Including Community Partners in the Development and Adaptation of Intervention Strategies to Prevent Initiation or Escalation of Opioid Misuse.

Current literature lacks clear examples of how to engage with communities in the development of opioid misuse interventions for diverse populations and across various settings. The National Institutes of Health (NIH) Helping to End Addiction Long-term® Initiative (HEAL) Prevention Cooperative (HPC) research projects work collaboratively with communities to develop and adapt their opioid misuse interventions to increase both feasibility and sustainability. Ten HPC projects were selected to receive NIH funding and are required to have partnerships with communities where their intervention is being conducted. This paper applies the Centers for Disease Control and Prevention (CDC)-adapted Public Participation Framework to examine the levels of community engagement used by each of these 10 HPC projects (Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement, 2015). Using this framework, this paper illustrates the range of community engagement approaches and levels that the HPC projects rely on to develop, adapt, and adopt opioid prevention interventions across diverse populations and settings. This paper also lays a foundation for future examinations of the role of community engagement in intervention implementation and effectiveness and the level of community engagement that is necessary to improve intervention effectiveness.

A quasi-experimental test of a virtual reality game prototype for adolescent E-Cigarette prevention.

OBJECTIVE: To test the preliminary impact and participant experience/satisfaction of Invite Only VR: A Vaping Prevention Game (Invite Only VR), an electronic cigarette (e-cigarette) prevention game prototype using virtual reality (VR) hardware. METHODS: Forty-seven adolescents (38 boys; mean age = 14.23 years, SD = 0.914) were enrolled to test the preliminary impact of Invite Only VR on knowledge, perceived likelihood of using e-cigarettes, perceptions of harm, attitudes, social norms, and self-efficacy to refuse e-cigarettes using a pre/post design. Experience/satisfaction was measured following gameplay. Paired-samples t-tests and associated effect sizes were used to assess changes in the dependent variables. Descriptive statistics were used to report on gameplay experience/satisfaction. RESULTS: From pre- to post-gameplay, players significantly increased in knowledge (t(34) = -5.594, p < .001, Cohen's d = 0.946) and perceptions of e-cigarette harm (t(34) = -3.370, p = .002, Cohen's d = 0.530) and decreased their perceived likelihood of using e-cigarettes in the future (t(35) = 2.140, p = .039, Cohen's d = 1.274). No significant change was found for attitudes towards e-cigarettes, social norm perceptions, nor refusal self-efficacy. Participants reported that they enjoyed playing the game (M = 3.00, SD = 0.99) and that they would tell their friends to play (M = 3.08, SD = 0.91). CONCLUSIONS: Invite Only VR may help players develop knowledge and correct harm perceptions regarding e-cigarettes while reducing their perceived likelihood of using them in the future. Participant enjoyment also provides an initial indication that the intervention may be acceptable for use with adolescents.

Videogame intervention to encourage HIV testing and counseling among adolescents.

BACKGROUND: Adolescents in the United States account for one-fifth of new HIV cases, and have the highest rate of undiagnosed HIV, with more than half (51%) not knowing their status. It is a crucial public health concern to help equip youth with the information and autonomy to minimize their risk and know their status. Serious videogames are emerging as valuable tools for health and behavior change in adolescents, and have potential to engage this population and increase their use of HIV testing and counseling (HTC). The purpose of this study was to: (I) modify an original serious game targeting risk reduction and HIV prevention developed by the play2PREVENT Lab and create a new serious game that focuses on HTC; (II) evaluate its feasibility and acceptability; (III) pilot-test the assessment measures that are subsequently being used in a large randomized controlled trial. METHODS: Three focus groups with adolescents, aged 14-17 (n=13, mean age =15), informed artwork and storylines for PlayTest! After the game was completed, a pilot test was conducted using a one-group pretest-posttest design to collect data on: (I) participants' gameplay satisfaction and experience; (II) the validity of the project's assessments. Twenty-six participants, aged 15-16 were enrolled from a local after-school program. Participants played PlayTest! twice weekly for three weeks. Data were collected on behavior, intentions, knowledge, perceived susceptibility, and attitudes related to HTC at baseline, post-gameplay (three weeks), and follow-up (six weeks). RESULTS: For the focus groups used in the game development, four major themes emerged: (I) adolescents have strong misperceptions about HTC, including who should get tested and what the test entails; (II) adolescents have incorrect knowledge about how HIV is contracted, spread, and treated; (III) adolescents are supportive of their peers getting tested for HIV, but are not likely to get tested themselves; (IV) while the majority of adolescents know where to get tested for HIV, social stigma, misperceptions around HTC, and fear of having a positive diagnosis keep them from seeking it. For the pilot study, overall, participant experience with the game was highly favorable. The assessments were sensitive enough to capture changes in our target variables: intentions (P=0.037) and knowledge (P=0.025) related to HTC at follow-up. CONCLUSIONS: The PlayTest! game provides promising results regarding using an engaging and evidence-informed videogame intervention to promote HTC in adolescents.

A videogame intervention for tobacco product use prevention in adolescents.

PURPOSE: This pilot study evaluated the short-term effects of an interactive videogame on changing adolescent knowledge, beliefs and risk perceptions, and intentions to use e-cigarettes, cigarettes, and other tobacco products. A secondary aim was to evaluate players' game experience. METHODS: Participants (N = 80 11-14 year olds) were recruited from 7 community-based afterschool programs in New Haven, Connecticut and Los Angeles, California. The design was a single group pre-post design with replication. A pre-test survey was administered that included demographic variables and knowledge, risk perceptions, beliefs, and intentions to use e-cigarettes, cigarettes, and other tobacco products. An interactive videogame focusing on risky tobacco use situations was subsequently played in four 60-min sessions over a four-week period, followed by a post-test survey. Analyses included paired t-tests of pre-post videogame change, regression analyses, and path analyses testing mediational effects of beliefs and risk perceptions on the relationship between knowledge and intentions. RESULTS: The videogame changed knowledge of e-cigarettes and other tobacco products (p's < 0.001), risk perceptions of cigarettes and e-cigarettes (p < .01 and p < .001, respectively), and beliefs about e-cigarettes and other tobacco products (p's < 0.05), but not intentions. Older adolescents reported greater e-cigarette knowledge and risk perceptions (p's < 0.05), and females reported greater risk perception of cigarettes (p < .05). Beliefs mediated the relationship between knowledge and intentions to use e-cigarettes (indirect effect p < .05). CONCLUSION: Results suggest that brief exposure (4 h over 4 weeks) to a videogame focused on changing knowledge and attitudes towards tobacco products may have a promising effect on preventing risk for early adolescent tobacco product use, particularly for e-cigarettes.

Development and Feasibility Testing of a Videogame Intervention to Reduce High-Risk Sexual Behavior in Black and Hispanic Adolescents.

Objective: Develop and test feasibility of a mobile videogame intervention to decrease high-risk sexual behavior in black and Hispanic adolescents. Materials and Methods: Iterative design to develop intervention in partnership with target audience. Feasibility and preliminary impact data collected at baseline, following 2-3 hours of gameplay and at 8-week follow-up. Results: Twenty-six 15-17-year-olds completed pilot testing: 16 (62%) were male, 20 (77%) black or Hispanic. Pilot testing demonstrated feasibility, including producing a usable videogame prototype, incorporating videogame testing within a high school, and participants' acceptability of the videogame. Participants' gameplay experience reflected that most would play the videogame again (77%), stated that they felt responsible for the choices they made in the videogame (73%), and would tell their friends to play the videogame (58%). Most suggested adding more videogame content to further engage participants. From baseline to follow-up, participants demonstrated improvements in condom and contraception self-efficacy (P = 0.003), risk perceptions (P = 0.009), and high-risk sexual behavior knowledge (P < 0.0001). Among black or Hispanic adolescents, we found improvements in summary measures of intentions (P = 0.04), self-efficacy (P = 0.003), risk perceptions (P = 0.002), and sexual knowledge (P = 0.0002). Adolescents with previous sexual experience showed similar improvements. Conclusion: Pilot testing of an innovative videogame, developed in partnership with the target audience, demonstrated feasibility and preliminary impact with this cohort of black or Hispanic adolescents. We developed a usable videogame prototype and gained important data about how to enhance the next videogame iteration. Future plans include targeting an older age group to maximize our ability to measure potential impact among sexually experienced adolescents.

Preliminary investigation of a videogame prototype for cigarette and marijuana prevention in adolescents.

BACKGROUND: Videogames are becoming increasingly popular to deliver health interventions; however, their role in the primary prevention of cigarette and marijuana use has not yet been evaluated. The purpose of this study was to conduct a preliminary test of the efficacy of a role-playing videogame prototype, smokeSCREEN, aimed at developing knowledge and behavioral skills associated with primary prevention of cigarette and marijuana use. The authors also explored participants' gameplay experience. METHODS: This study employed a 1-group pretest-posttest design with 25 adolescent boys and girls aged 11 to 14 years (Mage = 11.56, SD = 0.77) who had never tried cigarettes or marijuana. Participants played four 1-hour gameplay sessions over a 2-week period. Assessments of knowledge, self-efficacy, attitudes, perceived norms, and intentions related to cigarette and marijuana prevention were collected at baseline and 2-week and 12-week follow-ups. Ratings of gameplay experience were collected after the 2 weeks of gameplay. One-way repeated-measures analyses of variance (ANOVAs) were conducted. RESULTS: Findings are (1) improvements in knowledge for both cigarette (Wilks' λ = 0.62, F(2, 23) = 7.21, P = .004) and marijuana (Wilks' λ = 0.67, F(2, 23) = 5.75, P = .009) use from pre- to post-gameplay that were characterized by large effects; and (2) nonsignificant trends in the expected direction emerged for changes in self-efficacy and perceived norms related to both cigarettes and marijuana that were characterized by medium-large effects. Overall, the players provided positive reports of their experience with the smokeSCREEN videogame prototype. CONCLUSIONS: These findings provide preliminary evidence that a videogame has the potential to influence key cognitive and motivational variables and can be an engaging means to deliver a cigarette and marijuana prevention intervention.

Video Game Intervention for Sexual Risk Reduction in Minority Adolescents: Randomized Controlled Trial.

BACKGROUND: Human immunodeficiency virus (HIV) disproportionately impacts minority youth. Interventions to decrease HIV sexual risk are needed. OBJECTIVE: We hypothesized that an engaging theory-based digital health intervention in the form of an interactive video game would improve sexual health outcomes in adolescents. METHODS: Participants aged 11 to 14 years from 12 community afterschool, school, and summer programs were randomized 1:1 to play up to 16 hours of an experimental video game or control video games over 6 weeks. Assessments were conducted at 6 weeks and at 3, 6, and 12 months. Primary outcome was delay of initiation of vaginal/anal intercourse. Secondary outcomes included sexual health attitudes, knowledge, and intentions. We examined outcomes by gender and age. RESULTS: A total of 333 participants were randomized to play the intervention (n=166) or control games (n=167): 295 (88.6%) were racial/ethnic minorities, 177 (53.2%) were boys, and the mean age was 12.9 (1.1) years. At 12 months, for the 258 (84.6%) participants with available data, 94.6% (122/129) in the intervention group versus 95.4% (123/129) in the control group delayed initiation of intercourse (relative risk=0.99, 95% CI 0.94-1.05, P=.77). Over 12 months, the intervention group demonstrated improved sexual health attitudes overall compared to the control group (least squares means [LS means] difference 0.37, 95% CI 0.01-0.72, P=.04). This improvement was observed in boys (LS means difference 0.67, P=.008), but not girls (LS means difference 0.06, P=.81), and in younger (LS means difference 0.71, P=.005), but not older participants (LS means difference 0.03, P=.92). The intervention group also demonstrated increased sexual health knowledge overall (LS means difference 1.13, 95% CI 0.64-1.61, P<.001), in girls (LS means difference 1.16, P=.001), boys (LS means difference 1.10, P=.001), younger (LS means difference 1.18, P=.001), and older (LS means difference=1.08, P=.002) participants. There were no differences in intentions to delay the initiation of intercourse between the two groups (LS means difference 0.10, P=.56). CONCLUSIONS: An interactive video game intervention improves sexual health attitudes and knowledge in minority adolescents for at least 12 months. TRIAL REGISTRATION: Clinicaltrials.gov NCT01666496; https://clinicaltrials.gov/ct2/show/NCT01666496 (Archived by WebCite at http://www.webcitation.org/6syumc9C0).

If We Build It, Will They Come? A Qualitative Study of Key Stakeholder Opinions on the Implementation of a Videogame Intervention for Risk Reduction in Adolescents.

OBJECTIVE: Serious games are emerging as important tools that offer an innovative approach to teach adolescents behavioral skills to avoid risky situations. PlayForward: Elm City Stories, an interactive videogame targeting risk reduction, is currently undergoing evaluation. Collecting stakeholder data on its acceptability and real-life implementation strategies is critical for successful dissemination. MATERIALS AND METHODS: We collected interview data from four stakeholder groups regarding incorporating PlayForward into settings with adolescents. Transcripts were coded, creating a comprehensive code structure for each stakeholder group. RESULTS: We conducted 40 semi-structured interviews that included 14 adolescents (aged 12-15 years; 10 boys), eight parents/guardians (all women), 12 after-school/school coordinators (nine women), and 14 community partners (13 women). We identified four themes that reflected stakeholders' perceptions about how the videogame might be implemented in real-world settings. (1) Stakeholder groups expressed that the topics of sex, alcohol, and drugs were not being taught in an educational setting. (2) Stakeholder groups saw a videogame as a viable option to teach about sex, alcohol, and drugs. (3) Stakeholder groups thought that the videogame would fit well into other settings, such as after-school programs or community organizations. (4) Some stakeholder groups highlighted additional tools that could help with implementation, such as manuals, homework assignments, and group discussion questions. CONCLUSION: Stakeholder groups supported the game as a delivery vehicle for targeted content, indicating high acceptability but highlighting additional tools that would aid in implementation.

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.

BACKGROUND: To address the need for risk behavior reduction and human immunodeficiency virus prevention interventions that capture adolescents "where they live," we created a tablet-based videogame to teach skills and knowledge and influence psychosocial antecedents for decreasing risk and preventing human immunodeficiency virus infection in minority youth in schools, after-school programs, and summer camps. METHODS: We developed PlayForward: Elm City Stories over a 2-year period, working with researchers, commercial game designers, and staff and teens from community programs. The videogame PlayForward provides an interactive world where players, using an avatar, "travel" through time, facing challenges such as peer pressure to drink alcohol or engage in risky sexual behaviors. Players experience how their choices affect their future and then are able to go back in time and change their choices, creating different outcomes. A randomized controlled trial was designed to evaluate the efficacy of PlayForward. Participants were randomly assigned to play PlayForward or a set of attention/time control games on a tablet at their community-based program. Assessment data were collected during face-to-face study visits and entered into a web-based platform and unique real-time "in-game" PlayForward data were collected as players engaged in the game. The innovative methods of this randomized controlled trial are described. We highlight the logistical issues of conducting a large-scale trial using mobile technology such as the iPad(®), and collecting, transferring, and storing large amounts of in-game data. We outline the methods used to analyze the in-game data alone and in conjunction with standardized assessment data to establish correlations between behaviors during gameplay and those reported in real life. We also describe the use of the in-game data as a measure of fidelity to the intervention. RESULTS: In total, 333 boys and girls, aged 11-14 years, were randomized over a 14-month period: 166 were assigned to play PlayForward and 167 to play the control games. To date (as of 1 March 2016), 18 have withdrawn from the study; the following have completed the protocol-defined assessments: 6 weeks: 271 (83%), 3 months: 269 (84%), 6 months: 254 (79%), 12 months: 259 (82%), and 24 months: is ongoing with 152 having completed out of the 199 participants (76%) who were eligible to date (assessment windows were still open). CONCLUSION: Videogames can be developed to address complex behaviors and can be subject to empiric testing using community-based randomized controlled trials. Although mobile technologies pose challenges in their use as interventions and in the collection and storage of data they produce, they provide unique opportunities as new sources of potentially valid data and novel methods to measure the fidelity of digitally delivered behavioral interventions.