Ross Shegog - The Secret of Seven Stones: A Game to Impact Youth Skills and Parent-Youth Communication for Teen Pregnanc

1. ROSS SHEGOG, PHD UNIVERSITY OF TEXAS SCHOOL OF PUBLIC HEALTH CENTER FOR PREVENTION RESEARCH Funded by NIH/NICHD grant R42HD074324

2. Research & Teaching in the Service of Public Health … Disease Management Disease Prevention / Health Promotion “Watch-Discover-Think then Act.” (PI. Gold, Bartholomew) Asthma management simulation “ASPIRE” (PI. Prokhorov, Kelder) High school smoking prevention. “Stop Asthma.” (PI. Abramson, Bartholomew) Pediatrician decision support. “Headbutt”. (PI. McAlister) Middle school smoking prevention Epilepsy self-management Network (PI. Begley, Shegog) “Peacetest.org” (PI. McAlister) Violence prevention on-line. MINDSET Epilepsy self-management DSS (PI. Begley, Shegog) Clinical decision support “En Vivo” (PI. Kelder) Web-based motivational enhancement for reduced screen-time in Hispanic youth. MINDSET Science Training “Booster Break” (PI. Taylor) Work-based toning. “HeadsUp Virtual Molecular Biology Lab” (PI. Murray) AP science virtual transgenics

3. Research & Teaching in the Service of Public Health …Sexual Health Disease Prevention / Health Promotion Community-based Decision Support (PI Peskin) Adoption of evidence-based sexual health programs “It’s Your Game” (PI. Tortolero) “All About Youth” (PI. Markham) Middle school HIV/pregnancy prevention “It’s Your Game – Family” (PI’s McLaughlan, Shegog) IYG for parents and faimlies. “It’s Your Game” website (PI. Peskin) Middle school HIV/pregnancy prevention “It’s Your Game - Tech” (PI’s Peskin, Shegog) Middle school sexual health on-line “NATIVE It’s Your Game” (PI’s Markham, Shegog) IYG for Am. Indians / Alaska Natives Disease Management “+ CLICK” (PI. Markham) HIV+ youth web management training

4. Study Goals Develop and evaluate a home-based serious intergenerational computer game to: ❑ Provide developmentally-appropriate sexual health life skills education for youth (11-14 years) ❑ Improve parent-youth communication about sex and healthy relationships ❑ Increase youths’ intentions, knowledge, and skills for safe and healthy sexual behaviors ❑ Improve parent monitoring and parent-youth connectedness

5. ACKNOWLEDGEMENTS UT Research & Development: Ross Shegog, PhD (Principal Investigator) Christine Markham, PhD (Co-PI) Susan Tortolero, PhD (Co-I) Melissa Peskin, PhD (Co-I) Diane Santa Maria, PhD (Consultant) Mike Wilkerson, PhD (Consultant) Sara Dube, MPH (Project Director) Laura Ceglio, MPH (Research Assistant) Hsing-Yi Song, MD, MPH (Research Assistant) Angela Spencer, BS (Graduate Assistant) Pooja Chaudhary, MD (Graduate Assistant) Production: Jeffrey McLaughlin (Principal Investigator) Adrian Kecki: Senior User Experience Designer David Williams: Lead Developer Renjith Jose: Developer Gabby Alexander & Olga Prokhorov: Production Artists Brian White: Illustration Community Collaboration: Houston Area Schools and School Districts Parent-Youth Advisory Group

6. BACKGROUND

7. ADOLESCENT SEXUAL HEALTH • Many youth in U.S. engage in sexual risk behaviors resulting in unintended negative health outcomes.1 • Despite decline in teen pregnancy and STI incidence, U.S. rates higher than other industrialized countries.2 1. Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: Final data for 2013. Natl Vital Stat Rep. 2015;64(1):1-68. 2. United Nations Statistics Division. Demographic yearbook 2009–2010. http://unstats.un.org/unsd/demographic/products/dyb/dyb2009- 2010.htm. Published 2011. Updated 2011. Accessed February 25, 2015.

8. ADOLESCENT SEXUAL HEALTH 11%, 15%, 18% and 33% of 6th, 7th, 8th, and 9th graders respectively report lifetime sexual activity. 3,4 Teenagers (10-19 years) make up 7% of all births and 89% of unmarried mothers.1 • Nationally, teen pregnancy cost more than $9 billion.5 • • 1. Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: Final data for 2013. Natl Vital Stat Rep. 2015;64(1):1-68. 3. Centers for Disease Control and Prevention. Youth risk behavior surveillance: United states, 2007. MMWR Morbidity and mortality weekly report. 2008;SS-4(57). 4. Shanklin SL, Brener N, McManus T, Kinchen S, Kann L. 2005 middle school youth risk behavior survey 2007. 5. The National Campaign to Prevent Teen and Unplanned Pregnancy. Counting it up: The public costs of teen childbearing. 2014.

9. INTERVENTION APPROACHES • School vs. clinic-based programs Parental influence is key and provides support for home- based programs.6 • 6. Simpson AR. Raising teens: A synthesis of research and a foundation for action. 2001.

10. PARENTAL INFLUENCE Key factors related to parental influence: • Parent-child connectedness (closeness) protective for delayed sexual debut.7 Parental monitoring (knowledge of wherabouts) associated with lower levels of risk taking.8 • Parent child communication about sex that is open, positive, and frequent leads to delayed debut, fewer partners and using protection effectively.9 • 7. Neumark-Sztainer D, Story M, French SA, Resnick MD. Psychosocial correlates of health compromising behaviors among adolescents. Health Educ Res. 1997;12(1):37-52. 8. DiIorio C, Resnicow K, McCarty F, et al. Keepin' it R.E.A.L.!: Results of a mother-adolescent HIV prevention program. Nurs Res. 2006;55(1):43-51. 9. Hutchinson MK, Jemmott JB,3rd, Jemmott LS, Braverman P, Fong GT. The role of mother-daughter sexual risk communication in reducing sexual risk behaviors among urban adolescent females: A prospective study. J Adolesc Health. 2003;33(2):98-107.

11. WHAT WORKS? Empirically-based principles of parental interventions:11 1. Target parent-child relations early. 2. Focus on family for greatest effect. 3. Increase connectedness and monitoring. 4. Include skills-based activities to enhance behavioral capability and self-efficacy. 5. Longer and more intensive programs. 11. Spoth RL, Kavanagh KA, Dishion TJ. Family-centered preventive intervention science: Toward benefits to larger populations of children, youth, and families. Prev Sci. 2002;3(3):145-152.

12. THE missing links ❑ Communication: Most teens identified one or more sexual topics they wished their mothers (97%) and fathers (87%) would have discussed with them, but did not[1] ❑ Self-efficacy: Most parents reported being open about sexuality with their children, but very few conveyed direct messages about contraception and condom use [2] ❑ Accurate Information: Even when parents provide information, their knowledge about contraception or other sexual health topics may often be inaccurate or incomplete [3] [1]: Hutchinson, M. K., & Cooney, T. M. (1998). Patterns of parent-teen sexual risk communication: Implications for intervention.Family Relations, 47(2), 185-194. Retrieved from http://search.proquest.com/docview/213936519?accountid=7126 [2]: Hyde, A., Drennan, J., Butler, M., Howlett, E., Carney, M. and Lohan, M. (2013), Parents' constructions of communication with their children about safer sex. Journal of Clinical Nursing, 22: 3438–3446. doi:10.1111/jocn.12367 [3]: Eisenberg ME et al., Parents' beliefs about condoms and oral contraceptives: Are they medically accurate? Perspectives on Sexual and Reproductive Health, 2004, 36(2):50 57.

13. WHY games?  97% of American teens play computer, web, console, or mobile games  31% of teen gamers play games every day  Another 21% play games three to five days per week  Potential for ‘Edutainment’  Potential for developing developmentally and culturally appropriate interventions [1]: Lenhart, A., Kahne, J., Middaugh, E., Macgill, A. R., Evans, C., & Vitak, J. (2008). Teens, Video Games, and Civics: Teens' Gaming Experiences Are Diverse and Include Significant Social Interaction and Civic Engagement. Pew Internet & American ife Project. [2]: Shegog R, Peskin MF, Markham CM, et al. ‘It’s Your Game-Tech’: Toward sexual health in the digital age. Creative Educ 2014; 5(Special Edition):1428–1447

14. SERIOUS GAMES • Serious games, computer-based programs, are promising as an alternative to didactic approaches.10 • Serious games also present a means for developing intergenerational approaches. 10. Baranowski T, Buday R, Thompson DI, Baranowski J. Playing for real: Video games and stories for health-related behavior change. Am J Prev Med. 2008;34(1):74-82.

15. STUDY AIMS • Develop and test a home-based serious game to: • Provide sexual health life skills education for middle-school aged youth (11-14 years). • To enhance parents’ skills and confidence to support their youth.

16. STUDY DESIGN

17. STUDY OVERVIEW PHASE 1: Create and Test a Prototype PHASE 2: Create and Test Complete Program  Year 1 (Summer / Fall 2013)  Year 2 & 3 (2014 & 2015)  Literature review and needs assessment  Build complete SSS game  Alpha-Test complete SSS game in homes with 12 dyads  Focus groups  Evaluate existing activities  Randomized Control Trial efficacy testing of SSS in homes with 80 dyads (ongoing)  Build prototype of The Secret of Seven Stones  Usability Testing of prototype in lab-based setting

18. Intervention Mapping Intervention Mapping approach guided the design and application of the game from a theoretical perspective  Needs assessment to inform design, development, and implementation  Mapping behavioral/environmental outcomes and related determinants  Develop performance/change objectives  Develop theory-based methods and applications  Matrices covering: risk reduction, risk avoidance, parental monitoring, dyadic parent-child communication

19. LITERATURE REVIEW: CONCEPTUAL FRAMEWORK

20. QUALITATIVE NEEDS ASSESSMENT Focus groups & semi-structured interviews with parents (n=20) and youth (n=19). Themes:  to be a focal part of their child’s sexual health education Parents want …  to be a credible resource for their youth Parents and youth …  regard sexual health and communication as important.  want to be better at initiating the conversation.  want to keep the conversation going  want a fun, educational, and customizable game experience D’Cruz et al., Games For Health, 2015.

21. RESULTS: Focus Groups “It’s important to talk to your parents throughout the game, because… when all the lessons are over and you already learned about everything then what else you are going to do now? You can’t just go find another computer game or download another one. You have to be able to TALK TO YOUR PARENTS about anything. If you have questions, its really important to ask them while you are doing the game Qualitative Needs Assessment Data Table: Game Features Inventory -Female Youth “…I think (the proposed game) “…I think (the proposed game) opens up to more opens up to more GENUINE CONVERSATIONS CONVERSATIONS and sharing…to show that it is real. sharing…to show that it is real. It’s not just something that you It’s not just something that you see or know on TV see or know on TV GENUINE and - -Mother Mother “…you need to create something where parents are going to bring it to their kids and say, Look, I think this is cool, or not even I think this is cool. Hey, I want you to do this with me for a little bit, and it STARTS THE CONVERSATION” -Father

22. CONCEPTUAL GAME FRAMEWORK Source: D’Cruz et al., 2015

23. Intervention Mapping: DYADIC PARENT-CHILD COMMUNICATION MATRIX

24. Intervention Mapping: DYADIC PARENT-CHILD COMMUNICATION MATRIX Matrix for Environmental Condition 3-DYADIC ASKABLE PARENT MATRIX: Dyad relationship of parent-youth; Parents and children will interact in mutually engaging and responsive communication process to achieve shared goals Performance Objectives: Knowledge Skills Self-efficacy PO.1. 1. State that the right T&P is one where both parent and child are focused and calm 1. Demonstrate the ability to pick the right time and place to converse 1. Demonstrate the confidence to pick the right time and place to converse Parent and child will pick the right time and place (T&P) to talk 2. Describe the influence of emotions, preconceived thoughts and distractions on communication. 2. Demonstrate the ability to set aside emotional or cognitive predispositions before conversing 2. Demonstrate the confidence in ability to set aside emotional or cognitive predispositions before conversing 3. State the importance of being aware of these influences and setting them aside before initiating communication

25. PROGRAM DEVELOPMENT • Reviewed existing assets from other successful, evidence- based programs.

26. ADAPTED FROM…  Theory-based, multimedia program for 7th & 8th graders  Evaluated in two randomized controlled trials  Results showed IYG Delayed initiation of sex • N a t i o n a l l y R e c o g n i z e d Effective HIV/STI and Pregnancy Prevention Program for Middle School Youth Increased condom use • Increased positive beliefs about abstinence • Increased confidence to refuse sex • Increased intentions to abstain from sex • Tortolero, S.R., Markham, C.M., Peskin, M.F., Shegog, R., Addy, R.C., Escobar-Chaves, S.L., Baumler, E.R. It’s Your Game…Keep it Real: Delaying Sexual Behavior with an Effective Middle School Program. Journal of Adolescent Health. 2010; 46(2):169-179. Markham, C.M., Tortolero, S.R., Peskin, M.F., Shegog, R., Thiel, M., Baumler, E.R., Addy, R.C., Escobar-Chaves, S.L., Reininger, B., Robin, L. Sexual Risk Avoidance and Sexual Risk Reduction Interventions for Middle School Youth: A Randomized Controlled Trial. Submitted to Journal of Adolescent Health.

27. Strategies: Information transfer Refusal Skills Training Peer modeling Condom Skills Training

28. PROGRAM DEVELOPMENT Level 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Content Domain Virtue Communication Character & Goals Friendships Select, Detect, Protect - Friendships Developing Body & Reproduction Intentions - Sex Healthy Dating Healthy Dating Consequences of Sex Select, Detect, Protect - Sex HIV Dating Violence Pregnancy Sex Refusal Intro. to Condoms Condom Negotiation & Contraceptives Getting Tested for HIV/STDs The Future Communication Possible Me Friendship Respect Vision Persistence My Body Select, Detect, Protect Dating Caring Consequences Select, Detect, Protect Consequences Dating Consequences Select, Detect, Protect Safeguards Responsibility Courage My Future Integrity

29. GAME DESIGN

31. THE STORY A secret war between powerful forces is being waged across time in the town of Seven Stones. The Hero must uncover the secret of the town and liberate its citizens from the clutches of the evil villain Frostbyte, before it's too late.

32. THE STORY: CHRONOTITANS Zeroun Respect Iksha Vision Humiel Persistence Rith Karama Honor Jampa Caring Netis Courage Responsibility

33. HOW THE GAME WORKS • 18 levels, 150 embedded dojo skill training activities, and 54 ‘battle’ scenarios for youth • Hold 7 ‘PEP Talks’ with parent at game milestones

34. SKILLS TRAINING Train up in the Dojo to learn and build skills Take a Challenge to test knowledge, skills, and wisdom • • 6. User takes challenge/qui

35. THE STORY Battle Scenario: Suma want's Frolie to commit to a secret oath. "I will never tell my parents about our secret tree house hideout." Frolie doesn't like swearing to secrecy from her parents. Challenge: Help Frolie use negotiation skills and avoid breaking her rule about secrecy from her parents.

37. THE STORY Battle Scenario: Trixie pressured Herc into playing Truth or Dare. Herc is uncomfortable; Trixie is asking him to do something against his personal rules. He wants to stay friends, but he's just not ready to do what Trixie asks. Challenge: Help Herc get out of this risky situation gracefully.

38. THE ‘BATTLES’ • Get Wisdom, Skills, and Support battle cards • Battle to liberate the townspeople and demonstrate skills 8. User fights Battle

39. … you have to start here …

41. PEP TALKS • At 7 milestones, youth are locked out and instructed to meet with parent for a “PEP Talk” following a Partner - Engage - Plan paradigm.

42. PEP TALKS • Youth are provided with personal rules and prompted to enter a strategy for maintaining the rule.

43. PARENT WEBSITE Monitor youth’s progress and review game content • Prepare for PEP Talks • Get tips and resources •

44. STATUS

45. USABILITY TESTING • Study design: In-home testing of 2-level prototype of the SSS game and the SSS parent website with 10-dyads over a 2-week period with measures at baseline (T1) and 2-week follow- up (T2). •

46. USABILITY TESTING • Pilot testing of the SSS prototype indicated that parents and youth rated SSS as understandable (≥90%), credible (≥70%), and helpful in making healthy choices (≥80%). • Ratings indicated need for improvement in areas of ease of use (40-50%) and parental acceptability (29%). • Qualitative data supported these findings and informed design modifications to improve the parent and child experience.

47. USABILITY TESTING Youth Ratings for Prototype Levels 1 & 2

48. USABILITY TESTING Parent Ratings for Parent Website and Prototype Levels 1 & 2

49. EFFICACY TRIAL • Study design: Randomized controlled trial (RCT) with 80-dyads over a 6-month period with measures at baseline (T1) and 3- month (T2) and 6-month follow-up (T3). • Randomized into: Intervention group: tests SSS over 3-months (n=40) Control group: standard care, waitlisted (n=40) • • •

50. Methods STUDY PARTICIPANTS: ❑ Parents and their 11-14 year old ❑ English speaking ❑ Internet connectivity from home computer ❑ Parents with a cell phone with text messaging ❑ Willing to be randomized to intervention or comparison categories