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PlayForward: Elm City Stories


PlayForward: Elm City Stories is an interactive theory-driven videogame designed to improve sexual health outcomes in minority adolescents through role-playing, with an ultimate goal of HIV prevention.

PlayForward: Elm City Stories is a game-based program to teach adolescents about health risks, navigation of peer relationships, and consequences of behavior, with an ultimate goal of HIV prevention. The program consists of 5 skill-based mini games and 12 story narrative challenges in which players face peer pressure to consume alcohol and drugs and engage in unsafe sexual behaviors. Players create an Aspirational Avatar (a virtual character) that represents the future goals and hopes of the player. Players guide the Aspirational Avatar through middle school and high school, find clues, advance through levels, play mini-games, and experience story scenes in a graphic novel-style two-dimensional virtual world. Players have the power to make positive changes to the future of the avatar through challenges that have both short-term and long-term consequences. As the game continues, players see the effect of decisions on the life of the Aspirational Avatar. PlayForward also allows players to travel back in time and change a decision to witness how a different decision leads to a new outcome and altered life trajectory.

Link to commercial site here.


Theoretical Approach(es):
Social Learning Theory

Target Substance(s):
Illicit Drugs

Target Outcome(s):
Delay Initiation of Sexual Activity
HIV Prevention
Substance use

Adolescents (11-17)




Geographic Location(s):

United States


  • The design and implementation of a randomized controlled trial of a risk reduction and human immunodeficiency virus prevention videogame intervention in minority adolescents: PlayForward: Elm City Stories

    Fiellin L, Kyriakides T, Hieftje K, et al. Clinical Trials. 2016. 13(4): 400–408. doi: 10.1177/1740774516637871

    Summary: Researchers recruited 333 adolescents aged 11-14 years to participate in a randomized controlled trial to assess the impact of PlayForward: Elm City Stories on a primary health outcome (delay of initiation of sexual intercourse) and secondary health outcomes (attitudes around sex, knowledge of HIV/AIDS risk behaviors). Recruitment occurred at 12 urban school-based programs and summer camp programs through flyers for adolescents and presentations to parents at parent-teacher meetings. Researchers obtained informed assent from participants and informed consent from parents/guardians. Participants were randomized (stratified by gender and age group: 11–12 years and 13–14 years) into a PlayForward intervention group (n = 166) or a control group (n = 167) that played attention/time control games devoid of study-related content. All participants played the games on an iPad tablet, used headphones, and sat at separate tables at community-based locations (e.g. libraries, community centers). PlayForward software collected and stored in-game data, and research staff entered data from face-to-face assessments (completed at baseline, 6 weeks, and 3, 6, 12, and 24 months) into a secure web-based system. Throughout the study, researchers reengaged participants through creative methods (text messaged participants and families, hosted pizza and cupcake parties). Study retention remained high: most participants completed 6-week assessments (83%), 3-month assessments (84%), 6-month assessments (79%), and 12-month assessments (82%). Data collection for the assessment at 24 months was ongoing (76% had completed 24-month assessments, as of 1 March 2016).

    Take Away: PlayForward: Elm City Stories used novel methods to create, collect, and store in-game data and may offer a unique new source of valid data on sexual health outcomes and attitudes in minority adolescents.

  • Video game intervention for sexual risk reduction in minority adolescents: Randomized controlled trial

    Fiellin L, Hieftje K, Pendergrass T, et al. 2017. Journal of Medical Internet Research. 19(9): e314. doi: 10.2196/jmir.8148

    Summary: In a continuation of the 2013-2015 randomized controlled trial described in Fiellin et al, 2016, researchers examined the impact of PlayForward: Elm City Stories on the primary health outcome (delay of initiation of sexual intercourse) and secondary health outcomes (attitudes around sex, knowledge of HIV/AIDS risk behaviors and transmission) of the 129 intervention participants with available data from baseline through the 12-month assessment (compared with the 129 control participants). While PlayForward did not appear to have had a significant effect on delay of participant initiation of sexual intercourse at the 12-month time point, low rates of sexual initiation in both the PlayForward and control groups (94.6% of PlayForward participants delayed, 95.4% of control participants delayed) prevented researchers from determining the impact of PlayForward on delay in initiation of sexual intercourse. From baseline through the 12-month assessment, PlayForward group participants (male and female, younger and older (age 11-14 years) demonstrated significant increases in overall sexual health knowledge. Younger male intervention participants (age 11-12 years) also showed significant improvement in sexual health attitudes, compared with control participants (female intervention participants and older male intervention participants (age 13-14 years) did not exhibit significant improvement in sexual health attitudes).

    Take Away: The PlayForward: Elm City Stories videogame appeared to have significant beneficial effects on sexual health attitudes and knowledge in minority adolescents that persisted for at least 12 months.

  • “But do they like it?” Participant satisfaction and gameplay experience of a public health videogame intervention in adolescents

    Hieftje K, Pendergrass T, Montanaro E, et al. IEEE 6th International Conference on Serious Games and Applications for Health (SeGAH); 2018; Vienna, Austria. 1-7. doi: 10.1109/SeGAH.2018.8401349

    Summary: Researchers evaluated acceptability and gameplay experience in the 2013-2015 randomized controlled trial (described in Fiellin et al, 2016) of PlayForward: Elm City Stories. Analysis of study data collected after 6 weeks of gameplay from 133 intervention participants revealed high levels of engagement and satisfaction. Almost all participants felt responsible for choices made in the game (87.9%) and liked the way the game looked (84.1%). Most participants found the game challenging (80.3%), enjoyed gameplay (79.5%), and would make decisions in life like they made them in the game (78.8%). Several gender differences appeared: female participants reported significantly higher likeliness both to play PlayForward again (female: 72.3%, male: 55.2%) and to recommend the videogame to friends (female: 70.8%, male: 53.7%). Male participants felt significantly more connected to their avatar (male: 59.7%, female: 38.5%). Two significant associations between quantitative health outcomes and reported satisfaction emerged: male participants who reported they would make decisions in life like they made them in the game, older male and female participants (age 13 – 14 years) who liked the way the game looked, and older male and female participants who reported frustration with the game, all demonstrated significant improvement in sexual health attitudes, while younger male participants (11-12 years) who felt connected to other characters in the game showed significant increases in sexual health knowledge. Qualitative interviews revealed that almost all participants would rather play PlayForward than attend a traditional school class on the same topics, could describe the ultimate goal of the game (HIV prevention), and could provide specific examples of knowledge learned.

    Take Away: Participants found PlayForward: Elm City Stories effective, enjoyable, and challenging, results that suggest videogame interventions may have potential to improve sexual health outcomes in minority adolescents.