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  <front>
    <journal-meta />
    <article-meta>
      <title-group>
        <article-title>STD PONG: A Personalized Persuasive Game for Risky Sexual Behaviour Change in Africa</article-title>
      </title-group>
      <contrib-group>
        <contrib contrib-type="author">
          <string-name>Chinenye Ndulue</string-name>
          <email>CNdulue@dal.ca</email>
          <xref ref-type="aff" rid="aff0">0</xref>
        </contrib>
        <contrib contrib-type="author">
          <string-name>Rita Orji</string-name>
          <email>rita.orji@dal.ca</email>
          <xref ref-type="aff" rid="aff0">0</xref>
        </contrib>
        <aff id="aff0">
          <label>0</label>
          <institution>Faculty of Computer Science Dalhousie University</institution>
          ,
          <addr-line>Halifax, NS</addr-line>
          ,
          <country country="CA">Canada</country>
        </aff>
      </contrib-group>
      <pub-date>
        <year>2018</year>
      </pub-date>
      <fpage>111</fpage>
      <lpage>117</lpage>
      <abstract>
        <p>Persuasive games are more effective if they are personalized to the specific group of users under consideration. This paper presents a personalized persuasive game for motivating risky sexual behaviours in Africa. The arcadetype game simulates various sexual risky behaviours that could lead to contracting STDs and HIV and how to avoid them. It engages players in an interactive manner using various persuasive strategies with the aim of imparting knowledge and skills about safe sexual behaviours/practices and how to avoid risky sexual behaviours. The game uses the engaging concept of the popular ping-pong game and the principles of game-based learning to engage users in the game while subliminally persuading them to refrain from risky sexual behaviours/practices.</p>
      </abstract>
      <kwd-group>
        <kwd>Persuasive systems</kwd>
        <kwd>Sexually Transmitted Diseases (STDs)</kwd>
        <kwd>Design</kwd>
        <kwd>Behaviour change</kwd>
        <kwd>Games</kwd>
        <kwd>Game-based learning</kwd>
      </kwd-group>
    </article-meta>
  </front>
  <body>
    <sec id="sec-1">
      <title>-</title>
      <p>
        More than half of all people will have an STD/STI at some point in their lifetime [
        <xref ref-type="bibr" rid="ref1">1</xref>
        ].
A statistic conducted by the World Health Organization in 2016, shows that more
than 1 million sexually transmitted infections (STIs) are acquired every day
worldwide [
        <xref ref-type="bibr" rid="ref2">2</xref>
        ]. The same study shows that each year, there were about three hundred and
fifty-seven million (3.57 million) new infections with one of these four Sexual
Transmitted Infections: Chlamydia, Gonorrhea, Syphilis and Trichomoniasis [16].
This figure is even more alarming in the developing parts of the world. For instance, a
recent report by the Joint United Nations Programme on HIV and AIDS (UNAIDS)
shows that HIV and AIDS have almost become an epidemic in the Eastern and
Southern African with 19.7 million people living with HIV, 61% adults and 51 children are
currently on antiretroviral treatment. In 2016 only, there were 790,000 new infections
[
        <xref ref-type="bibr" rid="ref3">3</xref>
        ]. Despite, this alarming spread of both STDs and HIV, the African continent has
received the least attention from research. Most existing technological interventions
targeted at STDs and HIV are focused on people in the western country and are not
suitable for people from the African countries due to the uniqueness in their culture,
religion, and beliefs especially where it has to do with acceptable sexual practices and
approaches for avoiding risky behaviours.
      </p>
      <p>
        On the other hand, Africa has a high mobile phone penetration and adoption rate.
More than half a billion people across Africa now subscribe to mobile services, with
the number expected to grow to 725 million by 2020 [
        <xref ref-type="bibr" rid="ref4">4</xref>
        ]. For example, 90% of
Nigerian adults own at least a mobile phone [
        <xref ref-type="bibr" rid="ref5">5</xref>
        ]. Similarly, research has shown that 99% of
adolescent boys and 94% of adolescent girls, including all racial/ethnic groups, play
video games regularly [
        <xref ref-type="bibr" rid="ref6">6</xref>
        ] and Africa is not an exception.
      </p>
      <p>
        Persuasive games for health are designed as interventions with the primary purpose
of changing a user’s behaviour or attitude in an intended way [
        <xref ref-type="bibr" rid="ref7">7</xref>
        ]. Research has shown
that persuasive games can be an effective tool for motivating desirable behaviour
change [
        <xref ref-type="bibr" rid="ref10 ref7 ref8 ref9">7–10</xref>
        ]. Therefore, persuasive games could be an important tool for HIV and
STD prevention. However, most existing persuasive games for health are not targeted
at African audience. To bridge this gap, this paper presents the design and
development of a persuasive game for health called STD Pong which aims at promoting risky
sexual behaviour change among African youths. The arcade game simulates various
sexual risky behaviours that could lead to contracting STDs and HIV and how to
avoid them. The game portrays most factors that could lead to STDs and HIV
infections as game characters. The game also models nine common STDs that are common
among the African audience. It engages players using various persuasive strategies
with the aim of imparting knowledge and skills about safe sexual behaviours/practices
and how to avoid risky sexual behaviours that could put one at danger of contracting
STDs and HIV. It uses the addictive concept of the popular ping-pong game and the
principles and mechanisms of game-based learning to engage users in the game while
subliminally persuading them to refrain from risky sexual behaviours/practices.
      </p>
      <p>The underlying game storyline (narratives), the linguistic expressions, the
characters, and other game elements were intentionally designed to reflect Africanness. This
makes the game easy for the target audience to identify and relate with, hence
increasing the potential of the game to persuade and motivate the desired behaviour change.
2</p>
    </sec>
    <sec id="sec-2">
      <title>Related Works</title>
      <p>
        Playing digital games has become a preferred leisure time activity by most people.
According to recent findings, 99% of adolescent boys and 94% of adolescent girls,
including all racial/ethnic groups, play video games regularly [
        <xref ref-type="bibr" rid="ref6">6</xref>
        ]. As a result,
researchers are building on the increasing adaption of digital games to design games
that are aimed at purposes other than entertainment. One common example of such
games is persuasive games which are designed as interventions for promoting
desirable behaviour or attitude change [
        <xref ref-type="bibr" rid="ref7">7</xref>
        ]. Research has shown that persuasive games can
be an effective tool for motivating desirable behaviour change in various health
domain including healthy eating [
        <xref ref-type="bibr" rid="ref11 ref8">8, 11</xref>
        ], physical activity [
        <xref ref-type="bibr" rid="ref12">12</xref>
        ], smoking cessation [
        <xref ref-type="bibr" rid="ref13">13</xref>
        ],
and risky sexual behaviour change . This research focuses on persuasive games for
promoting risky sexual behaviour change.
      </p>
      <sec id="sec-2-1">
        <title>Persuasive Games for Risky Sexual Behaviour Change</title>
        <p>
          A number of persuasive games have been developed targeted at promoting risky
sexual behaviour change. A typical example of persuasive games for risky sexual
behaviour change is a web-based health game called Super Nurse: STD Game [
          <xref ref-type="bibr" rid="ref9">9</xref>
          ]. The
game helps to educate players about different kind of STDs, their prevention and
cures. The game employed several persuasive strategies to facilitate the desired
behaviours. For example, players are awarded points for correct choices related to STD,
otherwise, points are deducted. Finally, players are provided with descriptive
feedbacks informing them about STD prevention, their effects, and dangerous practices
that can lead to contraction of the disease. Similarly, PlayForward: Elm City Stories is
a game aimed at imparting American youths with skills and knowledge on how to
avoid risky sexual behaviours that could lead to STDs and HIV [
          <xref ref-type="bibr" rid="ref14">14</xref>
          ]. The game allows
the players to customize their avatar and travel through time while engaging in
various risky behaviour-related activities such as pressure by friends to drink alcohol and
dangerous sexual activities. The game simulates the long-term impacts of various
activities in player’s life. Players also have the ability to go back in time and correct
all their ‘mistakes’ to ensure a better future.
        </p>
        <p>In summary, while designing persuasive games to motivate healthy behaviour
change is increasingly attracting attention, most existing persuasive games to date are
targeted at people from the Western world. There is a need to African-centric
persuasive game intervention that reflects Africanness.
3</p>
      </sec>
    </sec>
    <sec id="sec-3">
      <title>STD Pong’ Persuasive Game Design</title>
      <p>STD Pong is an interactive two-dimensional arcade game based on a fictional
narrative of a small village (clan) called Okpongidi and an invasion by STDs and HIV. The
Clan of Okpongidi has been taken captive by King AIDS (Figure 2) and his eight evil
henchmen (other STDs). King AIDS challenges the entire Clan to choose someone to
compete with his henchmen in a game of STD Pong. For every Henchman the player
defeats, he would be rewarded with an STD Scroll which would enable him to free his
entire clan from that particular STD. Each scroll contains knowledge about the
strengths, weaknesses of the defeated sexually transmitted disease, and how to
prevent, manage or treat the infection if applicable. If the player attains the final level, he
engages in a final show-down (battle) with the King of the STDs (King AIDS) to earn
a total freedom from his clutches.</p>
      <p>
        The player plays the role of a young warrior that has been elected by the elders of
the clan to defeat King AIDS. The overarching objective of the game is to acquire all
the nine knowledge scrolls (corresponding to the nine different STDs) that would free
the ‘Okpongidi’ Clan from the shackles of King AIDS and his evil henchmen. The
henchmen of the King AIDS are as follows in descending order of rank: Prince HIV,
General Gonorrhea, General Syphilis, General Cancroid, Captain Chlamydia, Captain
Trichomoniasis, Captain Herpes, and Captain Scabies. We chose to focus on these
nine different STDs because they are the most popular ones especially among our
target African population [
        <xref ref-type="bibr" rid="ref6">6</xref>
        ]. The game is designed to be played on a variety of
platforms including PC and mobiles. The game was developed using Actionscript 3.0 on
Adobe Animate.
3.1
      </p>
      <sec id="sec-3-1">
        <title>STD Pong Game Play</title>
        <p>The game was developed using some of the principles and mechanisms of
gamebased learning [15]. Principles like Intrinsic Motivation, Learning through fun and
enjoyment and Authenticity were employed in the game. While mechanisms such as
Rules, Clear but challenging goals, fictional setting, progressively difficult levels,
uncertainty and unpredictability were employed in the game.</p>
        <p>The game can be played in any of the two modes: The Story Mode and Arcade
Mode. In the story mode, the player accepts the challenge to battle against King AIDS
and his henchmen in the game. There are nine game levels with progressive
difficulties. Specifically, in each level, the player encounters a tougher henchman with better
skills. The reward at the end of each victory is an STD Scroll containing secret details
on the strengths and weaknesses of that particular disease. The arcade mode allows
the player to select any henchman to play against, but a henchman is accessible in this
mode only when he has been defeated in the Story Mode.
3.2</p>
      </sec>
      <sec id="sec-3-2">
        <title>Deconstructing the STD Pong Game</title>
        <p>The Story and game sounds. The story illustrates a typical African setting, where
communities are grouped into clans and tribes led by kings and elders who make
decisions for the community. We decided to imbibe this concept to give the game an
African feel and hence increase its relatability to the African audience. We also used
African Jungle soundtracks to increase the Africanness. The complexion of the player
and his attire, as shown in Figure 1, also contributes to give the game an African feel.
The Pong Ball, movement buttons, the health bars and the player, STD Scrolls. A
player is associated with a player character as shown in Figure 1. The player character
battles against a game character called a henchman which represents a particular STD
that the player has to battle with. Each game level presents a unique STD. As shown
in Figure 3, the player character is positioned at the left-hand side of the stage while
the henchman is positioned at the right-hand side. Both the player and the henchman
possess a health bar each, located at the top of the stage. Figure 3 shows a screenshot
of the STD Pong game panel. A ball, called the pong ball, bounces in a diagonal
manner around the stage. This diagonal movement of the ball introduces some levels of
uncertainty and unpredictability with regards to the movement of the ball. This is in
line with the uncertainty and unpredictability game-based learning mechanism [15].</p>
        <p>The game also features an STD ball which represents a particular STD on that
game level. The primary task of the player is to move his character up and down using
the arrow keys on the screen, to prevent the ball from hitting his defence system (the
wall) and to push the STD ball out of his side of the court to the henchman’s side of
the court. Any time the pong ball hits the player’s defence system, he loses 10% of
the total health value. Similarly, any time the STD ball hits the henchman’s side of the
court, the henchman’s health bar reduces by 10%.</p>
        <p>A level ends whenever any of the two health bars get to 0%. If the player health
gets to 0%, he is given an opportunity to either replay that level or end the game.
However, if the henchman’s health gets to 0%, the player wins and hence gets
rewarded with an STD Scroll. The STD Scroll contains important details about the
defeated STD including how it is transmitted, its symptoms, how to prevent it, how to
get tested, and how it could be treated. Figure 4 shows a screenshot of a sample STD
scroll gotten after defeating Captain Scabies.
Player Power-Ups. The player power-ups represent various activities that can be
used to control or prevent the spread of STDs. To determine the activities to be
represented by these power-ups, we interviewed some stakeholders including various
medical personnel who provided some expert opinions regarding the best practices and
design choices. Based on their suggestions, the top three best practices for our target
audience are; abstinence from sex, condoms use, and routine blood tests. Therefore, to
integrate this as part of the game, we modelled them as power-ups. The three
powerups appear randomly and the player could use them to defeat the STDs. Using the
abstinence power-up increases the player health bar by 10% of its original size. The
Condom power-up makes the player resistant to STD attacks for a certain duration of
time (approximately 10 seconds). The Blood Test power-up makes the player move
two-times faster than his normal speed, enable him to block the pong ball, and avoid
STD bullets faster. This metaphor conveys how regular testing and early detection of
STD is vital in the effective treatment or control (in the case of HIV) hence
persuading the player to imbibe these safety behaviours and practices.</p>
        <p>STD Bullets. The STD bullets represent two major behaviours that could lead to
STDs common among our target population: unprotected sex and the use of
unsterilized sharp objects. During gameplay, henchmen randomly fire STD bullets with the
aim of hitting the player and decreasing his health values. The unprotected sex object
reduces the health of the player by 20% each time it hits him while the sharp object
causes the player to move slowly for about 10 seconds. Through this technique, the
player gets to understand that things like sharp objects and unprotected sex (damages)
can ultimately lead to getting any of the STDs.
3.3</p>
      </sec>
      <sec id="sec-3-3">
        <title>Conclusion</title>
        <p>In this paper, we described the design and development of a Persuasive game aimed at
promoting change in risky sexual behaviours targeted at the under-served African
populations. Through regular interaction with stakeholders including various medical
personnel, we designed an African-centric persuasive game called STD pong. The
underlying game storyline (narratives), the linguistic expressions, the characters, and
other game elements were intentionally designed to reflect the Africanness. This
makes it easy for the target audience to identify and relate to it, hence increasing the
potential of the game to persuade and motivate the desired change from risky sexual
behaviours to safe sexual behaviours.</p>
      </sec>
    </sec>
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