Stealth Health

Sexual Transmitted Infections (STIs)

Eric Briden1, Amy Cook2, Shannon Gould3, Karen Ramos4, and Christopher Young-Hong4
1

Faculty of Education, University of Ontario Institute of Technology, Oshawa, Ontario, Canada.

Faculty of Business and IT, University of Ontario Institute of Technology, Oshawa, Ontario, Canada.

Email: eric.briden@uoit.net, amy.cook@uoit.net, shannon.gould1@uoit.net, karen.ramos@uoit.net,

christopher.young-hong@uoit.net
AbstractAn undergraduate team of students from Video
Game Development and Adult Education and Digital Technology
merged to investigate, develop, and design a universally
accessible mobile serious game focused on Sexually Transmitted
Infections (STI). The purpose of the project was to follow the
development life cycle of game design and examine if a serious
game of this kind exists today. The team engaged in an extensive
review of the literature and discovered that there are 14 common
STIs, most do not elicit obvious symptoms, and young
adolescents are at a higher risk of becoming infected. What is
more, the review uncovered that few serious games associated to
sexual health education exist and there is little interest in
developing one of this kind. The team conducted an in-depth
needs and task analysis to explore the demand for an STI serious
game by consulting sexual health practitioners and educators,
and synthesizing research and data. It was revealed that learners
are in need of a more effective educational resource that
motivates them to enhance their sexual health awareness and
avoid sexual problems. Stealth Health is a dialogue driven
serious game that has the player interacting with a Non-Playable
Character (NPC) while players receive feedback throughout the
game. Stealth Health is a strategic approach that offers STI
education and awareness in a fun, safe, and engaging learning
experience. It connects with the player in a meaningful, realworld way, promotes a learning experience of achievement and
progression, affords the player curiosity and autonomy, and,
provides an inclusive, respectful, non-judgmental, pro-choice,
and evidence informed experience. By leveraging digital devices,
we assert that Stealth Health is a supplemental learning tool that
motivates learners to enhance their sexual health awareness and
make healthy sexual choices to avoid problems, thus,
transforming sexual education.
Keywordssexual transmitted infections; sexual transmitted
diseases; health; serious games; education; mobile games;
chlamydia; HIV; AIDS; crabs; human papillomavirus; HPV;
genital herpes, lymphogranuloma venereum; LGV; gonorrhea;
molluscum contagiosum, hepatitis A; hepatitis B, hepatitis C; pelvic
inflammatory disease; PID; syphilis; trichomoniasis

I. INTRODUCTION
A cross-disciplinary team formed from University of
Ontario Institute of Technology's Video Game Development
and Adult Education and Digital Technologies programs to
develop a serious game based on Inclusive Health Sex
Education. The team focussed the subject of the digital game
on bringing awareness about Sexually Transmitted Infections
(STIs) to learners in grades nine to twelve based on the

principles of the revised Health and Physical Education of The

Ontario Curriculum. The team delved into the exploration of
sexually transmitted infections and the importance of educating
and bringing awareness to learners as well as discovering the
current landscape for STI awareness and education. Likewise,
we explored serious games in sexual health, serious games for
sexually transmitted infections, and consider whether they are
age appropriate, incorporate learning theory, possess gamebased design principles, and highlight their teaching and
learning strengths and weaknesses. Sexual health awareness is
an important part of our overall well-being and the infusion of
serious games can transform a traditionally awkward topic of
sex education into a fun, safe, and engaging experience. By
integrating teaching strategies into games that leverage digital
devices we can aim to induce a meaningful learning experience
for the younger audience.
II. BACKGROUND/LITERATURE REVIEW
A. Sexually Transmitted Infections
According to the City of Torontos Sexual Health website1,
a sexually transmitted infection (STI) is an infection that you
can get from having sex with a person who is infected with
the disease. Sex does not only refer to intercourse, sex can
refer to oral, vaginal or anal contact. An individual can have
an STI and because they have no signs or symptoms, not be
aware that they have one. There are 14 common STIs, all of
which can be passed from one person to another via sexual
relations or transfer of bodily fluids. Because symptoms are
not always obvious, they can go untreated and certain untreated
STIs can increase an individuals risk of developing HIV, the
virus that leads to AIDS1. The common STIs include:
Chlamydia, HIV/AIDS, Crabs, Human Papillomavirus (HPV),
Genital Herpes, Lymphogranuloma Venereum (LGV),
Gonorrhea, Molluscum Contagiosum, Hepatitis A, Hepatitis B,
Hepatitis C, Pelvic Inflammatory Disease (PID), Syphilis and
Trichomoniasis.
It is important to educate and bring awareness to students
about STIs as Health Canada2 asserts that, sexual health
awareness is an important part of our overall well-being as
humans and the ability to understand and appreciate our
sexuality, helps us to make healthier choices, which is essential
to maintaining good sexual health throughout life , not just in
our younger years. As catalogued on Health Canadas Health
Concerns website2, the key information identified for young
people to learn about diseases and conditions includes: What is

an STI?, How to protect yourself from STIs, It's ok to ask

questions, Practicing safer sex is a key component to avoiding
STIs, and Respect yourself and the choices of others. In fact,
sexual health education enables individuals, couples,
families, and communities to develop the knowledge,
motivation, skills, and critical awareness needed to enhance
sexual health and to avoid sexual problems3.
B. STI Awareness and Education
Sexually Transmitted Infections awareness and education
are taught throughout the Ontario Health and Physical
Education Curriculum4 to support students develop the skills
and knowledge to understand themselves and others, think
critically, make and promote healthy choices, develop and
maintain healthy relationships, and be safe physically and
emotionally. The topic of STIs are introduced in grade seven
and explored in further detail during grades nine to twelve5.
The Centre for Communicable Diseases and Infection Control6
published in 2010 that many STIs were being contracted
between the ages 15-19 and predominantly in females. In fact,
the reported rates of chlamydia, gonorrhea, and infectious
syphilis, by sex in Canada between 1995-2010 can be seen in
Figure 1. What is more, according to the Public Health
Agency of Canada7, preventing STIs is the first step to
reducing them and since many teens are more promiscuous
now, participating in unprotected sexual transactions and
susceptible to contracting an STI, individuals can be infected,
not know it, and continue to be sexually active, contributing to
the spreading of STIs.
It is important to educate and bring awareness to students
about STIs, as sexual health awareness is an important part of
our overall well-being as humans and the ability to understand
and appreciate our sexuality helps us to make healthier choices,
which is essential to maintaining good sexual health
throughout life2. The Public Health Agency of Canada7
suggests, Comprehensive in-school educational programs can
be effective in changing youth behaviours when programs
combine learning about sexual risk and protection with nonsexual factors such as building healthy relationships...".
Essentially, this is what the Canadian Ministry of Education is
adopting with their revised curriculum in order to mitigate
challenges that are presented to many youth in the Ontario
education system.
C. Serious Games in Sexual Health
Our findings demonstrate that there are few serious
games for sexual education on the market and of those, most
are largely unsuccessful or not well known. What is more,
there is little evidence of successful development and
implementation of digital games integrated into sexual health
education curriculums. Likewise, there is even less evidence of
development teams having an interest and pursuing the
creation of a sexual health game to deliver to the market.
Despite the fact that the educational game market has been
around as early as the 1980s, a large number of serious games
are crippled by poor game design and well-designed ones are
few and far between. Simply, there has not been enough
resources devoted to developing these games which results in
lackluster games that have yet to prove value to schools. In
fact, it should not be surprising that a controversial topic such

Figure 1 Reported rates of chlamydia, gonorrhea and infectious syphilis by

sex, Canada 1995-2010

as sexual education has few serious games on the market. The

sexual health education sector would benefit from a serious
game design with a tailor-made platform targeting specific
audiences rather than the traditional teach everything at once
approach. In particular, digital games can provide separate
applications that can be age, gender, and culturally appropriate
to support the learning and knowledge acquisition for players8.
There are other valuable findings; Din Heiman,
BrainPOP COO and General Manager13 summarizes, Weve
learned that if you provide teachers a place to find quality
learning games, games that engage and challenge students, tie
directly into their curriculum, and play on the prevailing
classroom devices within the boundaries of their lesson period
- you will literally be overwhelmed with the response. The
concept of adding serious games to the list of tools used to
instruct or supplement sexual health education is backed by a
number of benefits. Notably, one such benefit and perhaps the
most obvious is that serious games can take the traditionally
awkward and potentially boring class instruction of sex
education and transform it into a fun and engaging experience8.
This is especially beneficial in the Millennial age where digital
devices are a more appealing medium to the present a youth
audience. Likewise, the internal instruction of serious games is
also considered a benefit since institutions would not
necessarily have to hire or train staff to educate students on the
topics but rather the games would provide the necessary
guidance8.
Non-digital games and activities like STD/HIV
Handshake9 and Between Me and You10 target the youth
audience and are backed by the belief that youth should be
exposed to sexual health instruction sooner rather than later.
The success of these classroom games can be linked to social
constructivism and activity learning theories. In social
constructivism, learners acquire knowledge through social
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interaction and knowledge is a shared, constructed outcome

crafted by the engagement of all participants involved. While,
activity theory is similar in that, it is inclusive of all
participants as they pursue a common goal which is presented
by the context of the activity. In the STD/HIV Handshake9
activity, each teen is given a card with a letter Z, O, X, or C
and instructed to shake hands with three other participants and
have those participants sign their card. Once everyone has
received three handshakes and signatures, the participants are
told that each letter represents a different infection and C
represents an exception; the use of a condom. Based on the
various handshakes implicitly representing sexual intercourse,
each participant explores whether or not they have been
infected and/or if they have infected others. Participants share
their feelings about sharing an infection, receiving an infection,
and collectively discuss the emotion and concern for one
another, in turn emphasizing the importance of safe sex
practices. The web and mobile game Safe Sex with Friends12
also employs a social learning experience where players use
Scrabble like mechanics to compete against one another to
produce higher scoring, safe-sex combinations. In doing so,
they are demonstrating safe-sex behaviours together as is done
between individuals engaging in sexual activities.
Behaviorism and reflection-on-action process are two other
learning theories present in a number of these safe-sex games.
Behaviorism involves invoking a stimulus and using it to either
reinforce or discourage certain behaviors while, reflection-onaction is simply evaluating the results of ones practices
following their occurrence in order to better inform future
courses of action. Referring back to STD/HIV Handshake9
game, guilt and fear are used to stimulate the learner's approach
to sexual activity in the future, and the instructor of the activity
guides them through a reflection period. Since teenagers are at
a higher risk of contracting STIs, integrating teaching strategies
into games that leverage digital devices can induce an
enjoyable learning experience for the young audience.
Learners are in need of a more effective educational resource
that motivates them to enhance their sexual health awareness
and avoid sexual problems. Our Stealth Health concept is a
thoughtfully designed serious game on the specific topic of
Sexually Transmitted Infections.
III. STEALTH HEALTH
A. Stealth Health Objectives
While we have discovered there is no shortage of STI
awareness and education, including the many facets of
resources on STI symptoms, short and long term effects,
testing and treatment methods, and prevention, we have
designed our game based on the following learning objectives:
Identify reasons why learning
Transmitted Infections is important;

about

Sexually

Recognize that Sexually Transmitted Infections often

have no symptoms; and
Identify personal decisions to avoid or to reduce the
spread of Sexually Transmitted Infections.

Further, we established that health professionals and

educators deem the following points to be integral to providing
an engaging learner experience when teaching about STIs:

Do not overload learners with data;

Do not demonstrate worst case scenarios, but rather the

most important; such as STIs often having no
symptoms or signs; and

Do not go into the fine details but rather impart the

things students will benefit from.

Additionally, Dan Rice11 suggests in Three Tips for

Teaching about STDs, that, providing learners with a safe and
comfortable learning environment and emphasizing choice and
healthy sexual relationships is another key message. Stealth
Health places the player in a dialogue driven environment
where they are engaged in conversation with an Non-Playable
Character (NPC). The NPC takes on the form of a peer who is
in distress over his or her most recent sexual engagement and is
concerned about his/her well-being and fearing the worst that
they may have contracted an STI and/or may be pregnant. The
players role is that of a bystander who attempts to support and
console the distressed friend while discussing the possibilities
of contracting an STI and counsel the appropriate form of
action the NPC should take to put his/her concerns to rest.
The game establishes a challenging environment with a
real-world correlation. Throughout the progression of the
game, the player engages with the NPC, responding to
questions by selecting responses from a list of predefined
options. The player makes influential choices that challenges
his/her knowledge of safer sex practices and STIs by forcing
him/her to assist their friend to the best of their abilities while
battling the conflict of doubt and insecurity in their responses..
B. Stealth Health Game Design
Our game developers for Stealth Health chose the Unity
Game Engine and paired it with Dialogue Management
System, a compatible plugin for its familiar and simplistic
interface to develop the operational prototype. The overall
design of the game incorporates a dialogue driven progression
in which the main mechanic is a conversation tree. The game
loop in this context begins with an NPC posing a question or
concern to the player who must then respond using a single
response from a predetermined list.
Actually, each response represents a separate branch on the
tree that advances the players' progression from the current
NPC question, which represents a particular node along this
tree. As a matter of fact, since each response may have its own
unique branch, players may navigate different paths along the
tree for each time they play and experience a new conversation.
In a like manner, the targeted game platform for Stealth Health
is mobile gaming. The game's controls were designed to be
minimalistic. The player touches the screen to select a
dialogue option while the remaining game elements are
automated in response to the player's selection.
As we considered the art style for the game, our objective
was to establish a universally adoptable learning experience
that is not restricted to a single demographic, such as gender,
age, or race. Therefore, the art style is simplistic and bland and
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does not suggest more or less relevance to any specific

demographic.
C. The Learning Experience
The intended learning experience in Stealth Health is built
upon conflict influenced by the role that the player assumes in
the game which is to assist a peer to the best of his/her abilities
while struggling with doubt and insecurities about the
responses they select. This conflict is further developed
through limiting players to a few select responses from a
predefined list. The constraints guide the player through a
variety of lessons that are meant to challenge his/her
knowledge of sexually transmitted infections in order to
provide an engaging experience with beneficial instruction.
The game successfully establishes a challenging
environment through a correspondence with the real world,
particularly recalling on the player's real life sexual knowledge
and practices. Ideally, the player selects responses based on
what he/she believes to be true or that correlates to how he/she
has approached sexual activity in real life. It is here, that the
player's knowledge of STIs and safe sex practices are exposed,
informed, and restructured as they attempt to influence the
NPC. Moreover, positive or negative influential effects will
induce an emotional reaction for the player based on their
selections and stimulating those behaviours and insecurities. In
the same manner, dominating a positive influence on the NPC,
the player may experience relief and satisfaction in their ability
to make informed, pro-choice sexual health decisions.
Alternatively, if the player conforms to negatively influencing
the NPC, they could experience discomfort and question their
knowledge of safe sex practices. Fortunately, the final result of
the play through and the NPCs responses along the way
provide closure for the player. The player's belief in their
practices and knowledge of STIs is either fortified following
positive results or it is seen as harmful following negative
results, provoking reflection, concern and potentially a change
in behaviour for the player.
Following the completion of the module play through, the
player has acquired a better understanding of the importance of
learning about sexually transmitted infections and acquired
new or reconstructed existing knowledge about STIs that they
otherwise might have remained oblivious about. Additionally,
mastering the module also means that they player is
successfully able to identify the personal decisions they make
that influence their ability to avoid and reduce the spread of
STIs, and can approach those decisions appropriately.

Concerning challenges and potential improvements of

the game design for Stealth Health, writing the dialogue is of
course, the most challenging aspect of a dialogue driven game.
Particularly, dialogue must be both engaging and educational
to retain a player's attention otherwise; the player may quit the
game. Alternatively, if the dialogue is too heavily entrenched
in expert knowledge, specific terms, and professional lingo, it
may be difficult for a player to interpret. Likewise, if dialogue
too hard to understand, a player will either grow bored or
become frustrated, thus, losing interest in completing the game.
Moreover, dialogue can become too wordy and/or text-heavy
further discouraging a player when confronted by a wall of
text.
Instead, dialogue should be concise, minimal, and
convey the intended message in as little words as possible.
The context of the dialogue also needs to be relevant to the
target audience, presented within a realistic and believable
scenario that is meaningful to the player.
Overall, the conversation in its entirety must be well
designed, keeping in mind that there are many possible
responses the player could intercept for each scenario. This
can become difficult to manage as there may be restrictions of
four or five responses to a wide variety of possible answers.
In the same way, articulating the context that is relevant to the
scenario adds another layer of difficulty in designing the
conversation tree. Let alone, on the NPC side of the dialogue,
it must be written to be able to guide the player through the
learning material as well as teach the topic and impart
knowledge.
Since the NPC is an expert in the dialogue
conversation, the NPCs dialogue options must be able to
accommodate the breadth and depth of a player's knowledge.
In this way, the dialogue remains accessible by providing an
appropriate level of difficulty to challenge players adequately.
STI and safer sexual practices are imparted to players
implicitly throughout the game. Stealth Health is a strategic
approach that offers STI education and awareness in a fun,
safe, and engaging learning experience. It connects with the
player in a meaningful, real-world way, promotes a learning
experience of achievement and progression, affords the player
curiosity and autonomy, and, provides an inclusive, respectful,
non-judgmental, sex positive, pro-choice and evidence
informed experience. By leveraging digital devices, we assert
that Stealth Health is a supplemental learning tool that
motivates learners to enhance their sexual health awareness
and make healthy sexual choices to avoid problems, thus,
transforming sexual education..
REFERENCES

IV. CONCLUSIONS
Although players are constrained by predefined responses,
they are provided with an environment to cognitively assess
possible outcomes for each answer and determine the best
course of action or experiment and choose an alternative
outcome. Stealth Health players may experience uncertainty
while selecting their answers however, learning from that
experience they can repeat the process with more knowledge
and a different perspective. Each decision the player makes is
meant to teach them to consider the situation, assess it
thoroughly, and making good or bad choices is done through
trial and error within a safe, non-judgmental environment.

[1]

[2]

[3]

City of Toronto. (n.d.). Our Philosophy on Sexual Health. Retrieved

from
http://www1.toronto.ca/wps/portal/contentonly?vgnextoid=adda0ab7717
90410VgnVCM10000071d60f89RCRD
Health Canada. (2015, February 20). Sexual Health and Promotion Healthy Living. Retrieved from http://www.hc-sc.gc.ca/hl-vs/sex/indexeng.php
Canadian Federation for Sexual Health. (2005). The right to sexual and
reproductive health (SRH) education. In Beyond the Basics: A
Sourcebook on Sexuality and Reproductive Health Education (p. 4).
Retrieved
from
www.halton.ca/common/pages/UserFile.aspx?fileId=25508

Page 4

[4]

[5]

[6]

[7]

Ministry of Education. (2015). Health and Physical Education - A

Parents Guide: Human Development and Sexual Health in the Health
and Physical Education Curriculum Grades 7-12. Retrieved on February
28,
2016
from
http://www.edu.gov.on.ca/eng/curriculum/elementary/HPEgrades7to12.
pdf
Ontario. (2015). The Ontario curriculum, grades 9 to 12: Health and
physical
education.
Retrieved
from
http://www.edu.gov.on.ca/eng/curriculum/secondary/health.html
Centre for Communicable Diseases and Infection Control (Canada), &
Canada. (2010). Infection control guideline for the prevention of
healthcare-associated
pneumonia.
Retrieved
from
http://publications.gc.ca/collections/collection_2013/aspc-phac/HP3710-2010-eng.pdf
Public Health Agency of Canada. (2013). The Chief Public Health
Officers Report on the State of Public Health in Canada, 2013:
Infectious DiseaseThe Never-ending Threat. Retrieved from
http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/sti-its-eng.php

[8]

[9]

[10]

[11]

[12]
[13]

Serious Games for Sexual Health [roundtable discussion]. (2015).

Games for Health Journal: Research, Development, and Clinical
Applications, 4(2), 1-9. Doi: 10.1089/g4h.2014.0139. Retrieved from
http://www.play2prevent.org/wp-content/uploads/2015/01/SeriousGames-for-Sexual-Health.pdf
STD/HIV Handshake [lesson plan]. (n.d.). Advocates for Youth.
Retrieved
from
http://www.advocatesforyouth.org/forprofessionals/lesson-plans-professionals/1262?task=view
Teachingsexualhealth.ca. (2013). Between Me and You Game.
Retrieved
from
http://teachers.teachingsexualhealth.ca/wpcontent/uploads/Between-Me-and-You.pdf
Rice, D., [Answer - Sex Ed, Honestly] (2014, September 17). Three Tips
for Teaching About STDs [Video file]. Retrieved from
https://youtu.be/aKeFLAKEp_0
Unknown Author. (n.d.). Safe Sex with Friends. Retrieved from
http://kahoabe.net/safesexgame.html
Teachers Surveyed on Using Digital Games in Class. (2014, June 9).
Retrieved from http://www.gamesandlearning.org/2014/06/09/teacherson-using-games-in-class/#impact

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