Supporting contraceptive self-care and reproductive empowerment with a digital health game in Barbados: Development and Pre-implementation study for What’s My Method?

Background

Contraceptive self-care has been identified by the WHO as critical to achieving milestones for female empowerment and well-being (World Health Organization, 2022). This focus reflects a shift in global public health attitudes regarding contraceptive education from a top-down approach—where childbearing persons receive directives, often from healthcare professionals and/or government institutions—towards an approach that encourages self-determination and agency (Hamidi et al., 2018). Reproductive empowerment is a means of implementing and interpreting contraceptive self-care and has been defined as:

Improving pregnancy planning and preventing unintended pregnancy remains a WHO priority, is one of the US Healthy People Objectives (Office of Disease Prevention and Health Promotion, 2023), and is also a desired outcome in Barbados. Implementing contraceptive counseling and education through the lens of reproductive empowerment requires that the focus of the intervention be on the childbearing persons and their needs. Ideally, this counseling also reviews the many non-contraceptive benefits of hormonal birth control methods, including menstrual regulation and relief of symptoms associated with conditions such as endometriosis and polycystic ovarian syndrome (PCOS). Some studies have been done to measure the impact of contraceptive self-efficacy on increased adoption of contraception. However, most studies focused solely on condom use (Burke et al., 2021; Whiting-Collins et al., 2020). These studies show that higher rates of self-efficacy relative to condoms result in increased condom use and recommend additional research measuring efficacy with other forms of contraception (Burke et al., 2021).

There is clear need for improvement in contraceptive counseling in Barbados. As per the United Nations dashboard, the contraceptive prevalence rate for any method among women aged 15–49 was 50% in 2022 (United Nations, 2023). Providers report that abortion is often used as birth control, and the fertility rate is declining (1.6 live births per woman in 2023). Childbearing women receive advice from older women propagating unsupported concerns about side effects which makes them reluctant to adopt modern methods. Low uptake of modern contraceptive methods leads to outcomes including unwanted pregnancy and use of abortion as birth control (Bearak et al., 2022; Claridge, 2021; Gipson et al., 2008).

Barbados includes contraceptive counseling (CC) as a standard part of post-natal and pre-abortion care. CC is an essential aspect of healthcare for women and child-bearing individuals. This counseling should be thorough, unbiased, and tailored to each patient’s specific needs and health conditions. Providing CC is complicated by patient use of the internet which provides a plethora of information that can be difficult to filter and interpret as well as abundant misinformation which must be countered. The proliferation of misinformation is accelerated by emerging technology use such as influencers on TikTok and YouTube (Pfender & Devlin, 2023). Barbadian clinics have not integrated digital technology to support CC; information about methods is delivered using pamphlets and posters on the walls.

Digital health interventions have been identified as successful high-impact practices to support healthy reproductive behaviors (Dehlendorf et al., 2019; Stephenson et al., 2020). Digital health interventions supporting contraceptive self-efficacy include SMS campaigns (Chukwu et al., 2021; Laidlaw et al., 2017), artificial intelligence-based chatbots (Wang et al., 2022), and interactive websites (Lepore et al., 2024) which provide information and offer tools to help choose appropriate methods. These interventions demonstrate that digital media are an effective way to reach the target audience and communicate information about reproductive health.

Demonstrating the impact of interventions on reproductive empowerment is complicated.

There are many different forms of contraception, which vary among mechanism of action, route of administration, frequency of dosing, side effects, and many other factors. Understanding and remembering these nuances is difficult even for healthcare providers. Videogames can be useful for this type of learning. Games are a validated means of presenting complex information in a format that provides context-based learning, encourages engagement through fun, and rewards success (Squire, 2011). People are more likely to seek out information and remember it if it is contextualized and relevant (Bado, 2022). Games focused on sexual health and education have been successfully deployed in other settings (Bertozzi et al., 2018; Fiellin et al., 2017; Haruna et al., 2018). This project is a development and pre-implementation study to prepare for a randomized controlled trial which will determine if the WMM game is effective in improving reproductive empowerment and contraceptive self-efficacy. Our process was informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to ensure consideration of the complex interactions between the game intervention (WMM), the intended audience, and healthcare providers (Nilsen et al., 2020) .

Aims

The aims of this research were to: 1) Conduct focus groups and interviews to determine the acceptability of the WMM game as a tool to educate players about contraception and improve reproductive empowerment. 2) Observe players to determine any usability issues or technical difficulties. 3) Assess the utility and accuracy of the pre/post questionnaire. 4) Conduct interviews with key stakeholders (healthcare providers at clinics, faculty at nursing school) to understand their needs and desired outcomes.

Development

The first version of the WMM game was designed to be integrated into the My Future Family (MFF) game funded by Grand Challenges in Global Health¹ in 2016 and deployed² in Mysore and Chennai, India in 2017 and 2018 (Bertozzi et al., 2018; Bertozzi et al., 2021). The MFF game was aimed at school-age children who otherwise received no, or very little, education about sex. It provided information about sexual and reproductive anatomy, and collected data from gameplay about family planning intentions. Post deployment qualitative interviews in India recommended adding information about contraceptive methods and modalities (Bertozzi et al., 2021). The WMM game was designed to deliver information about contraception by providing patients with foundational knowledge about methods, and then engaging their new knowledge to assist in-game couples with method selection. Each couple has different lifestyles, physiological needs, and personal preferences. Players have to research methodologies and side effects of methods to find the one/s best suited to each couple.

Due to the COVID pandemic, the WMM addendum was never deployed or tested in the field, though we were able to conduct informal usability testing on reproductive-age volunteers. In 2023, we began a partnership with the Barbados Family Planning Association and received funding to update WMM as a standalone game focused on supporting contraceptive counseling. The original version of WMM had three sections: Reproductive Anatomy, Contraceptive Methods and Modalities, and Couples. One of the goals of this pre-implementation study was to test and design updates for each of these sections, including integration of lessons learned from past deployments and addressing the needs of the new target audience informed by the EPIS framework (Nilsen et al., 2020). Game development is an iterative process requiring testing on the target audience during the production cycle to ensure that the game is fun, easy to use and understand, and achieves the study goals. We scheduled the pre-implementation study after building a prototype of the new graphic design for the game but before the design had been extended to the Couples section.

Reproductive anatomy

The focus groups in India for the MFF game (Bertozzi et al., 2018) revealed that players could not understand how contraception works without understanding sexual reproductive anatomy. Thus, the MFF game includes a section where players identify reproductive body parts and their functions. An unanticipated positive result of this part of the game was that it normalized study participant verbalization of anatomic vocabulary during gameplay and in post play conversations (i.e. many students were very uncomfortable saying “vagina” before playing the game, and afterwards did so without hesitation). We attempted a formal pre/post assessment of knowledge gain in the MFF deployment using a drag and drop quiz, but this was not well-received by players and many declined to complete the post-game assessment Bertozzi et al., 2021. Lessons learned from the India deployments guided our decision to both retain a reproductive anatomy section in the new WMM game and to use this segment as a knowledge assessment tool. This section assesses players knowledge of the names and functions of the body parts by seeing how quickly they solve the puzzle and how often they make mistakes. In the RCT we will see if familiarity with reproductive anatomy and normalization of pronouncing the terms facilitates frank conversations with healthcare providers as part of our assessment of reproductive empowerment.

Players in Barbados tested the updated Reproductive Anatomy section (Figure 1). When they click on a term, it is highlighted and a question appears. They then select the dashed oval which is the correct answer. If the selection is correct. The text fills the oval which becomes green. If the answer is incorrect the dashed oval flashes red and the text is not placed there. Players cannot proceed until each oval is filled correctly.

Figure 1. Screenshots from revised reproductive anatomy section deployed in Barbados.

Reproduced with permission from SolitonZ Games.

Contraceptive methods and modalities

The first version of the WMM game includes seven methods: Condom, Pill, Copper IUD, Hormonal IUD, Tubal Ligation/Vasectomy, Depo-Provera Injection, and None (Figure 2). Players can see a short animation for each method that explains how it works and how it might not. For example, a condom works by physically covering the penis and blocking sperm from entering the vagina and therefore reaching the egg. It does not work if you forget to buy one or use it incorrectly. The animations engage players by depicting cartoon facial expressions of emotions such as concern, embarrassment, and delight. This section of the game was very well received by test users in the India deployment (Bertozzi et al., 2021). However, healthcare provider reviewers requested that the game include significantly more information, including additional methods, discussion of side effects (both positive and negative), general efficacy (how often the method fails), duration of the method, and timeline for return to fertility.

Figure 2. Screenshots of condom information from original WMM methods section.

Reproduced with permission from SolitonZ Games.

One of the goals of our games is to provide complex, scientifically accurate information in formats that can be understood across a wide range of literacy levels. The addition of so much more information about each method required the design of a series of icons to represent side effects of different methods as well as icons that could communicate Return to Fertility, Failure Rate, and Duration. In Barbados, participants tested the legibility of the new icons and the revised Contraceptive Methods section, which at that point included 2 methods (Figure 3).

Figure 3. New icons and Methods section tested in Barbados.

Reproduced with permission from SolitonZ Games.

Couples

We deployed the original version of the Couples section of the game (Figure 4) to test the game mechanic and engagement among the Barbadian target audience and explained that the interface would be updated with the new graphic design and that Indian avatars and narratives would be replaced with Barbadian ones for the RCT. Players can view 4 couples each with different needs and characteristics which are communicated both in on-screen text and voiceovers. Players select a method at the bottom of the screen and the couples respond to that selection in a way that explains its features. For example, Reyansh is not interested in getting her tubes tied because she is afraid of the surgery and because she wants more children, but her partner would consider it.

Figure 4. Screenshots from original WMM game deployed in Barbados.

Reproduced with permission from SolitonZ Games.

Theoretical frameworks

Interactive learning games leverage several theoretical models for achieving desired behavior change. These include social learning theory and social cognitive theory, both of which posit that there are interrelated factors (embedded learning, repetition, enjoyment) that influence behavior after the completion of the experience (Krath et al., 2021). The efficacy of games for health and app-based gamification of health-focused education is now well established (Haoran et al., 2019; Sharifzadeh et al., 2020). The WMM game is designed to employ known educational learning game principles, utilize research-standard tools (Duncan et al., 2014), and include learning through empathy. Empathy is increasingly recognized as an important component of healthcare education and science learning (Mikkonen et al., 2015; Zeyer & Dillon, 2019).

Conversations about sexual reproduction, contraception, and family planning are often complicated by shame, cultural expectations, and countless other factors. Providing information in a format that allows participants privacy and freedom to explore topics without judgement can enable more constructive conversations (Bertozzi et al., 2018). The WMM game evokes empathetic behavior by asking players to help avatar couples in the game and select a method that best meets the couples’ physiological and behavioral needs. To succeed, players must literally listen to the expressed needs of the people in the game and observe their interactions with their partners. The in-game conversations reinforce information about how methods work, how they fail, and how side effects can be both negative and positive in different circumstances. They are motivated by compelling narratives to find the information needed to pick an optimal method that will satisfy both partners. The RCT seeks to determine if this engaged and contextualized approach improves patients’ reproductive self-efficacy and reported satisfaction with contraceptive counseling.

Measuring contraceptive knowledge is complicated by many factors including health literacy, assumptions about what constitutes basic contraceptive education, and participant willingness to complete a quiz. It is difficult to word text-based questions to accurately determine respondent knowledge. Our pre and post test questions were based on simplified questions from the Contraceptive Knowledge Assessment (CKA) (Haynes et al., 2017). We sought to determine if this metric would be useful for our purposes or if we should focus on collecting performance metrics from player behavior.

Design

The design of the pre-implementation study sought to ensure that the research, game design, and implementation teams had input from all stakeholders. We conducted focus groups and collected both qualitative and quantitative data.

Participants

As this was a development and pre-implementation study no sampling was involved. We included anyone who volunteered to participate from our target demographics including: staff and administration from the Barbados Family Planning Association (BFPA), faculty and students from the Nursing program at Barbados Community College (BCC), and volunteers from the Youth Advocacy Movement (YAM), representing the childbearing persons who are the target audience of the intervention (Table 1). Staff and administrators at the BFPA are our partners and agreed to participate in usability testing as healthcare providers. The BFPA is a hybrid governmental and non-profit organization. It was incorporated in 1967 by an Act of Parliament and provides sexual and reproductive health information, clinical services, education, training, community outreach, and research. A recruitment call was sent out to the YAM volunteers who meet at BFPA prior to conducting community outreach. Nursing students from BCC were recruited as play-testers who would serve both as representatives of our target population (childbearing persons in Barbados) and as future healthcare providers. BCC provides education and training for entry-level nurses and post-registration nursing programs in Barbados and attracts students from across the Caribbean. There is a renewed focus on supporting research among nursing faculty that provides experiential education opportunities for students. BCC faculty and students will be involved in the RCT.

Procedures

Playtesting and focus groups with each category of participant were conducted on separate days during October 2023. The research team had 6 tablets loaded with 2 files. One was a beta version of the new WMM game with a tutorial for understanding the side effect icons, new icons to represent birth control methods, the Reproductive Anatomy puzzle, and a test version of the Methods section. The other was the original WMM with the Methods and Couples sections.

The protocol began by having participants complete paper consent forms. They then were provided with a QR code to access the pre-test (Figure 5) on their phones. The pre-test asks for optional gender identification and 5 questions about contraceptive knowledge. Following submission of the pre-test, tablets were handed to participants. They were encouraged to work together if desired (which was necessary when participants outnumbered tablets). The following instructions were provided: Play the new version of the WMM game which includes a tutorial section with icons, the Reproductive Anatomy puzzle, and a Methods section; and then play the Couples game from the older version. They were told they could stop playing at any time and could ask questions or receive help if they were confused about how to proceed. When they were finished playing, they were provided with a different QR code for the post-test (Figure 6) to be completed on their phones. The post-test consists of 10 questions that collect player and usability feedback on the play experience and then 5 questions about contraceptive knowledge that mirror those in the pretest, though the wording is different. Data was collected using anonymized Outlook forms stored on secure academic servers.

Figure 5. Participant knowledge pre-test.

Figure 6. Participant knowledge post-test.

The YAM ambassadors who agreed to participate met with researchers at BFPA main clinic. They were all given the consent forms, then pre-test, tablets, and post-test. Some participants chose to play next to each other and discuss the process. Others sat apart and completed it on their own. Following the experience, researchers led an informal discussion where more feedback and suggestions were collected.

The BFPA staff and affiliates who participated met individually with researchers. They went through the same protocol and then provided additional verbal feedback about playing the game as a participant and how they would use the game as part of their provision of healthcare to childbearing patients and their partners.

BCC students participated in a classroom setting. Participants clustered in groups of 3 or 4 per tablet and played communally after having completed the pre-test individually on phones.

Analysis

Researchers observed and documented participant behavior during playtesting sessions and post play group discussion. Salient and recurring themes were collected, and technical and usability issues were noted.

40 participants completed the pre-test, and 33 completed the post-test. Average time needed for all three steps was 47 minutes. Given that all of the participants in the pre-implementation study are either healthcare professionals or undergoing related training, we expected high rates of knowledge of reproductive anatomy and contraceptive knowledge. We sought to determine the usability of the Reproductive Anatomy puzzle and comprehensibility of the questionnaire items.

The pre-test consisted of 5 multiple choice questions about contraceptive knowledge. These questions were coded as either correct or incorrect. The post-test asked the same 5 questions in a different order with slightly different wording and were coded as correct or incorrect. Feedback on the overall playability and acceptability of the game and on specific parts of the game was collected using a 1-5 Likert scale.

Ethical considerations

All the study procedures were approved by the Quinnipiac Institutional Review Board (protocol #15923, approved 10/17/2023). Given the sensitive nature of the topics covered by the game, participants were informed in advance that they would see representations of reproductive processes and reproductive anatomy. They were also informed both in the consent document and verbally that they could stop participating at any time without penalty. All participants completed a written informed consent form prior to participating in the study and were verbally advised that they could stop at any time. 2 participants did not complete the pre-test and 7 did not complete the post-test. Thus our comparison of pre/post results utilized a data set of 33 responses.

WMM

Although the prototype included a short tutorial demonstrating how to tap on an icon to see what it represented, some participants wanted more instruction. The WMM will therefore have a more complete tutorial depicting a cartoon hand completing the necessary actions.

Participants were unable to understand the icon we developed for decreased libido and suggested a new one which we implemented (Figure 7).

Figure 7. Previous and current icons for decreased libido based on user recommendations.

Reproduced with permission from SolitonZ Games.

We noted that when participants tested the revised Methods section, they did not pay attention to the icons on the top of the screen that indicate duration, failure rate, and return to fertility for each method. This was also confirmed by participants during group discussions. They found the design to be visually overwhelming and could not interpret the icons or pay attention to the information they conveyed. This information led to a redesign of the Methods interface (Figure 8). In the revision, after the animation demonstrates how a method works, it is replaced by new icons and the information is reinforced by color and placement.

Figure 8. Screenshots from tested and revised Methods sections.

Note icons on top of screen at left. Reproduced with permission from SolitonZ Games.

The Couples section of the game will be supplemented given its popularity with participants. The narratives and avatars will be representative of Barbadians with input from our local partners. Male partners will be more fully characterized with a more active role in the discussion of the methods and how they fit into family life. It will also create an opportunity to provide more detailed information about positive and negative side effects and the likelihood of experiencing them.

Questionnaire

Given the limited utility of the pre/post questionnaire for assessing knowledge gain, we plan to change both the process and the measure for the RCT. There will no longer be a pre- or post-test quiz. Our primary outcome will instead be a measure of Contraceptive Self-Efficacy (CSE) based on a validated survey published in 2020. The purpose of the RCT is to measure the impact of the WMM game on participants’ sense of agency, education, and empowerment around contraceptive decision-making. For this reason, it is important that the primary outcome not be based on the ultimate choice of contraception, but rather on a measure of personal capabilities around behavior change. CSE is a person’s belief in their own ability to succeed in contraceptive management, initiation, and continued use (Lillian Whiting-Collins et al., 2020).

The scale to measure Contraceptive Self-Efficacy among women in sub-Saharan Africa (CSESSA) is a modification of the original CSE and is divided into three sub-scales measuring “Husband/partner communication,” “Provider communication,” and “Choosing and managing a method.” This tool was selected for its high relevance to our study and for its focus on participant-directed education and decision-making.

Limitations

As in a previous deployment, our post-intervention assessment was hampered by some participants choosing not to complete the post-game survey. Providing participants with some form of compensation appears to be necessary to ensure a higher completion rate. We will plan the RCT with some incentives to achieve this. We also acknowledge that having the participants in this deployment having to toggle between two different games may have affected the results. The final version of the game will integrate all sections into one app.