FightHPV: Design and Evaluation of a Mobile Game to Raise Awareness About Human Papillomavirus and Nudge People to Take Action Against Cervical Cancer

There is an identified need for efficient, sustainable, culturally appropriate, and societally relevant approaches to inform women of the disease risks associated with human papillomavirus (HPV) infection, ways to prevent it (e.g., vaccination), and recent changes in cervical cancer prevention strategies, especially in younger generations who use different media to get their (health) information. Mobile apps, including mobile games, have the potential to change the way healthcare systems communicate with their patients and to facilitate the delivery of patient-centred health care globally. This article describes the development of a mobile app called FightHPV, a game-based learning tool that "nudges" users to engage in the learning process with the goal of facilitating knowledge acquisition, positive health-related attitudes, and positive behavioural changes.

The article details the iterative design methodology that shaped FightHPV's development. As FightHPV aims to leverage the power of mobile communication and social nudging by allowing players to share information about HPV vaccination and other preventive methods with their social network, the team included adolescent boys as well as girls, as boys can benefit from vaccination both directly and indirectly and can nudge others to adopt a healthier lifestyle on the basis of the knowledge they acquire from playing FightHPV.

The article includes a description of FightHPV game mechanics, characters, rules, and storylines. In brief, the team incorporated the following features into FightHPV: (i) a set of rules and constraints that describes relationships and effects among characters, (ii) several dynamic responses to players' actions, for example, sound, scoring, animations of effects, and characters, which communicate if a player made a right or wrong move; (iii) direct access to episodes with different levels of difficulty, enabling learners to experience a feeling of self-efficacy, and (iv) gradual advancement in learning outcome within an episode. The combination of amusing characters with animation is meant to be entertaining and to increase player willingness to repeat levels. To enhance player/learner motivation and engagement, the team created storylines that would help the layperson to understand virus transmission and what actions can be taken to avoid viral infection and cancer progression. They drew a parallel between the relationships among HPV concepts and typical video game quests, for example, the enemies - Low-risk HPV and High-risk HPV - trying to threaten other characters, and a hero, that is, the player, who needs to use tools (e.g., the character HPV Vaccine) to defeat the enemy. Short sentences appear at the beginning of each level and were purposely designed to be in a dialogue form, as if the characters in the game were telling a story.

FightHPV was also designed to trigger the desire to do something for others: "Should I vaccinate my children?" Players are encouraged to share information with their relatives and acquaintances so that, even though they may not ever play, they can receive the information that the team wants to transmit. Along those lines, players are encouraged to share their score on social media to drive user acquisition and engagement. (The team programmed direct links to all the social network platforms already loaded in the player's device.) As social norms shaped by social media had a detrimental effect on HPV vaccination in Japan and Denmark, the team wanted FightHPV to be easily shared in social circles - not only to engage more people in the game, but also to share correct information and send a reminder about the importance of screening to family and friends.

Development of the first version of FightHPV started in April 2015, and beta testing was carried out in December 2015. Participants in the beta test were invited to download a private release of FightHPV for Android through the testing facilities provided by Google Play. Version 2 of FightHPV was released and discussed with focus group 1 in June 2016, and version 3 of FightHPV was released and discussed with focus group 2 in November 2016. Characters, episodes, levels, textual information, in-game communications, and competitive elements were changed in response to the feedback from the focus groups. FightHPV was available to download for free in the App Store and Google Play in Norway in November 2016 and worldwide in April 2017.

Of the 29 individuals who participated in the focus group discussions, 26 (4 from focus group 1 and 22 from focus group 2) returned a questionnaire about the game and a test of their knowledge of HPV before and after playing the game. The data from 22 players from focus group 2 were analysed.

Overall, participants positively received the appearance of all 14 animated characters in version 1 of FightHPV, and they considered the textual information presented in the game, which reinforced the health messages, to be useful. Of the 26 participants who returned their questionnaire, all stated that FightHPV is an appealing educational tool, 69% (18/26) reported that they liked the game, and 81% (21/26) stated that the game was challenging. Participants from focus group 2 had little prior knowledge about HPV and HPV-related diseases; during the discussion session, participants in this group found the game to be thought provoking and requested more information on HPV. Of the 22 participants in focus group 2 who returned a questionnaire, all showed a statistically significant improvement in their knowledge about epithelial cells, HPV, and HPV transmission, with a median and interquartile range (IQR) that ranged from very low to low before playing FightHPV, to low and medium after playing FightHPV. All participants from focus group 2 were willing to share this information within their close social circles.

As of this writing, the game had been downloaded more than 12,000 times in more than 45 different countries on the Android and iOS platforms. The researchers note that, although FightHPV was developed in the Norwegian context, the organisation of the information into episodes allows developers to introduce new topics "with minimal technical effort. For example, in Africa, it might be relevant to add an episode to communicate the interaction between HIV and HPV. Translation of the content to other languages is technically simple," though they suggest that each country should evaluate the local context and communicate correct guidelines for vaccination and cervical cancer screening. "Furthermore, short textual messages can be redesigned into pictograms to reach a wider audience. Hence, FightHPV can be adapted for use in different cultural and medical contexts."