authentic and relevant.

Youth in high HIV-prevalence settings need to be optimally prepared for safer sexual debut in the most cost-effective way possible. Interactive mobile technologies provide unprecedented opportunities to deliver culturally relevant skills-building interventions at scale [9]. Increasingly accessible smartphone technologies in Africa make it possible to engage youth—at scale and at low cost—in culturally adapted prevention interventions that require little personnel to implement with consistent quality, have high entertainment and motivation appeal and incorporate automated data collection.

Digital games represent a promising intervention strategy, especially for youth HIV prevention [11]. By allowing players to experience real agency in a virtual and safe environment, well-designed games provide a level of experiential learning unparalleled by many other interventions. A growing body of evidence supports the effectiveness of games for health outcomes. Notable clinical outcomes in RCTs have included a 77% reduction in diabetes-related emergency department visits and urgent care visits [12] and improved treatment adherence in adolescents and young adults undergoing cancer therapy [13]. There is a pressing need to expand our understanding of and evidence base for the use of games in HIV prevention [14, 15], especially in low-resource settings.

‘Tumaini’ is a smartphone game designed to provide African adolescents (aged 11–14 years) with the knowledge, motivation and behavioral skills to delay sexual initiation and use a condom at first sex. Developed in collaboration with a US game developer with input from US-based and Kenyan specialists in adolescent sexual health and from Kenyan adolescents and their parents, it is grounded in (i) theory on narrative and narrative-based applied communication, including Entertainment-Education [16] and (ii) social behavioral theory, above all Social Cognitive Theory [17] and existing evidence-based HIV prevention interventions [18]. ‘Tumaini’ is grounded in extensive research on HIV-themed narratives by young Africans [19–24]. It uses interactive narrative to promote observational learning, cognitive and behavioral rehearsal, problem-solving and immersion.

The game is made up of three intersecting components:

1. The interactive role-playing narrative uses a choose-your-own-adventure format where the player makes decisions for six diverse characters and observes the short- and long-term consequences on the characters’ lives, relationships and health. Players guide each of the young characters (three girls and three boys), one of whom is HIV-positive, as they pass into or through adolescence, facing real-life challenges that the players are likely to face in their own lives. These include peer pressure, puberty, violence and decisions about smoking, alcohol, drugs and sex. The story takes place over eighteen chapters, distributed over three levels, during which characters encounter increasingly challenging situations as they grow older.

2. The mini-games reinforce knowledge and skills relating to: puberty; HIV and other sexually transmitted infections; pregnancy and avoiding pregnancy; identifying, avoiding and responding to risk situations and resisting peer pressure.

3. The third component, ‘My Story’, incorporates a customizable avatar and invites players to connect the knowledge and skills they learn in the game with their own lives. Players set goals and plan how to achieve them. They respond to prompts that promote cognitive rehearsal of how they would respond to situations their characters face in the narrative.

‘Tumaini’ comprises approximately 12 h of discrete gameplay and is designed to be replayed so that players can observe the outcomes of different decisions. A rewards system where players receive different prizes (items for a virtual house) depending on what choices they make for their characters encourages them to replay and explore pathways associated with different decisions. The theoretical framework for ‘Tumaini’, presented in Fig. 1 [18], is divided into three parts: intervention design, mediators and outcomes. These are represented by (i) the entertainment components of intervention design and the psychological process mediators, (iii) the behavior change components of intervention design and behavioral outcome mediators and (iii) the instructional components applied in intervention design. These are inter-linked and are integrated within the game structure.

Fig. 1.

Theoretical framework for ‘Tumaini’, an HIV prevention game rooted in interactive narrative.

In a 2017 randomized pilot study in Kisumu, Western Kenya, with 60 participants aged 11–14, ‘Tumaini’ showed promising results. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<0.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=0.006) and overall survey scores (P<0.001) compared with the control arm six weeks post-intervention. A post-intervention survey revealed high subjective measures of the game’s value, relevance and appeal, while post-intervention focus groups with pre-adolescents and their parents identified a wide range of knowledge and skills they had gained [25, 26].

Several studies have questioned the adequacy of current behavioral theories to account for the distinctive affordances of using new interactive digital media in health education, with some suggesting the need to develop new theories that acknowledge the multidisciplinary background and genealogy of such interventions [7, 14–16]. Descriptions of the development and evaluation of such interventions often lack detail regarding interventions’ theoretical grounding [15]. Additionally, theory building, when present, is rarely grounded in contextual realities, including when working cross-culturally or in post-colonial settings. To assess the local relevance of our theory of change and success in translating it into ‘Tumaini’, and thereby to inform mediation analyses to be conducted in an upcoming efficacy trial, we sought to better understand ‘Tumaini’s’ mechanisms of effects as perceived by adolescent participants and their parents.

Materials and methods

Children were instructed to play the game for at least 1 h/day during the 16-day study.

Intervention arm participants (n = 27) and parents (n = 22) took part in focus group discussions (FGD; n = 8) shortly after the 16-day intervention period, to provide qualitative feedback on the game experience. The four adolescent focus groups were stratified by age (11–12 and 13–14) and sex of the study child; the four parent focus groups were stratified by age of the study child alone.

Table I presents demographics of participants, which we believe to be broadly reflective of the source population. FGDs included all intervention-arm participants who were able to attend. The mean age of adolescent participants was 12.9 years; 55% were male. The diversity of housing type suggests that participants came from a range of socioeconomic backgrounds. The vast majority of adult participants was female; additional demographic data were not collected from parents on the presumption that these would approximate to those of their children.

Table I.

Demographics of FGD participants

Characteristics	Adolescents (n = 27)	Parents (n = 22)
Gender, n (%)
Female	12 (44.4)	19 (83.3)
Male	15 (55.6)	3 (16.7)
Age (years), mean (SD)	12.9 (0.9)
Religion, n (%)
Catholic	13 (48.2)
Protestant/Anglican	6 (22.2)
Muslim	2 (7.4)
Seventh Day Adventist	4 (14.8)
Other	2 (7.4)
Living with both parents, n (%)	19 (70.4)
Housing type, n (%)
Permanent	8 (29.6)
Semi-permanent	9 (33.3)
Temporary	8 (29.6)
Iron sheets	2 (7.4)
Smartphone ownership, n (%) (check all that apply)
Parent	19 (70.4)
Self	2 (7.4)
Sibling	10 (37.0)
Other adult	4 (14.8)
No one	3 (11.1)
Have used a smartphone before baseline, n (%)	20 (74.0)

The FGD guide for adolescent participants included questions about: players’ impressions of the game, parts they liked and did not like and what they would tell their friends about the game; how it felt to play different characters, including those of the opposite sex and the character living with HIV and to replay the narrative making different choices; individual game components and what skills they learned. The discussion guide for parents included questions about: their experience with their child playing the game; how their child played and interactions related to the game.

The FGDs were conducted in a mixture of English, Dholuo and Kiswahili by moderators fluent in all three languages. All participants were invited to use any combination of languages they felt comfortable with (code-switching is common). FGD transcripts were translated into English and uploaded to MAXQDA software, where they were labelled with inductive (e.g. ‘motivation to play,’ ‘advocacy with other children,’ ‘parent and game messaging reinforcing’) and deductive codes (e.g. ‘role-playing opposite sex,’ ‘future planning,’ ‘outcome expectancies’). The data were analyzed thematically, drawing on grounded-theory based approaches and compared across demographics.

Results

Motivation and mode of learning

Participants in parents’ and children’s FGDs indicated that children were highly motivated to play ‘Tumaini’, which they frequently framed as a learning activity. Parents ascribed their children’s motivation to play to the general appeal of the game: ‘The game was so interesting that they did not want to put the phone down even for a minute’ (FGD1 for parents of 13–14 year-olds). For some, it was specific features of the game that motivated children to play, among them the rewards system, the replayable quizzes or the fact that the game reflected the children’s lives: ‘it is something that he can relate to because these things happen in real life, so that made it enjoyable’ (FGD1 for parents of 13–14 year-olds).

Parents and children embraced the mode of learning, contrasting it with more traditional—and less engaging—approaches. One father said of his daughter, ‘I am happy because if you give her a piece of paper like this one to read [showing the study consent form], she will not concentrate and enjoy like the way she was using the phone’ (FGD2 for parents of 13–14 year-olds). Another parent reported her son telling her, ‘This phone has helped so much that if the teaching done in school was like this, I know I will be okay’ (FGD1 for parents of 13–14 year-olds).

Future goals and planning

Participants identified a wide range of skills they had gained through playing ‘Tumaini’, including saying a strong no, how to use condoms and recognizing and avoiding bad influences. Participants across all focus groups—children’s and parents’—acknowledged the value of these lessons and skills ‘for the children’s future’. Indeed, when children were invited to say how they would describe the game to a friend, most focused on what they perceived to be its benefits for their future. For example, a younger female participant recalled telling a boy that the game was ‘for advice and […] the game is encouraging because it helps you plan your future and not make bad choices so that when you grow up you may have a smooth future and a happy family’ (FGD for females, aged 11–12 years).

The value of the game in helping children set goals and plan how to achieve them, including when faced with challenges, was a common theme in both parent and child focus groups. Parents reported that their children’s newly set goals were encouraging them to study hard and make positive choices to be successful. Older adolescent participants commented that ‘it was good because it shows us that there are some obstacles on our way to achieving our goals’ (FGD for males, aged 13–14 years). They and parents appreciated the fact that ‘Tumaini’ stressed the value of hard work in achieving goals.

The future orientation fostered by ‘Tumaini’ was articulated in terms of motivation [‘what we could achieve’ (FGD for males, aged 11–12 years)]; awareness of and preparation for potential obstacles [‘what we will encounter in future’ (FGD for males, aged 13–14 years)] and of planning and steps to be taken [‘where we stand and how we can work hard to achieve our goals’ [FGD for females, aged 13–14 years)]. Parents spoke of their children’s excitement and motivation about their future goals. A parent whose daughter wanted to be a lawyer commented, ‘After playing the game I would tell her that being a lawyer requires some effort and that made her happy’ (FGD1 for parents of 11–12 year-olds). One mother commented that ‘it made my son have goals in life’ (FGD1 for parents of 13–14 year-olds) and described her son’s new interest in his older sister’s career path.

This future orientation was presented by parents and children as a key motivator for risk avoidance and risk reduction. Some linked this future orientation to the characters’ narrative. For example, one younger girl said, ‘it also taught me to plan my future like Ruth and Richard were doing, they were keeping their relationship slow until they finish secondary and went to college so like their dream was finally coming true’ (FGD for females, aged 11–12 years). One older girl saw the characters in the role-playing game as ‘more learned’ mentors (FGD for females, aged 13–14 years).

Decision-making

Some participants described how the game allowed them to see the outcomes of their choices and practice resisting peer pressure in decision-making. Some linked this learning to the feedback system in the mini-games or the interactive role-playing narrative. For example, one mother reported her son describing the mini-game feedback, ‘If you do that the game will tell you that is wrong and then correct you. If you pick another option the game tells you that is correct and it smiles at you, meaning what you did is good’ (FGD1 for parents of 13–14 year-olds). Another reported her daughter’s description of the interactive narrative, ‘She told me that in the game if you made a wrong decision it would lead you to a bad place and if you made a right decision it would lead you to a good place’ (FGD1 with parents of 11–12 year-olds). This mode of interactive learning was linked by some adolescents to the development of their decision-making capacities. A male participant explained that ‘it taught me how I can make my own choices for my future’ (FGD for males, aged 13–14 years).

Older boys linked replaying the role-playing component and choosing different paths for their characters to learning to make good choices in life by observing the consequences of the choices they had made for the characters: ‘the first time we were making good choices so that we can see the outcome. And the second time when we played, we made bad choices for them so as to see the outcome and prepare for the future’ (FGD for males, aged 13–14 years).

Relationship to characters

The younger participants were more concrete in their descriptions of the role-playing component, tending to link learning to the characters’ experiences, such as when a young girl explained, ‘It taught me how to build the future […] through Ruth’s behavior’ (FGD for females, aged 11–12). The older boys were most expansive and articulate about their interaction with the role-playing game. One said, ‘it felt good because as I was playing the game I was imagining these things happening in real life’ (FGD for males, aged 13–14 years). Parents commented on how relevant the content was and how it presented familiar situations: ‘The challenges that the characters in the game were going through are the same challenges that these children face in school… like someone looking down upon you’ (FGD1 for parents of 13–14 year-olds).

Some participants articulated the relationship between themselves and the characters in the game in terms of advice. When asked how it felt to play older characters a younger girl said, ‘I felt like the characters that were in the phone were friends who were advising us on things that they come across’ (FGD for females, aged 11–12 years). Others, in contrast, framed their own role as that of purveyors of advice to the characters. An older boy described a scenario where Juma is under considerable pressure to drink, ‘When he was going to drink, he asked me what he needs to do and I told him to refuse it and he refused to drink’ (FGD for males, aged 13–14 years). This discrepancy reflects a shift in perspective within the game from the role-playing narrative, when the characters ask the players for advice, to the mini-games, in which characters provide feedback as virtual mentors.

In a few cases, girls blamed behavior that they controlled through their gameplay choices during narratives or mini-games on the character in question. Other participants expressed pride in their character when, through their own (i.e. the player’s) gameplay decisions, the character made the right choice. A younger girl described how she felt in the situation when she played Juma refusing to drink alcohol: ‘Encouraging and also proud because he did the right thing’ (FGD for females, aged 11–12 years). An older boy described how when he was bored with TV, ‘it felt good’ to play the game, specifically replaying the part where Juma has the choice whether or not to step in and prevent the rape of a girl who is drunk (FGD for males, aged 13–14 years).

Adolescent participants were asked how they felt when bad things happened to their characters. The younger boys, several of whom tended to express themselves in moralistic terms, expressed discomfort or confusion when characters of both sexes were in challenging situations or behaved badly. The older boys were more sanguine: ‘it felt good because those things that were happening to them, you as an individual you will face them in life’ (FGD for males, aged 13–14 years). The younger girls described the interactive narrative as ‘encouraging’, focusing on the mentoring role played by certain of the characters. However, some found certain content, namely the predatory older men (the game includes a sugar daddy storyline and a predatory male teacher, as well as a predatory older female neighbor), ‘frightening’, arguing ‘we are still little’ (FGD for females, aged 11–12 years). One of the older girls said she felt uncomfortable when the girls were facing challenges, especially Grace, whose family is financially precarious following the death of her father and who is propositioned by her father’s former employer who is paying her school fees. The participant explained, ‘This is because I was seeing them as myself so if they are in trouble I see like am the one who is in trouble and there was no way I could persuade them to get off the trouble…’ (FGD for females, aged 13–14 years). One of the older boys expressed anger at Grace’s treatment by her father’s boss; another said he felt ‘very bad’ when the other pupils were telling Grace to drop out of school (FGD for males, aged 13–14 years).

Playing characters similar to and different from themselves

The older boys appreciated the diversity of learning provided by the range of characters: ‘playing different characters was good because each of the characters was facing different challenges. So it was easy to know how we can solve the challenges’ (FGD for males, aged 13–14 years).

The moderator asked specifically how it felt to play Daniel, who discovers during the course of the game that he was born with HIV. Some felt ‘bad’ or ‘sorry for him’ and angry or disappointed at his parents who did not disclose to him sooner, but happy that he was able to disclose (based on their choices for him) and then find support from other characters. One of the older boys expressed the emotion he empathically shared with the fictional character, ‘I was so embarrassed because it was not good for Daniel that he has HIV because he was feeling so bad. It was not also good to me’ (FGD for males, aged 13–14 years). Another older boy expressed a sense of unease followed by relief, ‘although it was shocking, he prepared himself and went to the hospital where he got some ARVs and started treating himself and protecting others’ (FGD for males, aged 13–14 years).

In responding to the question about how it felt to play characters of the opposite sex, girls focused on pressures the male characters faced (e.g. to drink alcohol or have sex) without addressing gender as a driver. The boys, especially the older boys, were much more expansive. When asked how it felt to play female characters, the younger boys said it was ‘uncomfortable’ and/or ‘confusing’ when a character learns about the female reproductive system and menstrual hygiene management or is faced with negative peer influence to flirt and have a boyfriend (FGD for males, aged 11–12 years). The older boys expressed appreciation for their increased understanding of pressures, issues and challenges faced and exerted by girls. For example, one stated, ‘I liked how these character were because you should know something about both boys and girls; how girls are being pressured and how girls can pressure you and how you can pressure girls’ (FGD for males, aged 13–14 years). Another said ‘I felt good because they have some different issues that boys don’t have; like some good advice. Boys always get into trouble because they do not know these things’ (FGD for males, aged 13–14 years).

Bridging of virtual and real worlds

Participants across the adolescent focus groups expressed appreciation and enjoyment of the customizable personal avatar in ‘My Story’, which linked the virtual and real worlds by allowing players to create an image of themselves in the graphic idiom of the game. One of the older girls stated that it reinforced her sense of feeling part of the game world: ‘The image was wonderful, it was good for me creating my image using other people’s ideas and being part of the ‘Tumaini’ story’ (FGD for females, aged 13–14 years).

Across all focus groups, adolescent participants clearly apprehended the symbolism of the house and prizes and linked it to the personalized goal-setting component in ‘My Story’, thereby bridging virtual and real worlds. Their comments suggested that this reward system conveyed a sense that their future dreams were within reach if they worked hard and made good choices. Participants described feeling or imagining, that the virtual house was their home and that they had built it themselves. One younger girl said of answering questions about her future in ‘My Story’, ‘it felt as if it was real… it made me feel that I was now older, that if I attain the age of 16 I will go to secondary, college, then get a job, build a house, help people in the community and then get married’ (FGD for females, aged 11–12 years). The virtual prizes symbolized both the rewards for their actions in the game [‘I felt comfortable with the prizes I won because I helped Sally say no firmly’ (FGD for females, aged 13–14 years)] and the real-life rewards they could achieve through hard work [‘it made me feel comfortable and to struggle and work hard in school so that I can get those things’ (FGD for females, aged 13–14 years)]. One older boy summed up the symbolic linking of virtual and real in ‘Tumaini’, ‘I realized that in real life if you make good choices you can find your real prize in life’ (FGD for males, aged 13–14 years).

Discussion

In intervention research, it is common to verify that the intervention is being implemented with fidelity, e.g. that facilitators of a group-based intervention are delivering it in ways that accurately and consistently reflect intervention design. Certain aspects of intervention fidelity [27], such as facilitator performance, are not an issue with an intervention like ‘Tumaini’, delivered on a smartphone without facilitator involvement. It is nonetheless important to ensure that participants are receiving it as intended, i.e. that the intervention, as received by participants, reflects its theoretical foundations.

Our formative research both on young Africans’ narratives [19–24] and with parents and adolescents in Kisumu, along with our dialogue-rich US–Kenyan partnership, allowed us to optimize the intervention’s relevance and acceptability through the course of its development. However, we were unable to assess participants’ and their parents’ perceptions of ‘Tumaini’s’ mechanisms of effect until after they had played it in full. This step, although apparently rare in intervention research (we have been unable to locate literature on the subject), was particularly important to us, given both the cross-cultural nature of our study and the novel nature of the intervention. Our findings reassured us that ‘Tumaini’ was being played and understood as intended, with fidelity to our design. Had our theory of change not aligned with participants’ perspectives, we would have first sought to better understand those perspectives, then either modified the intervention or incorporated constructs based on local perspectives into our theory of change.

Unprompted, FGD participants directly or indirectly addressed the major components and mediators from our theoretical framework. These intersected and overlapped, suggesting that the various game components were well integrated in the gameplay experience. In addition, in the FGDs, the adolescent participants appeared to have difficulty differentiating between game components, suggesting that these were mutually reinforcing, as intended. Participants placed less emphasis on certain of the more instructional aspects, such as guided mastery and scaffolded learning objectives; in a well-designed curriculum, it is appropriate that these should be unobtrusive.

Motivation to play: FGD findings on motivation to play shed light on data collected in the pilot study by other means. Preliminary analysis of game log files also indicates that intervention-arm participants played ‘Tumaini’ for an average of 27 h over the 16-day trial period, more than 50% longer than instructed [25]. In a post-intervention survey, 28/30 (93%) indicated that they would like to play more. Together, these findings indicate that the game was successful in generating high levels of intrinsic motivation and that it was both enjoyed and appreciated [28].

Future orientation and decision-making: Adolescents and parents placed considerable emphasis on the game’s value in helping children set personalized goals and plan how to achieve them in spite of challenges. They linked this future orientation, which they interpreted as a key motivator for risk avoidance and risk reduction, to the characters in the role-playing game (modeling and cognitive and behavioral rehearsal), the ‘My Story’ component (goal-setting and planning) and the rewards system (motivation), in line with the game design.

Interactive learning, including skills practice and visualization of short- and long-term consequences, through the role-playing narrative and the mini-game feedback system was linked by some to the development of their decision-making capacities. Specifically, replaying the game and choosing different paths for the characters in the role-playing narrative was described as allowing them to see the outcome of their choices (informing outcome expectations per Social Cognitive Theory [17]) and thereby learn to make good choices.

Relationship to characters: Adolescents described the strength of their immersion in the narrative world and their emotional engagement with the characters and situations they could relate to. Several expressed pride in the characters when they, as the player, made the ‘right’ choice for them.

For some participants, identification with certain characters made it emotionally challenging when the characters were in difficult situations. The phenomenon whereby consumers of non-interactive media feel as though a media character is talking to them is known as parasocial interaction [29]; in ‘Tumaini’, this phenomenon is presumably reinforced by the fact that the characters do in fact address the player directly asking how they would respond to a situation the character encountered. Some participants referred to the characters specifically as role models (observational learning).

Some participants, particularly younger children, had difficulty differentiating events generated by their own actions as players from the scripted behaviors of characters, suggesting that interactivity may not be being fully processed. Older boys, in contrast, deliberately replayed with the aim of exploring different outcomes.

In their examination of the psychological processes and outcomes of reader engagement with interactive narratives, Green and Jenkins [30] found that most people make decisions for a character based on what they personally would do in real life, by identifying with the character and putting themselves in his or her shoes, rather than by trying to understand a character’s unique motivations. Participants’ comments on Grace’s storyline of poverty and transactional sex suggest that they may feel responsibility for choosing not to allow her to escape risk arising from her financial vulnerability. There is a need to further examine players’ feelings as they make decisions for characters and ensure that the emotions generated by their interactions with the narrative support the game’s intended objectives.

Adolescents appreciated the opportunity to play a range of characters and to be exposed to a diversity of perspectives, including Daniel, the character living with HIV. While younger boys expressed some discomfort at playing girls facing the challenges of puberty, older boys appreciated the insights this afforded into the pressures, issues and challenges faced and exerted by girls. In a post-intervention survey on their experience of the game, most boys (14/16) and girls (9/14) indicated they preferred playing both male and female characters rather than characters of one sex or the other. However, more girls (5/14) than boys (2/16) preferred playing characters of their own sex. This is reflected in the FGDs, where the older boys described the benefits of playing the female characters, while the girls tended to elide the theme of gender.

Players’ affective response to the game as they identify with and respond emotionally to characters’ challenges may facilitate the gains in self-efficacy and behavioral intentions evident in post-intervention surveys [25, 29, 30]. Studies suggest that affective responses are primary: they occur before and influence subsequent cognitive processing [31]. Some studies have explored the potential of the increased empathy fostered by this process to reduce stigma towards marginalized groups. A study of the effects of an interactive narrative on attitudes towards un-documented immigrants [32] suggests that simply adopting another person’s perspective in such a narrative ‘may be effective tools in helping reduce pre-judice toward marginalized social groups’ (p. 374). Adolescent participants’ emotional responses to Grace, to Daniel, and, particularly in the case of older boys, to characters of the opposite sex, suggest the potential for increased empathy and understanding. Future studies will determine whether these lead to an increase in supportive attitudes.

Bridging of virtual and real worlds: Many adolescent participants described a bridging of virtual and real worlds, with prizes symbolizing the rewards they could expect for good choices in real life. This bodes well for the transferal of learning from the virtual to the real world, a key component of successful behavior change games [33], as reported by comments by parents and participants. Referential reflection or ‘the degree to which audience individuals relate a media program to their personal experiences’, mediates the effects of entertainment-education soap operas on behavior change [29]. Through its integrated components ‘Tumaini’ appears to successfully engage players in this type of reflection.

This qualitative feedback suggests that participants were well able to articulate ‘Tumaini’s’ mechanisms of effect, suggesting that they were functioning as intended and that there was strong alignment between the game’s theory of change and participants’ perceptions of how it worked. In a future efficacy trial, enrolling participants at age 13–14, the mechanisms will be further examined through mediation analyses of game logfile data in combination with data from behavioral surveys and formal quantitative assessments of the psychological process mediators. Qualitative research with adolescents and parents will also continue to play a prominent role both at endline and throughout the trial with the objective of monitoring participants’ experiences with and perceptions of the intervention and any implications these may have for the intervention’s theory of change.

Limitations

While FGDs were conducted by research staff who were not involved in game development and this was stressed at the start of each discussion, as with studies of this kind, we cannot rule out the possibility of social desirability bias.

Conclusion

Participants in the FGDs shared their perceptions of ‘Tumaini’s’ mechanisms of effect, contextualizing a range of mediators within their gameplay experience. They placed particular emphasis on: (i) motivation to play through interactivity, narrative, engaging game mechanics, relevance and value and personalization, leading to enjoyment/appreciation and intrinsic motivation; (ii) future orientation and decision-making through personalized goal-setting and planning in ‘My Story’, and modeling, cognitive and behavioral rehearsal and outcome expectancies in the interactive narrative and mini-games; (iii) decision-making, particularly regarding resisting peer pressure, founded in outcome expectations generated through interactive engagement with the narrative; (vi) emotional engagement with a diverse range of characters with whom they identified, facilitating narrative transportation, observational learning and reinforcement and (v) a bridging of the virtual and real worlds, key to transferal of learning, through identification with characters, reflection on how the game relates to their own life, and cognitive and behavioral rehearsal. Participant feedback suggests not only that players were engaging with the game’s components enthusiastically and identifying with the characters and storylines but also that the older participants in particular were consciously apprehending the intended mechanisms of effect, confirming the successful translation of our theoretical framework into the intervention. Further study of these mechanisms of effect, through mediation and other means, has the potential to inform the development of other interactive media-based interventions in a range of cultural settings by identifying and leveraging the most ‘active’ ingredients to maximize the transferal of effects from the virtual to the real world and their potential to catalyze behavior change. It is hoped that such research will ultimately support the development of increasingly effective games for health.