A Qualitative Study to Inform the Development of
a Videogame for Adolescent Human Immunodeficiency
Kimberly Hieftje, PhD,1,5Marjorie S. Rosenthal, MD, MPH,2,3Deepa R. Camenga, MD, MHS,2,3
E. Jennifer Edelman, MD,1,3,4,5and Lynn E. Fiellin, MD1,5
We used qualitative methods to inform the development of an interactive videogame focused on behavior
change to reduce risk and promote human immunodeficiency virus (HIV) prevention in young minority ado-
lescents. Guided by community-partnered research principles, we conducted and analyzed 16 individual
interviews and six focus groups with 10–15 year-old boys and girls (36 unique participants) at a neighborhood-
based nonprofit organization serving youth from low-resource neighborhoods. Three recurrent themes lent
themselves to translation into a videogame-based intervention. Adolescents reported protective factors and
facilitators to engaging in risk behaviors, including (1) their personal ability to balance the tension between
individuation and group membership, (2) the presence of stable mentor figures in their life, and (3) the neigh-
borhood in which they live. We used these themes to inform the design of our videogame intervention with the
goal that these methods may increase the intervention’s efficacy at promoting HIV prevention by making them
more tailored and relevant to a specific population. Our qualitative study provides a practical understanding of
how important elements identified by minority youth regarding negotiating around risk behaviors can be
integrated into a videogame intervention. These findings offer valuable insights to researchers whose goal is to
design effective and tailored interventions to affect behavior change.
including human immunodeficiency virus (HIV).1In 2009, 33
with one-third of them reporting not using a condom during
their last sexual encounter.2Young adults and adolescents
have the highest rates of acquiring HIV. In 2009 39% of new
HIV infections occurred among individuals 13–29 years old, a
21 percent increase in incidence since 2006.3More specifically,
minority youth are disproportionately affected by HIV in-
fection. In 2009, 17 percent of adolescents were identified as
African-American, but an estimated 73 percent of diagnoses
of HIV infection in 13–19 year olds were in African-American
adolescents.4Less dramatic but still significant is the statistic
that 16 percent of total incident cases of HIV were among
he high-risk behaviors of young adolescents increase
their chances of sexually transmitted infections (STIs),
Hispanic/Latino, even though they only represented 13 per-
cent of the population.4Given that only 3–15 percent of all
adolescents state that they have engaged in sexual activity
prior to 13 years of age, the age group of 10–15 year olds may
be an optimal window of opportunity to target for primary
In order to address HIV risk behaviors in this population,
several sexual risk reduction programs for adolescents have
been studied and found to be effective.5–7A systematic review
of STI/HIV programs suggested that interventions that were
most successful at decreasing sexual risk behaviors in adoles-
cents were those that were specifically tailored and delivered
the intervention to a particular subgroup.5Additionally, the
review described other effective strategies for STI/HIV pre-
vention interventions for adolescents, including (1) targeting
behaviors that are most amenable to change, (2) using behav-
Departments of1Internal Medicine and2Pediatrics, Yale University School of Medicine, New Haven, Connecticut.
3Robert Wood Johnson Foundation Clinical Scholars Program, New Haven, Connecticut.
4VA Connecticut Healthcare System, West Haven, Connecticut.
5Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut.
This research was presented, in part, at the Yale Center for Interdisciplinary Research on AIDS (CIRA) AIDS Science Day on March 23,
2011, New Haven, Connecticut.
GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications
Volume 1, Number 4, 2012
ª Mary Ann Liebert, Inc.
overall risk and not just sexual risk in interventions. Building
on proven components of these interventions, we sought to
develop an interactive videogame for HIV prevention in ado-
lescents who are at high risk for HIV and other STIs.
To inform the development of a videogame for HIV pre-
vention targeting minority young adolescents, we conducted
a qualitative study, guided by community-partnered research
principles, to determine factors among young minority ado-
lescents that impact their decisions whether to participate in
HIV risk behaviors. Whereas previous technology-based HIV
interventions have used theory to guide their development,
community-partnered research techniques to enhance the
tailoring of the intervention have not been commonly used.8
Community-partnered research is a useful technique for
videogame-based intervention development because it en-
gages the users throughout the game development process
and therefore may increase the game’s appeal, salience, and
realism. Therefore, the purpose of this study was to use
community-partnered research principles to determinefactors
in young minority adolescents’ environments that impact their
decisions whether to participate in HIV risk behaviors and
then use these findings to directly inform the development of
the virtual environment in an HIV prevention videogame. We
present this work as a case study to demonstrate how these
methods represent animportantstrategyforinforming anHIV
prevention videogame intervention.
Subjects and Methods
In partnership with a well-established neighborhood
afterschool program in the area, we conducted a qualitative
study using in-person in-depth interviews and focus groups
to explore the perspectives and experiences of young mi-
nority adolescents to understand the factors impacting whe-
ther they participate in HIV risk behaviors. We used a
purposeful sampling approach targeting ‘‘information-rich’’
individuals with first-hand experience of our research inter-
est,9,10which included identifying the protective elements
and risk factors associated with engaging in HIV risk be-
haviors. We recruited adolescents 10–15 years old who at-
tended a subsidized nonprofit youth afterschool/summer
enrichment program in New Haven, CT. Inclusion criteria
were that participants were English-speaking and between 10
and 15 years old for the interviews and 11 and 14 years old for
the focus groups. We chose to use a broader age range for the
individual interviews in order to capture the perspectives
of both younger and older children in our target population.
We then narrowed the age range for the focus groups. The
Human Investigation Committee at Yale University School of
Medicine approved the research protocol. All participants
provided written informed assent, and participants’ parents
or legal guardians provided written informed consent. Par-
ticipants and their parents or guardians were reimbursed
with gift cards.
Interviews and focus groups
We used two different data gathering methods—individual
interviews and focus groups—to enhance the breadth and
depth of our data. We used in-depth interviews to generate
data that explore individual experiences and perceptions,11
while we conducted focus groups to discover more about
topics that involved social norms.12
In collaboration with the afterschool program’s leadership,
we designed the recruitment strategy for study participants,
including placing posters and distributing fliers at youth
programs. We developed our interview guide in an iterative
process with input from key personnel at the afterschool
program. One research team member (K.H.) conducted the
in-depth interviews and the subsequent focus groups with
the support of key program personnel using semistructured
qualitative guides. We conducted 16 in-depth face-to-face
individual interviews, and these results were used to develop
our focus group guide. Discussion guides evolved as data
collection and preliminary analysis progressed.13Domains
explored included videogame play, risk taking, decision-
making, peer influence, and future orientation. Probes were
used to encourage clarification and evoke greater detail into
participants’ narrative. Interviews and focus groups were
audiotaped, professionally transcribed, and reviewed by a
research team member (K.H.) to ensure accuracy. Focus
groups included three female-only and three male-only single
gender groups, each including four or five participants.
A three-person multidisciplinary team, composed of indi-
viduals with expertise in pediatrics, HIV, qualitative meth-
ods, community-partnered research, and health behavior,
conducted data analysis of the in-depth interviews. For the
analysis, we used the principles of grounded theory, includ-
ing the constant comparative method.13We developed the
codes in a stepwise fashion,10beginning with the creation of
an initial code structure from the first two transcripts that
were independently reviewed by each team member. We
continued to code the transcripts in sets of two until a com-
prehensive code structure was created that captured all data
concepts. To reach consensus, the team met regularly to ne-
gotiate code structure and discuss emergent themes. Once a
final code structure was established, one of theteam members
(K.H.) systematically applied the codes to the remaining se-
ven transcripts. Data were entered into ATLAS.ti (version 5.0;
Scientific Software Development, Berlin, Germany) to facili-
tate data organization and retrieval.
Data analysis for the focus groups followed a similar an-
alytic approach; however, we expanded the team to include
two additional team members with expertise in HIV and
adolescent medicine. All focus group transcripts were inde-
pendently reviewed one at a time, with the team meeting to
refine codes, negotiate consensus, and compare content with
previously coded data to ensure consistent classification. The
team then identified themes using the codes from the indi-
vidual interview and focus group data. We then considered
how these themes would directly inform the videogame de-
velopment. We conducted recruitment and data collection for
both the interviews and focus groups until we reached the-
In total, 36 adolescents (16 boys and 20 girls) 10–15 years
old (mean age, 11.6 years) participated in either the
QUALITATIVE ADOLESCENT HIV PREVENTION STUDY295
individual interviews (n=11), the focus groups (n=20), or
both (n=5). Seventeen (47 percent) were Hispanic/Latino, 14
(39 percent) African-American, 3 (8 percent) multiracial, and
2 (6 percent) white.
We identified three themes that describe the adolescents’
perspectives on factors in their lives that influence whether
they engage in HIV risk behaviors. Adolescents of both
genders perceived their ability to avoid HIV risk behaviors,
increasing their chance for future success to be based on (1)
their personal ability to balance the tension between indi-
viduation and group membership, (2) the presence of stable
mentor figures in their life, and (3) the ability to be inde-
pendent of the neighborhood in which they live. We then
considered how each theme could be translated into our vi-
Personal ability to balance the tension between individu-
ation and group membership.
self-preservation was impacted by group participation. To
avoid risky behaviors, one adolescent reported compromis-
Adolescents described how
Like if your friends were doing something like bad, and they
wanted you to come with them, and you were like, "No I got to
do something," and you got to make sacrifices. Like they don’t
want to be your friend anymore.
One adolescent provided an example of how the tension
between self and group was life-threatening:
I’m in the gang, say.they have a choice, shoot this person or
you die.The risk of shooting the person is; you’ll just have
that memory all in your head every day. The risk of not
shooting the person you will get killed. You’ll just have that
memory in your head. Like you’ll go to sleep and be like you’ll
be like oh man, I can’t sleep, just thinking I shot that innocent
guy. You know, he did nothing. I just shot him so he wouldn’t
tell on my gang or something like that. Ugh. And now look at
me; I’m a bum. Ugh.
In partnership with our videogame developers, we will
incorporate this theme of self versus group by creating situ-
ations in which the player has to choose between following
his or her own choices or belonging to a group. For instance,
one scenario will include having the player decide whether or
not to attend an unsupervised party where alcohol will be
served. As the game progresses, the player will experience
how his or her choices about whether or not to participate in
the group might influence different life outcomes. The game
will also include a skill-building component that provides the
player with the opportunity to practice self-preservation
skills by refusing their peers.
Adolescents highlighted the importance of having support-
ive, stable mentor figures in their lives to provide them with
guidance and encouragement as well as teach them essential
life skills to navigate their environments. These individuals
included parents, older siblings, cousins, aunts, uncles, and
teachers and provided the youth with a sense of security and
confidence. One adolescent described his fifth grade teacher
as his supportive mentor figure:
of stablementor figuresin their lives.
She was, like, hard and tough on me. Say, if I tell her some-
thing I was worrying about and stuff like that, she will always
tell me that, ‘‘Are you smart enough?’’ or if I wanted to do
something bad, she will send me to the principal’s office to
learn my lesson.She’s nice to me sometimes. She’s mean to
me just to, like, I guess, to set me straight.She always be-
lieved in me when I didn’t believe in myself.
Another adolescent described his uncle’s role as a stable
Someone that I look up to is my 17-year-old uncle because like
he tells me the right things to do and the wrong things to do.
He like role models for me.He like shows me a lot.he shows
me a lot of love and like shows me that he cares about me and
stuff like that.
For these adolescents, evidence of security also translated
into both forgiveness and disciplinary action. One adolescent
specifically described how a supportive mentor set limits and
enforced rules and boundaries:
They tell me what’s not right and what’s right. Sometimes,
they may help me control myself if I’m in a bad situation, what
to do, howto solve that problemandstay awayfrom stuff, bad
things, keep me out of the streets, and stuff like that.
We will incorporate this theme of stable mentor figures
throughout our videogame by providing supportive, older
characters who demonstrate their investment in the player
through encouragement, setting boundaries, giving feedback
and guidance around risk-taking, and articulating expecta-
tions for success.
The neighborhood in which they live.
pressed the feeling that their neighborhood or community
possessed inherent risks that had the potential to limit their
success. To succeed, they described overcoming barriers in
their current environment. They reflected that when people
were able to extricate themselves from a high-risk environ-
ment, such as leaving a bad neighborhood, their chances to
succeed substantially increased. For example, one adolescent
described his neighborhood in terms of it being his destiny;
the environment defined his chance for success or failure:
Like, if you live in a place where there’s a lot of shootings,
knifings, cuttings.in a place with a lot of thieves and things
that can change your life.then you can live in a good place
and you can’t afford it and then you can move to a bad place
and then your life gets messed up again.
This adolescent acknowledged the difficulty of trying to
separate himself from his surroundings:
Sometimes like, the environment that you live in can make it
hard to be successful because you see everybody doing one
thing, and you try to be just like them.
We will incorporate this theme of their neighborhood’s
influence throughout our videogame by creating opportuni-
ties for the player to establish personalized future goals and
aspirations, such as educational attainment, career choice,
and important relationships that would potentially allow him
or her tomove beyond orout of theneighborhood. To achieve
these aspirations, the player will need to learn how to navi-
gate risks in his or her neighborhood, orient him- or herself to
the future, and make decisions that will ultimately influence
the likelihood of achieving future goals and aspirations.
296 HIEFTJE ET AL.
In this study, adolescents described factors within them-
selves and people in their lives and their neighborhood that
impacted their ability to negotiate high-risk situations. These
factors included balancing the tension between individuation
and group membership, having stable mentor figures in their
lives to teach them essential life skills, and being able to navi-
upon research that highlights the importance of resilience, role
modeling, and mentoring as constructs of particular value in
efforts to influence health-risk and health-protective behaviors
potentially ‘‘portable’’ to a videogameinterventionfocusing on
behavior change around risk reduction.
These findings are consistent with the ecological theory of
Bronfenbrenner16,17which describes the progressive, mutual
accommodation between an active, growing human being
and the changing elements within his or her immediate
settings, including peers, family, and neighborhood. Bron-
fenbrenner emphasized protective processes at different
levels that can foster resilience in adolescence. Although ad-
olescents may not have control over various aspects of their
larger environment, such as the neighborhood they live in or
the school they attend, they may be able to counteract the
negative effects of these systems by controlling other, closer
aspects of their environment, such as interactions with peers
and mentor figures. One of the primary goals of the current
videogame intervention is to provide adolescents with risk
reduction skills and the venue in which to safely practice
these skills in order to better navigate risk in the different
levels of their environments.
The qualitative research phase of this study identified
themes consistent with previous work.18–22For example, in a
study exploring Latino adolescents’ perception of barriers to
and facilitators of success, these adolescents identified peers
more as potential barriers to success than sources of support
and identified mentors outside the family as facilitators of
success.18Our findings are also consistent with findings in the
literature examining resilience in youth that argue that any
intervention to reduce high-risk behaviors needs to address
the three levels of influence described by youth: Self versus
group, presence of stable mentors, and the neighborhood in
which youth live.23,24It is notable that our study expands
on the existing literature by using qualitative methods to di-
rectly inform the development of our videogame, including
community-partnered research, which is recognized as impor-
tant for developing HIV prevention interventions.8,25We be-
lieve that our study is one of the first to use these well-validated
methods to inform the development of a novel intervention.
As we incorporate these data into the proposed videogame
we are developing, our goal is to first help adolescents rec-
ognize the realms in which they do have control over their
lives. Our second goal is to help them to develop the skills to
modify how they interact with the three levels of influence. In
the proposed interactive videogame, adolescents will have
opportunities to adopt and practice skills, such as learning
how to refuse peer pressure, differentiate positive and nega-
tive mentor figures, and negotiate high-risk environments
within the game play with the goal that these skills will
transfer to real life.
Our study has several limitations. First, our sample was
drawn from a single community-based program serving
urban, mostly minority adolescents living in high-risk
neighborhoods. The experiences and perceptions of older
adolescents or those from other racial and ethnic groups and
other neighborhoods may be different. Second, participants
may not have been as forthcoming in their discussion about
their engagement in certain high-risk behaviors. We believe
we were able to counteract this, in part, by including trusted
staff members of the program as co-facilitators.
Our findings reveal a rich sense of adolescents’ perceptions
of the three spheres of influence in their ongoing negotiation
to avoid risk behaviors. Additionally, these qualitative data
provide a practical understanding of the important elements
identified by our target audience as being crucial components
to be integrated into our videogame intervention. The infor-
mation collected through our interviews and focus groups
provides important content for the development of the pro-
posed videogame that is currently under development and
will be evaluated through a large-scale randomized clinical
trial. In addition, the process outlined in this article highlights
the feasibility and potential utility of using qualitative re-
search methods to inform the creation of a targeted and
relevant technology-based intervention for the purposes of
skill-building and behavior change. We believe our results
offer valuable insights to researchers whose goal is to design
effective and tailored interventions to affect behavior change
in order to help adolescents better negotiate risk in their en-
This study was supported by grant RO1 HD062080-01
from the National Institute of Child Health and Human De-
velopment and by the Yale Robert Wood Johnson Foundation
Clinical Scholars Program. Lynn E. Fiellin, MD, Principal
responsibility for the integrity of the data and the accuracy of
the data analysis. We are grateful to Gail Slap, M.D., M.S., for
her critical review of earlier versions of this manuscript.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Kimberly Hieftje, PhD
Yale University School of Medicine
367 Cedar Street
P.O. Box 208093
New Haven, CT 06520-8093
298 HIEFTJE ET AL.