2011. Vol.2, No.4, 393-397
Copyright © 2011 SciRes. DOI:10.4236/ce.2011.24056
Middle School Students Want More than Games for Health
Education on the Internet
Henna Muzaffar1, Darla M. Castelli2, David Goss2, Jane A. Scherer3, Karen Chapman-Novakofski1,3
1Division of Nutritional Sciences, University of Illinois, Urbana-Champaign, USA;
2Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, USA;
3University of Illinois Extension Service, University of Illinois, Urbana-Champaign, USA.
Received September 14th, 2011; revised October 15th, 2011; accepted October 28 th, 2011.
Our aim was to assess the views of participants in the “the HOT project: Healthy Outcomes for Teens”. Twelve
focus group interviews (n = 42) were conducted using a structured questionnaire ranging from 2 to 5 per focus
group. Discussions were recorded, transcribed, and analyzed by two investigators following content analysis.
Emerging themes were consensus of research team. Three main themes emerged from the focus group data
analysis with subcategories: kid appeal (social, entertainment, and information, that reflected why they used the
internet, why and what they liked from the HOT project website), healthy living (diet, exercise, sleeping,
friendship, and studying), and living with and without diabetes (those who had relatives with diabetes or not).
Subjects appreciated the design, information, and entertainment. They had specific suggestions for increased fun,
options for social interaction, broader health coverage for topics, and more depth and scenarios for diabetes in-
formation for those with limited exposure to the condition.
Keywords: Health Education, Online Learning, Diabetes, Focus Groups
As the prevalence of obesity and type 2 diabetes continues to
increase in adolescents and youth, the number of interventions
aiming to attenuate this situation has also increased. Adolescent
interventions targeting healthy behaviors have been imple-
mented in school and home environments. Evidence suggests
that the most promising approaches for adolescents involve
both families and schools and include a combination of physi-
cal activity and nutrition or nutrition alone. These interventions
have demonstrated significant weight reduction effects, with
theoretical framework providing significant impact (Waller,
Eiser, Heller, Knowles, & Price, 2005; Katz, O’Connell, Yeh,
Nawaz, Njike, & Anderson et al., 2005). Interventions integrat-
ing lessons about nutrition, physical activity, and reduction in
screen time into the standard curriculum have a more profound
effect than those outside of the school day that do not address
this content (Gortmaker, Cheung, Peterson, Chomitz, Cradle, &
Dart et al., 2006; Mo-suwan, Pongprapai, Junjana, Puetpaiboon,
1998; Burke, Thompson, Taggart, Spickett, Beilin, & Vandon-
gen et al.,1998).
However, researchers have also used interactive learning,
such as computer and video games, as a means of enhancing
learning and fostering prevention. Proponents argue that com-
puter games promote active learning and can enhance under-
standing of complex topics, while others believe computer
games do not enhance learning and may create distractions (Ke,
2008). A recent literature review of computer and video games
in health and physical education concluded that although con-
clusive evidence may be lacking, online health education fea-
tures can be motivating and engaging (Papastergiou, 2009). In
addition, it is estimated that teens in the United States (US)
spend more than two hours a day online (Hasker & Somosi,
2004), visiting such websites as MySpace, Facebook, and
Twitter; the top three in social networking sites, with over two
billion mo n thl y v isits c o lle c t ive l y (K azeniac, 2009; Wang, 2010).
Given findings from previous interventions and the rapidly
changing dynamic of the US demographics, this study used
innovative technology to develop a prototype website focused
on increasing diabetes and overweight awareness (Healthy Out-
comes for Teens: HOT Project). The purpose of this study was
to use focus groups to stimulate evaluation of the HOT Project
website as a way to enhance sustainability and usability by the
The Healthy Outcomes for Teens Project
The HOT project website included content specific to 14 - 17
year olds with type 2 diabetes or at risk for type 2 diabetes,
focused on skills and knowledge assessment, an overview of
diabetes and food, relationship between diabetes and food,
physical activity and weight management, and eating for target
blood glucose levels organized in five modules (Castelli, Goss,
Scherer, & Chapman-Novakofski, 2011). The website was ad-
apted from a previously effective website targeting adults which
was developed in 2006 (Herrejon, Hartke, Scherer, & Chap-
man-Novakofski, 2009). Similar to other healthy eating and
physical activity online programs (Thompson, Baranowski, Cul-
len, & Baranowski, 2007), the HOT Project was framed in So-
cial Cognitive Theory (Bandura, 1986).
An interactive, participatory design was used so that sus-
tainability and usability could be maximized. A distributed
interactive environment (DIL) which permitted self-regulation
and exploration at their own pace was used to ensure effective-
ness and efficiency in learning (Kubik, Lytle, & Fulkerson,
2005; Ott, Rosenburger, Woodcox, & McBride, 2009). This
non-linear design allowed individuals to revisit information
based upon interest and need. We developed a teen council to
assist in the design, topic coverage, and interactivity (Castelli,
Goss, Scherer, & Chapman-Novakofski, 2011).
H. MUZAFFAR ET AL.
Two versions of the website were created with exactly the
same information except the site for the treatment group had
int era cti ve features (animated pictures, videos, game s and voice-
overs) while the control group had passive, non-interactive texts.
A total of 165 middle school students participated in the pro-
gram which was incorporated in the regular school day in the
physical education or health class, or in an after-school program
(Castelli, Goss, Scherer, & Chapman-No vakofski, 2011). The su-
bjects were recruited from three middle schools, housed in dif-
ferent school districts of a Midwest county.
Focus groups have been used successfully with the adoles-
cent population to obtain qualitative information from relatively
homogenous populations about attitudes, perceptions and opin-
ion s that can influence their behavior. Furthermore, focus groups
also give the opportunity for exchange of ideas among the par-
ticipants, to assess the degree of consensus and diversity of
opinion, and to promote responses with depth and complex- ity
(Weinger, O’Donnell, & Ritholz, 2001). Focus groups are con-
ducted using a general format of open-ended questions and the
data are analyzed qualitatively to determine appropriate codes,
themes and patterns (Ott et al., 2009; Weinger et al., 2001;
The focus group interviews began with broad topics, pro-
gressing to more focused questions concerning which parts of
the intervention they believed might be most compelling or
appealing (Krueger, 1994). The script was developed by the
research team and was field-tested for flow and clarity of the
dis cussion questi ons. The University Institutional Review Board
approved the protocol, and parental consent and child assent
was obtained. Subjects were recruited from three school dis-
tricts that participated in the HOT project and were in the
treatment group (n = 101). Subjects (n = 42) participated in the
focus groups in the last session of the HOT project. Twelve
focus groups were conducted with 2 to 5 students in quiet pri-
vate small rooms near the computer labs in the schools. Topic
saturation indicated enough subjects had participated to provide
Debriefing of moderator and co-moderator occurred immedi-
ately after the focus group to capture first impressions, and then
highlight and contrast findings from earlier focus groups. These
discussions were collected in formal observational notes as well
as the fidelity-to-treatment logs. Additionally, each researcher
recorded any unique demographics (i.e., gender, race) and situ-
ational events that may have taken place during the focus
groups. The interview sessions took an average of 45 - 60 min-
utes. The focus group interviews were audio-taped and then
Specifically, the focus group data were analyzed using con-
tent analysis, which involves identifying coherent and impor-
tant examples, themes and patterns in the data (Patton, 1987).
First, these data were analyzed inductively, without regard to
theory, by coding discrete statements and identifying patterns
and themes, according to inductive category development meth-
ods (Mayring, 2000). Two researchers analyzed the tran-
scribed focus group data separately to develop a list of key-
words and codes. Independent summaries of the codes and
patterns were presented in group debrief to audit the results.
During the debrief, two analysts met with one principal inves-
tigator to arrive at a consensus for the final summary and to
achieve greater than 85% agreement on the coding of the dis-
crete statements. From the codes and frequency counts three
overarching themes emerged.
A negative case analysis was conducted to ensure that all
ideas had been accounted within the act of coding (Lincoln &
Guba, 1985). Negative cases were single or a collection of dis-
crete statements that did not fall within the established defined
codes. In this study, one negative case appeared suggesting that
participants with relatives may have better insight into the pre-
vention and treatment of diabetes. Given the potential effects of
this finding, these data were again analyzed to determine if
there was a difference in the responses of participants who had
relatives with diabetes as compared to those without known
relatives having diabetes for four questions. The four questions
were frequency of Internet use, defining healthy outcome, de-
fining diabetes, and recommendations for improving the web-
The second phase of analyses used deductive reasoning in
that frequency counts and qualitative data, analyzed in a previ-
ous study (Castelli, Goss, Scherer, & Chapman-Novakofski,
2011), were used to confirm the trustworthiness of the codes,
patterns and themes in the present study. In this phase, the
codes were compared holistically with the quantitative data of
code frequency counts, knowledge test scores, risk for diabetes,
and website hit counts, because themes should be identified
before, during, and after the data collectio n (Denzi n & Lincol n,
1998). Further, the patterns and themes were reexamined from
a theoretical perspective for consistencies.
All subjects had access to the Internet, with more than 50%
using it daily, up to two hours per day. There were no substan-
tial differences between genders or across schools in use, both
in frequency and time. The results indicated that the Internet
appeared to be an extension of daily living utilized for commu-
nication and information access.
When asked about defining healthy outcomes or diabetes, the
subjects gave responses in the categories of diet, physical activ-
ity, studying, sleeping, and friendship. The diet category had
the most varied responses and included answers such as healthy
eating in general, eating fruits and vegetables, eating in mod-
eration, no junk food and eating less meat. The participants
expressed interest in learning more information about healthy
living, diabetes and varied topics such as leukemia. Subjects
also recommended adding more games, videos, pictures, music,
social interaction features, voiceovers and cartoons, and less
reading and easy vocabulary. The students thought the use of
humor on such a serious topic would be valuable to gain and
The secondary analysis for identifying differences in re-
sponses from those with or without diabetes family histories
indicated one difference. Subjects with family history of diabe-
tes (n = 22) were more likely to comment on sugar level or
sugar intake. Therefore, experience with a diabetic family
member only minimally affected these findings.
Three main themes emerged from the focus group data
analysis: kid appeal, healthy living, and living with and without
Three main themes emerged from the focus group data
analysis: kid appeal, healthy living, and living with and without
H. MUZAFFAR ET AL. 395
The kid appeal theme was composed of three categories,
namely social, entertainment, and information. These three ca-
tegories were representative of the reasons these students used
the internet, why and what they liked from the HOT project
website, and what recommendations they gave to make the
Social. MySpace was by far the favorite website for these
subjects, with facebook being the third most favorite. These
two websites fall in the social networking category. Other fa-
vorite websites were you tube, yahoo, games, and music web-
sites for entertainment. The subjects recommended adding some
social interaction features on the website such as having their
own home page, username and password; getting in touch with
people who have diabetes; chatting with friends who are also
participating in the HOT project; and allowing people to choose
what’s on the page.
Entertainment. Games were the favorite part of the HOT
project followed by videos and pictures. Among the games,
jeopardy was the most popular and some subjects also men-
tioned liking blast off, foods on a plate, and word search. In
addition to entertainment from the website, the students also
liked the information presented, surveys, and design of the web
page. Subjects want to make the website more entertaining by
adding more games, music, pictures, videos, and funny text.
Information. The diabetes, exercise and health information
presented on the website was well perceived by the subjects and
they recommended adding information about how to get active,
more examples of people having diabetes, translating to other
languages, more voiceovers, easier vocabulary, and making
websites with information on how the brain works and cancer/
The second prominent theme in the focus group data was
‘healthy living’. Their responses fell in five categories namely
diet, exercise, sleeping, friendship, and studying. Most of the
answers were in the diet category and included responses such
as eating healthy foods, eating fruits and vegetables, following
a diet, eating in moderation, not eating junk food, and eating
good nutrition. The exercise category included exercising, play-
ing sports, and staying fit.
Living with and without Diabetes
The third theme emerging from the focus group analysis was
‘living with and without diabetes’. The responses of subjects
who had relatives with diabetes to diabetes related questions
were more knowledgeable. Twenty-two subjects had family
members who had diabetes. The subjects’ responses to defining
diabetes included “can’t eat a lot of sugar, blood glucose level
low/high, insulin low/get shots, a sickness/disease, causes fre-
quent urination, high blood pressure causes diabetes, and kid-
neys might die”. Subjects who had family members with dia-
betes were three times more likely to make a comment related
to sugar intake or insulin level.
Despite developing a highly interactive website, the partici-
pants requested that there be more interactivity and social in-
teraction. These concepts reflect the “Toy” and “Telephone”
attributes of a 5-T model (Tool, Toy, Telephone, Territory, and
Treasure of Information) used to describe elementary school
students in Taiwan’s attitude toward the internet (Chou, Yu,
Chen, & Wu, 2009). However, if the researchers were to ac-
commodate this request, it is unclear at what point there would
be too much interactivity. Some researchers have suggested that
too much interaction can be a distraction to learning and there-
fore future studies should examine the effects of hyper-interac-
tivity on learning (Ke, 2008). Further study with this population
A study by Schiffman et al. on Internet use among adolescent
and young adults with cancer supports the findings of our focus
groups. Most subjects reported Internet use daily and for an
average of two hours (Schiffman, Csongradi, & Suzuki, 2008).
They identified 21 desired features on a health website to make
it more appealing to browse. Most of them fell in the three
categories, social, information and entertainment; the same
themes were also identified in the HOT project study, and may
reflect the Tool/Treasure of Information, Telephone/Territory,
and Toy perspectives of the 5 T model (Chou et al., 2009).
Like older adults, Internet use for seeking health information
is becoming popular in the adolescent population, thus making
Internet a well-suited medium to provide a variety of resources
(Schiffman et al., 2008). Brown, Teufel, & Birch, 2006 sug-
gested adolescents learn the most about health from school and
the Internet. Similar to our study, a project involving children
aged 7 to 8 concluded that even young students valued fun in
educational software (Sim, MacFarlane, & Read, 2006). How-
ever, learning was not always correlated with fun and usability
was important. Consequently, to enhance the impact of health-
related websites, social and entertainment features must be
incorporated with learning and usability remaining as the pri-
mary foc us.
Most but not all responses concerning healthy living re-
flected content provided in the online modules. Indeed, most
interventions for this age group that target obesity prevention
focus on healthy eating and physical activity (Weight Realities
Division of the Society for Nutrition Education, 2003; Zenzen
& Kridli, 2009). Sleeping, friendship, and studying were also
mentioned. Some studies report less sleep to be associated with
higher BMI in children (Hitze, Bosy-Westphal, Bielfeldt, Set-
tler, Plachta-Danielzik, & Pfeuffer, 2009). Although the major
determinant of sleep in this study conducted by Hitze et al. was
age, physical activity was not a major determinant. In other
studies as well, short sleep is a modifiable predictor of over-
weight and obesity in adolescents (Bibiloni, Martinez, Llull,
Juarez, Pons, & Tur, 2010). Interestingly, one study of sleep
and children found fatigue equal to that of cancer patients in
obese but not normal weight children (Varni, Limbers, Bryant,
& Wilson, 2010). These findings suggest perhaps sleep could
be included in healthy outcomes programs for this age group.
Research has found that peers or friends can influence body
weight both positively and negatively. That is, friends can pro-
vide support or pressure for healthy behaviors, or conversely
unhealthy behaviors (Lytle, Murray, Perry, Story, Birnbaum, &
Kubik, et al., 2004; Eisenberg, Neumark-Sztainer, Story, &
Perry, 2005). One study also reported that children with higher
body mass indices tended to associate with similarly weighted
peers, and this clustering also seemed to have gender influences
as well, with similar genders being most sensitive to each other
(Renna, Grafova, & Thakur, 2008). The mentioning of friends
as part of a healthy outcome coupled with the request for more
social interaction suggests that friends, peers, and positive
guiding of this influence may be very important to successful
H. MUZAFFAR ET AL.
Those subjects who had relatives with diabetes more fre-
quently reported diabetes-related knowledge about treatment
(care) but not necessarily prevention. The interpretation of fam-
ily history of disease in adults has been explored to a limited
degree. In one study, the adults had little worry that their chil-
dren would develop a chronic disease although they themselves
felt at risk (Walter & Emory, 2005). Unfortunately, there is a
paucity of studies concerning children’s perception of risk for
chronic disease for which they have a family history. Future
research could explore this within a social learning context.
The limitation of these findings must be noted. Because the
focus group participants were recruited from the HOT project
intervention study, there is concern of limited transferability
and the possibility of selection bias. However, the focus groups
sessions provided an opportunity for in-depth discussion of
questions and reaction to comments made by other participants.
These results confirmed the researchers’ hypothesis that “kid
appeal” would make the program attractive to this audience.
However, the teens also wanted more information and social
interaction. Future studies should address other aspects of heal-
thy outcomes, particularly sleep and academics. Finally, how
adolescents perceive the impact of family history for disease
needs to be more fully evaluated to successfully design effec-
This project was supported by funding from the American
Dietetic Association Foundation, the National Soybean Re-
search Laboratory, University of Illinois Extension Service, and
the Illinois Soybean Association.
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