Evaluation of the ZIG-ZAIDS game : an entertaining educational tool for HIV / Aids

This article presents the evaluation process for the ZIG-ZAIDS game, i n vestigating the m a t e r i a l ’s applicability in formal and informal educational contex t s , i . e . , h ow the game has been used by health pro f e s s i o n a l s , p a re n t s , and the target population (pre a d o l e s c e n t s , or child ren over 9 years old). The study invo l ved evaluation questionnaires sent to a list of schools and institutions using the game, plus interv i ews and visits to places where the game was used as well as tested with groups of students. It also includes an analysis of evaluation previously sent by the authors to people who had requested the game. The results showed that the population’s level of information is more re l e vant than age in relation to the game’s impact. Another important aspect relates to ZIG-ZA I D S’ applicability to different situations: t raining of health and teaching p ro f e s s i o n a l s ; activities with street childre n ; municipal institutions and eve n t s , s c h o o l s , c o m p an i e s , c o m m u n i t i e s , and health care centers. In summary, Z I G ZAIDS was found to be an entert a i n i n g , c re a t i ve , and innova t i ve alternative for providing information on AIDS and sex u a l i t y.

A RTIGO A RT I C L E Evaluation of the ZIG-ZAIDS game: an entertaining educational tool for HIV/Aids pre v e n t i o n Avaliação do Jogo ZIG-ZAIDS -um recurso lúdico-educativo para informação e prevenção da AIDS entre pré-adolescentes 1 Ce n t ro de Pesquisas Re n é R a c h o u , Fundação Os w a l d o C r u z .Av. Augusto de Li m a 1 7 1 5 , Ba r ro Pre t o, Belo Ho r i zo n t e , MG 3 0 1 9 0 -0 0 2 , Bra s i l .v t s c h a l l @ c p q r r. f i o c r u z .b r 2 La b o ratório de Ed u c a ç ã o em Ambiente e Saúde, De p a rtamento de Bi o l o g i a , Instituto Oswaldo Cruz, Fundação Oswaldo Cruz ( Ce n t ro colaborador da U N A I D S / W H O ) .Av. Brasil 4365, Ma n g u i n h o s , Rio de Ja n e i ro, RJ 2 1 0 4 5 -9 0 0 , Bra s i l .

AIDS among children and youth in Brazil
Although there is considerable underre p o rt i n g in Brazil relating to AIDS, other STDs, and dru g abuse during adolescence, seve ral studies have s h own that initial sexual activity and experimentation with different psyc h o a c t i ve substances generally occurs between 10 and 19 years of age.As suggested by Santos (1996), despite the re l a t i vely small number of AIDS cases re p o rted in Brazil in the 15-19 year age bra c k e t as of August 1995 (1,633), given the long incubation period, there signs that individuals diagnosed with AIDS at 20 to 29 years of we re actually infected during adolescence, re i n f o rc i n g the notion of vulnerability to STDs and dru g abuse during this stage of life.
As of August 1998, a cumulative total of 140,362 AIDS cases had been re p o rted in Bra z i l since 1980 (MS, 1998).The most significant HIV exposure category in people over 12 ye a r s of age was sexual contact (64%).The vast maj o rity of cases exposed to contaminated blood (12.9% of a total of 13%) we re intra venous dru g u s e r s.Among individuals under 13, peri n a t a l t ransmission accounted for 89.3% of infect i o n s.In the 15-24-year age gro u p, 18,271 cases had been re p o rted, corresponding to 13.1% of the cumulative total, while the 25-39 age gro u p accounted for 59.7%.Due to HIV's pro l o n g e d incubation period (approximately 8-10 ye a r s ) , one can conclude that a significant portion of infections occur in yo u t h .
Ac c o rding to recent data from UNAIDS/ WHO (1998), new cases keep appearing at the same or increased rates in some countri e s, req u i ring further investment in pre vention.Acc o rding to UNAIDS/WHO (1998), the number of people with HIV/Aids worldwide incre a s e d by 10% in 1998.Half of the new infections occ u r red in individuals 15 to 24 years old.
Other data point to the occurrence of unp rotected sexual activity among youth, as do the data on teenage pregnancy (under 19), which occurs in 13% of Brazilian females.Acc o rding to data from the Mi n i s t ry of He a l t h (1996), 23.44% of the 2,821,211 births assisted by the Unified Health System (SUS) in 1995 we re in mothers 15-19 years of age.In Rio de Ja n e i ro, 17% of live births in 1994 we re in m o t hers from 12 to 19 years of age, or a total of 15,697 babies.Of these mothers, 60% we re illite rate or had an incomplete pri m a ry education, re i n f o rcing the association between sex-re l a ted behavioral vulnerability and gender and social factors, i.e., less access to schooling, information, and the ability to access and use cont ra c e p t i ve methods.
De m o g raphic statistics on HIV tra n s m i ssion in the 1990s point to the increasing number of AIDS cases in women (of the 79,906 c a ses re p o rted as of Fe b ru a ry 1996 in Bra z i l , 14,464, or 18%, we re women).This has an inc reasing impact on the pre valence among child ren: 78.3% of pediatric AIDS cases re s u l t e d f rom ve rtical transmission.In addition, conside ring the increased mean surv i val time for people with AIDS due to combination thera py, many HIV-p o s i t i ve children are now in early adolescence and becoming sexually active, hence re q u i ring safer sex/pre vention measure s in their re l a t i o n s h i p s.

ZIG-ZAIDS: creating alternatives for HIV/Aids prevention
The proposal to produce educational materi a l s on HIV/Aids pre vention among youth began in 1988, with the re p e rcussions of the grow i n g number of AIDS cases in the general population.Although the first cases we re identified in homosexual males in the United States in 1981, due to homophobia and prejudice on the part of gove rnmental institutions and segments of civil society both worldwide (Sh i l t s, 1987) and in Brazil (Daniel & Pa rk e r, 1991), there was unn e c e s s a ry delay in formulating policies to stem the growth of the epidemic (Mann et al., 1993).
Co n t roversy concerning the origin and t ransmission of the HIV and the lack of medicines and vaccines capable of reducing HIV t ransmission had contributed to a fatalist, pre judiced, and erroneous view of the disease.It was thus important to change the proposals so as to promote information that might encourage pre ve n t i ve pra c t i c e s.Around this time, an e x t e n s i ve survey conducted by Schall et al. (1987) on health issues among students included questions about elementary students' k n ow ledge of AIDS.Answers by 365 students fro m two Brazilian cities, Rio de Ja n e i ro (RJ) and Belo Ho ri zo n t e, identified misconceptions, ignora n c e, and a fatalist view of the epidemic (Rebello et al., 1989).These data confirmed the i m p o rtance of identifying educational app roaches with contents capable of fosteri n g p re ve n t i ve pra c t i c e s.Me a n w h i l e, an analysis of the litera t u re, the media, and AIDS-related nongove rnmental organizations pointed to the need for Bra z i l i a n educational materials focusing on HIV pre ve ntion among children and youth.In addition, inf o rmation provided by public health departments and the media (Ca r ra ra & Mo ra e s, 1986) was also fatalist and could hardly be viewed as educational.The ove rwhelming impre s s i o n f rom AIDS pre vention campaigns was that of a fatal disease.In the litera t u re, re s e a rch conf i rmed the results of our investigation with students as to the lack of information and wides p read misconceptions (Pinho et al., 1989), besides highlighting the challenges of adopting p re ve n t i ve pra c t i c e s, given the complexity of issues invo l ved in AIDS, like sexuality and death, which have always been taboo duri n g childhood.The lack of dialogue on the issue stemmed from the exclusion of topics that neither family nor school found proper for child ren, maintaining a sort of traditional mora l it y, h a rdly constru c t i ve or pre ve n t i ve.Ac c o rd i n g to another pre vailing notion, to speak about sex or drugs with children and youth might i nduce them to try dru g s, if such issues we re b rought up outside the family, school, and health pro g ra m s.
Since the advent of AIDS, society itself and the political power between the ideological rep ression of sexuality inside the family (once p ri va t i zed by the social model) began to searc h for altern a t i ve pedagogical approaches to this question, observing the need for more communication and pre s s u red by AIDS' potential ri s k to life and health.In short, both the surve y among students and the litera t u re analysis suggested the importance of creating pedagogical re s o u rces in the HIV/Aids pre vention area to foster learning and debate about the epidemi c's social and symbolic aspects.
The ZIG-ZAIDS game: t h e o retical basis and development Z I G -ZAIDS was created in the context of a labo ra t o ry (the Health and En v i ronmental Ed u c ation Labora t o ry -LEAS -in the Biology De p a rtment at Instituto Oswaldo Cru z / Fundação Oswaldo Cruz -IOC/FIOCRUZ) focused on res e a rch and strategies to develop educational m a t e rials to promote disease pre vention and health promotion from childhood onward.T h e re s e a rch considers the need to stimulate dialogue and exchange of knowledge betwe e n adults and children, and among children t h e ms e l ve s, considering such aspects as self-est e e m , respect and responsibility tow a rds one's ow n life and that of others as well as nature, and a commitment to improved quality of life.T h e s t a rting point is an attempt to understand how c h i l d ren construct the meanings of health and disease in their own context, interacting with unique individual aspects such as self-esteem, p rior experi e n c e, and family and school re l a-ZIG-ZAIDS GAME 1 0 9 tionships (Schall, 1996).In addition, the interviews and questionnaires provide a basis for obtaining better knowledge of the inform a t i o n l e vel and appro p riate language for the targ e t population.A theoretical basis is essential to p rovide support for educational practices and new materials developed at LEAS.Vygotsky (1991Vygotsky ( , 1993) ) underlies this curre n t a p p roach tow a rds different processes of language constitution and concepts, consideri n g c h i l d re n's spontaneous concepts tow a rds the c o n s t ruction of scientific concepts.This is h e l pful in the construction of useful life skills.T h i s a p p roach is fostered by the game's own dynami c s, in which misconceptions are replaced by a k n owledge built collectively through conve r s ation and cooperation.In developing the new m a t e ri a l s, we considered what Vygostky proposes re g a rding the development of higher intellectual functions as the re f l e x i ve consciousness and deliberate control that, once added to the notion of the proximal development zo n e, might help parents and schools to ove rc o m e the re q u i rements fixed solely to the hiera rc h y of mental age and to grasp the childre n's possib i l i t i e s, considering the cooperation pro c e s s e s.A dialogical relation is added to the necessary c o o p e ration among partners in the game as p roposed by Bakhtin (1985), favo ring an elaboration of meaning in health/disease, making it possible to attain a complex meaning beyo n d the association limited to the biological body and achieving social and affective we l l -b e i n g , respect, and tolerance in human re l a t i o n s h i p s.In addition, it promotes responsibility for environmental pre s e rvation, ove rcoming notions focusing only on immediate re a l i t y.T h u s, scientific know l e d g e, once built, is not re s t ri c t e d to memori zed definitions, rather health meanings are interlinked with other aspects of daily l i f e, mixing unique points of view with collect i ve perspectives consolidated by both cognit i ve and affective aspects (Schall, 1996).
It must also be emphasized that in the p rocess of developing the ZIG-ZAIDS game the a rguments described above we re articulated as c ritical analyses of the limits of the curre n t policies in the field of pre vention that we re based solely on biomedical information, individual re s p o n s i b i l i t y, and/or an alarmist and fatalist vision, as indicated in studies on HIV/ Aids pre vention.Clearly pre vention pro g ra m s needed to consider the socioeconomic and political dimensions of the epidemic, as well as the diversity of the presentations and pra c t i c e s of the different social segments in relation to the disease (Homans & Aggleton, 1988;Bo l t o n , 1992;Ingham et al., 1992).This analytical perspective is linked to a g i ven critical vision of education (Me l o, 1993) that influences discussion of the educational n a t u re of pre vention work in the health field and consequently the development of materia l s.This focus is based on proposals by Fre i re (1979) on the role of education in social tra n sf o rmation, in which the former relates to the a w a re n e s s -raising process chara c t e ri zed by p e rmanent critical action by humans tow a rd s re a l i t y.Using this theoretical approach, this author questions pedagogical, domesticated actions centered on the educator's authority and k n owledge and proposes a liberal concept of education, where educator and educated participate and collaborate in the learning p ro c e s s, in a relation using dialogue and pro b l e m -s o l ving.This theoretical orientation introduces a political and social dimension to education, expanding the discussion of learning and analyzing the pri o rity of the cognitive and emotional development of the person to be educated.This perspective is discussed by Mo n t e i ro (1995) and Pa i va (1996) when planning HIV/ A i d s p re vention pro g ra m s.
Based on these perspective s, the process of c reating ZIG-ZAIDS was chara c t e ri zed by content selection and choice of the materi a l's app roach.We attempted to differentiate the content from the pre vailing alarmist view of the epidemic, highlighting explanations identifying the possibility of safer sex pra c t i c e s, cons i d e ring that sexual awareness takes place in p re-adolescence and adolescence, and that this re q u i res sympathetic attitudes.
In relation to the approach, due to the target population's specificity, we tried to incorp o rate entertaining elements capable of motivating learning and stimulating thinking about the epidemic's social and symbolic aspects.We thus opted to create a question-and-answe r game (which we named ZIG-ZAIDS), using accessible language and explora t o ry illustra t i o n s w h e re the participants got information and would be motivated to talk about different scientific and social aspects of the epidemic.
Z I G -ZAIDS consists of a board with 23 n u mb e red spaces and other spaces illustrated with a condom ("wild card s") and others with dire ctions such as "go one space forw a rd", "go one space backward", and "w a i t", two dice, six game p i e c e s, 23 numbered question cards (with q u e stions on one side and answers and dire c t i o n s for the next move on the other) and 20 wild c a rd s.The question cards deal with subjects such as the immune system, transmission patt e rn s, treatment, and pre vention.The need for s o l i d a rity and cooperation in human re l a t i o n-ships is emphasized.Unlike other games, thre e questions ask for opinions rather than ri g h t -o rw rong answe r s.By asking about visits to AIDS p a t i e n t s, the importance of solidari t y, and participation by children with HIV in school activi t i e s, the game creates opportunities for players to reflect on the social and psyc h o l o g i c a l consequences of AIDS.The wild cards contain i n f o rmation on topics such as HIV, hemophilia, blood tra n s f u s i o n s, dru g s, job opport u n i t i e s, new tre a t m e n t s, and other subjects re l e vant to people with HIV.ZIG-ZAIDS further contains a leaflet for parents and teachers, posing discussion questions on topics such as the difficulty and discomfort adults experience in discussing sex and the importance of listening to what c h i l d ren feel and think about sex.Also included are a mini-dictionary with words re f e r ri n g to sex org a n s, sexual re l a t i o n s h i p s, and STDs.T h e re is also a suggestion to include a condom as the first pri ze, and the recommendation that it be opened and shown to classmates.
In order to match the material to the targ e t p o p u l a t i o n's re a l i t y, the product was tested t h rough an experiment including interv i e w s b e f o re and after playing the game, in addition to direct observation.Using a test version of the game, we observed seve ral episodes with e l e m e n t a ry students from public and pri va t e schools in Rio de Ja n e i ro.These episodes all owed us to ve rify the game's capacity to motivate learning and provides us with tips to alter and adjust it (Mo n t e i ro et al., 1990; Mo n t e i ro et al., 1991).
Based on the data from the test game, we d e veloped the final version.At this stage, ru l e s we re changed, language adapted, and new c o ntents included.We also evaluated the game's new visual layout, produced by expert s.Besides testing the game with students, we also c o n s i d e red pare n t s' and teachers' opinions.Int e rviews with the latter led to the production of a manual (included with the game) targ e t i n g p a rents and educators, with suggestions for additional reading, teaching activities, and add resses of gove rnmental and nongove rn m e n t a l institutions working with HIV pre vention and/ or treatment for people with HIV/Aids.
Once the final version of the material was d e veloped, we attempted to identify publishers or companies that might be interested in producing the game on a commercial scale in order to market and distribute it.Mo re detail on this stage of the methodology has been prov i ded by Mo n t e i ro & Rebello (1999).
The ZIG-ZAIDS game was developed from a re s e a rch project applied to health education which also included training of human re-s o u rc e s, since we felt that the game as an educational re s o u rce was complete, but did not replace teaching in pra c t i c e.In this sense our commitment was not only to concentrate on the game's scientific impact, but also to eva l uate its impact in the search for part n e r s h i p s that would foster access to its use, i.e., teaching institutions and health professionals invo l ve d in pre vention education (Mo n t e i ro, 1998).
It is commonly felt that the production and e valuation of educational materials should be combined with training of human re s o u rces to augment the materi a l's educational potential.We see the game as a teaching aid, and not as a replacement for educational activity.Based on the related litera t u re on children (Schall, et al. 1987;Schall, 1996;1999), entertaining educational aids like the ZIG-ZAIDS game (Mo n t e i ro et al., 1991) and the Jogo da On d a game (or the "Wa ve Ga m e") (Rebello & Mo n t e i ro, 1998) focusing on drug pre vention (Mo n t e i ro et al., 1994) can be seen to play an inform a t i ve role and to serve as excellent instruments for initiating discussions and raising awareness on health-related issues.

The need to evaluate educational s t r a t e g i e s
Evaluating an educational activity can assess p revious and baseline measures in order to e valuate the change achieved.Evaluation can also be used to measure an educational prop o s a l's feasibility and reach, re c o rding and analyzing its applicability to the proposed teaching situations.
Our evaluation aimed to ve rify the quality of intervention invo l ved in the ZIG-ZA I D S game in va rious situations: from an initial situational analysis, which showed the need for e ducational material on STDs/Aids targ e t i n g youth.The process thus incorporated elements f rom this situational evaluation, attempting to i n vestigate the game's acceptability, followe d by an evaluation of the pro c e s s, consideri n g the quality of the health education practice m ot i vated by the game and stimulating differe n t a l t e rn a t i ves and in-depth consideration.It also included an impact evaluation on the efficacy in promoting knowledge-building and cri t i c a l reflection concerning symbolic and social aspects of the AIDS epidemic among adolescents.
These levels of evaluation have been interp reted in different ways by va rious authors.Ay res (1996) makes an interesting analysis of the evaluation of educational interve n t i o n among students, related to the analysis of thre e p rinciples: 1) realism, where the author leads the reader to conclude in favor of the re l e va n c e of evaluation cri t e ria for real experience; 2) fec u n d i t y, highlighting the importance of "p roducing awareness of what is effectively being d o n e" ( Ay re s, 1996:3) from a differentiation of the elements which determine the interve nt i o n's success; 3) pra c t i c a b i l i t y, expressed by the definition of objective methods that are acc e s s i b l e, motivating, and capable of pro d u c i n g significant data and likely to produce feedback.Through strategies described as examples, Ay re s s h ows both the complexity and feasibility of c o n s t ructing and conducting an eva l u a t i o n p rocess and thus offers important re s o u rces for e valuating educational interve n t i o n s.
From a similar and complementary pers p e c t i ve, Aggleton (1995) discusses the eva l u ation of health education programs and att e m p t s to differentiate between monitoring and eva l uation, based on WHO definitions chara c t e ri zing them as complementary actions.Pl a n n i n g these actions, in turn, invo l ves the definition of themes to be investigated (e.g., cognitive and b e h a v i o ral aspects and attitudes), as well as the indicators and methodological strategies to be used.This definition is based on the pro p o s a l's o b j e c t i ve s, re s o u rc e s, and pra c t i c a b i l i t y.Due to this are a's diversity and magnitude, Aggleton highlights the limits and adequacy of thre e common evaluation strategies: the comparat i ve approach, the approach on evaluation of o b j e c t i ve s, and the interpre t a t i ve appro a c h (Aggleton, 1995:198-204), suggesting a genera l o ri e n t ation for the questions.

Methodology for evaluation of ZIG-ZAIDS
Co n s i d e ring the educational materi a l's methodological possibilities, the present study attempted to evaluate the ZIG-ZAIDS game's impact, establishing as a goal the analysis of its use and effective n e s s, as a re s o u rce for motiva t i o n , l e a rning, and pre ve n t i ve and non-discri m i n at o ry behaviors.We established complement a ry re s e a rch methods, planned by the authors and conducted by To r res (1995), where the res e a rcher was not invo l ved in the pre v i o u s p h a s e, creating the game.The stages we re as f o l l ows: 1) LEAS/FIOCRUZ file analysis, org a n i ze d by the ZIG-ZAIDS authors on demands, def i n e d as situational analysis.A list of questions we re sent to people who ord e red the game in ord e r to help them to re c o rd their observations on the material.The leaflet sent to game users requested the following information: full name, p rofession, telephone, and addre s s, and inc l u ded questions such as: • W h e re was the game played?(e.g.institution, community, business, school...) • What was the age group of the playe r s ?
• What was the gro u p's level of inform a t i o n about AIDS?How was the material re c e i ve d ?• Was the game presented within a pro g ra m of AIDS pre vention or sex education?We re any activities developed based on the materi a l ?• Did the game reach its objectives as an educational tool?If necessary, please add yo u r s u g g e s t i o n s.
2) Opinions from the interviews and quest i o n n a i res filled out by game users, known as p rocess analysis.The interviews done with the game users included the following questions: • Name of institution where the game was p l a yed; • What was the age group of the players?
• What was the playe r s' level of inform a t i o n about AIDS?• How was the material re c e i ved?
• Was the game presented within a pro g ra m on AIDS pre vention or sex education?• A re any other activities applied within this p ro g ram?What are they?• As an educator, did you feel pre p a red to use the material or was it necessary to consult other sources to better understand it?After the m a t e rial was used, we re other activities carri e d out to assess the assimilation of the inform ation by the players?Did the game achieve its o b j e c t i ves as an educational tool?
The questionnaires we re sent by mail to 42 schools and other institutions along with a lett e r.The letter explained the objectives of the e valuation pro c e s s, as follow s : "We are conducting an evaluation on the impact of the educational game ZIG-ZA

I D S h e re at the En v i ronmental and Health Ed u c ation La b o ra t o ry of the Oswaldo Cruz Fo u n d at i o n . The game was developed by re s e a rc h e r s f rom this institution within the educational component pro g ram of the Institutional AIDS p ro g ra m / F I O C RU Z , which is supported by the Division on Sexually Transmitted Diseases of the Brazilian Mi n i s t ry of He a l t h . The purpose of the game is to focus on the AIDS issue together with different groups from governmental and n o n g overnmental organizations, p r i vate comp a n i e s , and schools, with a view tow a rds prov i ding basic information on the disease to a bro a d p u b l i c , especially children and adolescents.
To help achieve our objective s , we are contacting professionals and institutions curre n t l y d e veloping studies on pre ve n t i ve education in H I V / A i d s .Kn owing that you are invo l ved in this f i e l d , we consider your collaboration to be of the utmost importance for the success of our study.
As a starting point, we would like to know whether you have access to the game or use it in any specific work?If so, we would ask you to answer the questionnaire below and return it to the ZIG-ZAIDS project as soon as possible.
1) How did you re c e i ve the game: t h ro u g h an institution or from some other source?How many sets did you re c e i ve ?
2) Was the material distributed to schools or other institutions that work with AIDS?
3) Is there a follow-up system for the pro j e c t s that are being carried out by the institutions that re c e i ved the material?4) Is there some re c o rd of how the game is be-

ing applied, to what age gro u p, to what scholastic level and with what level of prior know l e d g e about AIDS?
Thanking you in advance for your cooperat i o n , ( . . . ) " 3) Observation of ZIG-ZA I D S' use by preadolescents and adolescents, chara c t e ri zed as impact analysis.Ef f o rts we re made to combine q u a n t i t a t i ve evaluation (statistical analysis) and qualitative analysis, i.e., analysis of the o p i n i o n s' content, interv i e w s, direct observation, and photographic documentation.We also attempted to achieve an extensive re g i o n a l sampling and diversity of the study population, attempting to include samples from a wide a rea of Brazil and from different situations in the game's use.The re s e a rch was conducted within a diversified universe of pro f e s s i o n a l s and institutions including public org a n i z at i o n s, civil and pri va t e, national and intern a t i o n a l , b e yond the fields of education and health.We thus attempted to ve rify the institutional and p rofessional demands pertinent to requests for the game submitted to FIOCRU Z .

R e s u l t s Situational analysis: the game's acceptability
The first acceptability test refers to the mark e t reaction itself on the occasion of the first edition in Ja n u a ry 1991, in which 5,000 sets we re released.Although part of this edition was purchased by institutions and companies, like the National office of the SESC (Se rviço Social do Co m é rcio) (1,000 sets), the publisher (Ed i t o ra Sa l a m a n d ra, Rio de Ja n e i ro) considered it a m a rket failure.The market had not accepted the condom (included as a pri ze for game winner) or the "s t ro n g" language used in the minid i c t i o n a ry included with the game.Many larg e 1 1 3 Cad.Saúde Pública, Rio de Janeiro, 15(Sup.2):107-119, 1999 s t o res rejected the game, and this re c e i ved ext e n s i ve media cove ra g e.This suggests that the public was not really pre p a red for a table game dealing with AIDS.T h e re f o re, after an agre ement with the authors, the manufacturer left the condom out of the subsequent editions, and its use was only a suggestion in the manual, to be purchased at the user's discretion.T h e publisher began using a distribution stra t e g y emphasizing gove rnmental and nongove rnmental education and health institutions and companies promoting pre vention pro g ra m s with their work e r s.As a result, the publisher sold games to pri vate businesses and va ri o u s Se c re t a ries of Education and Health aro u n d the country; the National STD/Aids Co n t ro l Pro g ram purchased 100,000 sets to distri b u t e to public schools and nongove rnmental org an i z a t i o n s.
The acceptability was also evaluated t h ro u g h q u e s t i o n n a i res re t u rned from 1991 to 1994, that had been attached to the sets donated by the Oswaldo Cruz Foundation to various g ro u p s and institutions (schools, health pro m o t e r s, p a re n t s, companies, courses, communities, a n d others) from Brazil and abroad.Table 1 show s the items analyzed in a 20-questionnaire samp l e, including the name of the institution that used the game, opinions on ZIG-ZAIDS as an educational re s o u rc e, target public, activities d e veloped, other educational re s o u rc e s, place used, and general observa t i o n s.Among the 20 institutions that answe red the questionnaire s, 10 we re from Rio de Ja n e i ro, four from São Pa u l o, and one each from Pe rn a m b u c o, Mi n a s Ge ra i s, Mato Grosso do Sul, Rio Grande do Su l , Ethiopia, and Ge rm a n y.The institutions included pri m a ry and secondary schools, health clini c s, NGOs, boarding institutions for minors, and social and educational re s e a rch institutes.
Ac c o rding to the data, the game was used in va rious situations: classrooms (pri m a ry and s e c o n d a ry), pare n t s' meetings, women's g ro u p s, vocational courses, dayc a re centers, community health work e r s' supervision, companies' educational pro g ra m s, courses for educational c o u n s e l o r s, and meetings with psyc h o l o g i s t s, social work e r s, and other health pro f e s s i o n a l s and educators.The information highlights the p o s i t i ve reaction to the material and its efficacy as an educational tool.In general the game was considered a good motivating factor, capable of generating interest and stimulating debates and learning about such controve r s i a l themes as sexuality and AIDS.The positive e valuation is certified by the quotes below: " Excellent as an educational re s o u rc e .Informs and stimulates reasoning about pre v i o u s k n ow l e d g e" (STDs Pro g rams -Dourados/MS -1 9 9 5 ) .
" Great!Discussing AIDS, s ex , and drugs became nice and educational" ( Sociedade Di a d emense de Proteção ao Menor -1995).
"After ZIG-ZA I D S ,c h i l d ren wrote letters to people with HIV (...) It became part of eve ry d a y life in the classro o m , and besides teaching about AIDS, it reduced discrimination ( C I E P Me s t re André, Rio de Ja n e i ro -1995).
The possibility of discussing sexuality is presented in some re p o rts as having been spark e d by ZIG-ZAIDS within the gro u p.The game was used by parents and teachers who often had not k n own how to cope with this subject among c h i l d ren and adolescents, as stated below: "The game makes it possible to discuss AIDS n a t u rally and without pre j u d i c e .AIDS is a disease that invo l ves many issues that are still taboo and are often not discussed because of difficulties among teachers, p a rents and institut i o n s .The initiative of producing the game was c e rtainly ve ry cre a t i ve , a facilitating factor, a n d a great social contribution.(Municipal Se c re t a ry for Social Promotion, Nova Fri b u rg o, Rio de Ja n e i ro) Ac c o rding to 50% of the 20 questionnaire s, Z I G -ZAIDS was used together with other res o u rc e s, in sex education pro g rams which also included videos, lecture s, debates, leaflets, and i n f o rm a t i ve pamphlets.One of the points emp h a s i zed in the sample was the inclusion of social issues in the game, e.g., sympathy for and d i s c rimination against children with AIDS, which has motivated debate among the yo u t h who have used the material.
Some criticism was aimed at the re p e t i t i o n of questions, mainly by the kids with more k n owledge about AIDS.The lack of a pri ze (the condom) for all playe r s, or at least one for each c l a s s room, the need for more difficult questions for older students (8th graders and high school).Some suggestions on the card s' content we re useful for the second edition, as we l l as inclusion of themes in the wild cards set, in o rder to always include updated inform a t i o n in each new edition.Both international institut i o n s, Mesganan Nega Addis Ababa ( Et h i o p i a ) and an institut from Berlin, Ge rm a n y, highlighted the quality of the game, telling us about the lack of such materials in their countri e s.Since the cards had not been translated, they we re not evaluated with the international target p o p u l a t i o n s.In short, although commerc i a l acceptability was initially jeopard i zed, we obs e rved, through teaching, health surve y s, and p re vention institutions, that the material was not only we l l -re c e i ved, it was also evaluated as a d e q u a t e, necessary, and useful for the ongoing educational pro c e s s.
The process analysis: the game's context and utilization In order to complete the information obtained t h rough the form s, we sent a standard letter containing a questionnaire, from Fe b ru a ry to Ap ril 1995, to 42 schools in different St a t e s, i.e. , the ones which had re c e i ved the game thro u g h the Health Mi n i s t ry (the National STD/Aids Pro g ram.A standard questionnaire was also sent to seve ral institutions and companies.We re c e i ved answers from a total of 34 institutions.Data analysis, org a n i zed in a table, with the same contents described in the previous item ( Table 2), re i n f o rce the evaluations alre a d y mentioned and related to the game's effectiveness as a factor for educational motivation, as an easy-to-understand teaching tool.Although the game has been used by va rious gro u p s, the m a j o rity we re among adolescents from the 5th t h rough 8th gra d e s, with ages ranging from 10 to 16 ye a r s.Some examples of re p o rts: "Z I G -ZAIDS is what eve ry student needs to understand what is imagined not to be near h i m .If you give a book or lecture , 90% of them will remain silent" ( Carla Ja rdim, ru ral are a teacher in Bagé, Rio Grande do Sul, 1995).
"T h e re has been great enthusiasm over the game among the kids.The cre a t i ve approach to AIDS was emphasized and the opportunity that the game offers to discuss ample questions, s u c h as social aspects, p re j u d i c e , and solidarity" (Antônio Te i x e i ra, Di re c t o r, Labor Relations Dep a rtment, Brazilian Postal Co m p a n y, 1995).
This analysis also considered the ZIG-ZA I D S e valuation addressed to the National S T D / A i d s Co n t rol Pro g ram.As of Ma rch, 1995, 10 months after the purc h a s e, 25% of the sets (25,000) had been distributed.Of the 27 letters sent by To rres to the State health and educational departments that re c e i ved the material, only 5 re p l i e d .Among these, 4 had re c e i ved a larger number of sets and distributed them to schools to integ rate them into the pre vention pro g ram.In o rder to complete this analysis, To r res interv i e wed the people responsible for distri b u t i n g the materi a l .
Co n s i d e ring the 54 institutions which re present the total number of questionnaires sent to LEAS (1991LEAS ( to 1994) ) and to To r res in 1995, 84.2% state that the objectives of the game h a ve been "fully re a c h e d"; 3.70% say "s a t i s f a c t o ri l y ", and 1.7% "reasonably we l l".Nobody noted "a l i t t l e", and 9.3% failed to answer this question.

Impact analysis: observations on use of the game
This analysis is based on direct observations of the game matches with kids from 11 to 17 ye a r s of age from two pri vate schools and the In s t it uto de Ação Cu l t u ral (Cu l t u ral Action In s t it u t e ) , by which we observed that students constru c t new cognitive elements by playing the game.Filled with excitement, the game's content is g rasped easily, besides initiating debates and explanations on the topic.One teacher commented, "We noticed that even the children who k n ew the material got invo l ved in the activity" (1995).Competition stimulates learning while playing, making it right to win and paying attention to the right answers so as not to make mistakes again.Howe ve r, the question's re p e t ition as a consequence of the game's dynamics was cri t i c i zed by the more informed s t u d e n t s.Some young people's opinions: " Z I G -ZAIDS is perf e c t .If it were any better, i t would be worse" (1995).
"I would like to know more things not informed by the game" (1995).
"I have learned to not be prejudiced tow a rd s people with HIV.They deserve all our care and a t t e n t i o n" ( 1 9 9 5 ) .
"If I were you, I would manufacture more games to distribute them all over the worl d" ( 1 9 9 5 ) .
To r res also org a n i zed the comments by some professionals invo l ved in the testing of Z I G -ZAIDS.In general, the game was conside red a teaching re s o u rce capable of appro a c hing a controversial theme in an entert a i n i n g and efficient way.Ac c o rding to suggestions, its use should be strengthened by educators' actions in the sense of delving more deeply and/ or adapting the contents to different re a l i t i e s.The few criticisms tow a rds certain contents and the materi a l's dynamics we re all documented by the authors and turned into improve m e n t s in the game, including the proposal for an expanded version on CD-ROM, containing 6 levels of difficulty, making it possible to prov i d e choices by age and previous know l e d g e. T h i s a l l ows for the acquisition of scientifically advanced and complex knowledge according to the user's curiosity and cognitive capacity.
A second experience was re p o rted by the Pa raná State De p a rtments of Education and Health, which used the game integrated into a p re vention pro g ram developed in seve ra l schools and health centers around the St a t e.The pro g ram aimed at improving drug abuse and STD/Aids pre vention.Du ring June 1996 the game was used with 3,345 adolescents fro m 1 1 6 Cad. Saúde Pública, Rio de Janeiro, 15(Sup.2):107-119, 1999 p ri m a ry and secondary schools under the orientation of 223 supervisors trained to deve l o p p re ve n t i ve activities with young people and their teachers.The re p o rt describes three experiences at different levels: one with 7th and 8th g rade students, another with 5th to 8th gra d e s t u d e n t s, and a third with first-year secondary school students.Observations by superv i s o r s and teachers highlight the game's ability to stimulate the learning process in a highly ent e rtaining way.Some important comments: "The game provides valuable information, which is passed on to the students in a light and n a t u ral form." "The same question is asked seve ral times, emphasizing the essential points on the topic of A I D S ." "I was impressed by the students' e n t h u s iasm and their dedication in reading and answering the questions, to the extent of memorizing the right answers.The interest in winning the prize (a condom) was most notable in 5th g rade students, who would find it more difficult to obtain prophylactics under normal circ u ms t a n c e s ." "I'm going to order more sets, at the insistence of my students.This is a ve ry positive way to talk about a ve ry daunting subject.I myself had a cousin who died as a consequence of AIDS in July 1995.. ."Some teachers commented that in spite of the fact that repetition of the cards helps memo ri ze the correct answe r s, "they didn't like this p rocess of re p e t i t i o n , p referring to move on to n ew questions".Se ve ral teachers said that the students wanted more questions to enrich the game and give it more va riation, increasing its i n t e rest and catering to different levels of curi o s i t y.Although the older, more advanced students agreed that the game was an intere s t i n g way of dealing with the matter, facilitating dialogue on sexuality which they felt is still somewhat re p ressed even today, they found some questions too easy for students in the second year of high school.This is natural, since the game was created for pre-adolescents (9-12 years old).Howe ve r, comments by these older students illustrate the need to create ve r s i o n s with increasing levels of complexity and depth of know l e d g e. lescents meet their partners and rehearse their l ove live s.Despite theoretical advances in psychology and pedagogy, educational practice is still chara c t e ri zed by emphasis on tra n s m i ssion of contents which are not always useful to students in life.Ne ve rt h e l e s s, in classroom, beyond the formal subject, there is another context happening which is chara c t e ri zed by a scheme of relations and hidden conflicts with the busy teacher and which can be made explicit if altern a t i ves are created for their expre ssion, and games like ZIG-ZAIDS could be useful in this sense.
Although aware of the limited know l e d g e c o n c e rning behavior change, we have here the g reatest challenge for educational activity.As Rosenstock (1990) states, knowledge is important, sometimes essential for behavior change, but it is ra rely enough.It is in the unknow n world of reason that people are dri ven to beh a ve in one way and not in another, where one finds health and disease, happiness and gri e f , and success and failure, amongst other phenomena.T h u s, the educational process must be integrated with affect in order to begin the n e c e s s a ry changes.The mere acquisition of k n owledge is not enough to engender the attitudes and actions that are the ve ry goal of educational initiatives in the health area.
Ma t e rials like ZIG-ZAIDS are certainly facilitators of this pro c e s s, which re q u i res enabling of educators to achieve its goals, along with o rientation and evaluation of its effective n e s s, c o m p a ring the stra t e g i e s' va riations and contexts of the current work.Schall (1996) alre a d y re p o rted that health-related knowledge exp resses that children place value on thems e l ves as healthy and re veals the meaning and values they ascribe to this fundamental aspect of their live s.T h u s, it also re veals each child's i d e n t i t y, his/her perc e p t i o n s, experi e n c e s, mot i va t i o n s, and actions expressing an image of oneself, making it possible for them to work b e yond physical and cognitive aspects.
It is believed that in relation to STD/Aids and dru g s, it is necessary to go beyond both t raditional practices of knowledge tra n s m i ssion and a climate of threats to consider a longt e rm intervention begun in pre-school.T h i s would be capable of strengthening childre n and adolescents in order for them to not only better understand themselves but to also pra ctice community activities that stimulate respect and responsibility for themselves and o t h e r s.This is necessary for children from an early age to not accommodate themselves to unbalanced and unfair social situations, to enable them to make choices, without feeling emb a r rassed by the gro u p, and to achieve better human relations and better communications and empathy through an educational pro c e s s in which families and schools intera c t .

Table 1
Examples of answers received on use of the game.Situational evaluation.

Table 2
Examples of answers received from 34 institutions.Process analysis.