ROSS SHEGOG, PHD

UNIVERSITY OF TEXAS SCHOOL OF PUBLIC HEALTH

CENTER FOR PREVENTION RESEARCH

Funded by NIH/NICHD grant R42HD074324

Research & Teaching in the Service of

Public Health …

“Headbutt”.

(PI. McAlister)

Middle school smoking prevention

“ASPIRE”

(PI. Prokhorov, Kelder)

High school smoking prevention.

“Stop Asthma.”

(PI. Abramson, Bartholomew)

Pediatrician decision support.

“Watch-Discover-Think then

Act.”

(PI. Gold, Bartholomew)

Asthma management simulation

“Peacetest.org”

(PI. McAlister)

Violence prevention on-line.

“En Vivo”

(PI. Kelder)

Web-based motivational enhancement for

reduced screen-time in Hispanic youth.

“HeadsUp Virtual Molecular Biology

Lab” (PI. Murray)

AP science virtual transgenics

Disease Management

Science Training

Disease Prevention / Health Promotion

“Booster Break” (PI. Taylor)

Work-based toning.

Epilepsy self-management Network

(PI. Begley, Shegog)

MINDSET

Epilepsy self-management DSS

(PI. Begley, Shegog)

Clinical decision support

MINDSET

“It’s Your Game - Tech”

(PI’s Peskin, Shegog)

Middle school sexual health on-line

Disease Prevention / Health Promotion

“NATIVE It’s Your Game”

(PI’s Markham, Shegog)

IYG for Am. Indians / Alaska Natives

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” website

(PI. Peskin)

Middle school HIV/pregnancy prevention

“It’s Your Game – Family”

(PI’s McLaughlan, Shegog)

IYG for parents and faimlies.

“+ CLICK” (PI. Markham)

HIV+ youth web management training

Disease Management

Research & Teaching in the Service of

Public Health …Sexual Health

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

Study Goals

ACKNOWLEDGEMENTS

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

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)

Community Collaboration:Houston Area Schools and School Districts

Parent-Youth Advisory Group

BACKGROUND

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.

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.

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.

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.

WHAT WORKS?

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.

Empirically-based principles of parental interventions:11

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.

[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.

❑ 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]

THE missing links

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

WHY games?

[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

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.

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.

STUDY DESIGN

Year 1 (Summer / Fall 2013)

Literature review and needs

assessment

Focus groups

Evaluate existing activities

Build prototype of The Secret of

Seven Stones

Usability Testing of prototype in

lab-based setting

Year 2 & 3 (2014 & 2015)

Build complete SSS game

Alpha-Test complete SSS

game in homes with 12 dyads

Randomized Control Trial

efficacy testing of SSS in

homes with 80 dyads

(ongoing)

PHASE 1: Create and Test a Prototype

PHASE 2: Create and TestComplete Program

STUDY OVERVIEW

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

Intervention Mapping

LITERATURE REVIEW: CONCEPTUAL

FRAMEWORK

QUALITATIVE NEEDS ASSESSMENT

Focus groups & semi-structured interviews with parents (n=20)

and youth (n=19).

Themes: Parents want …

to be a focal part of their child’s sexual health education

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 experienceD’Cruz et al., Games For Health, 2015.

RESULTS: Focus Groups

Qualitative Needs Assessment DataTable: Game Features Inventory

“…I think (the proposed game) opens up to more GENUINE

CONVERSATIONS and sharing…to show that it is real. It’s not just something that you

see or know on TV

-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

“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

-Female Youth

Source: D’Cruz et al., 2015

CONCEPTUAL GAME FRAMEWORK

Intervention Mapping: DYADIC PARENT-CHILD COMMUNICATION MATRIX

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.

Parent and

child will pick

the right time

and place

(T&P) to talk

1. State that the right T&P is

one where both parent and

child are focused and calm

2. Describe the influence of

emotions, preconceived

thoughts and distractions

on communication.

3. State the importance of

being aware of these

influences and setting them

aside before initiating

communication

1. Demonstrate the

ability to pick the

right time and

place to converse

2. Demonstrate the

ability to set aside

emotional or

cognitive

predispositions

before conversing

1. Demonstrate the

confidence to

pick the right time

and place to

converse

2. Demonstrate the

confidence in

ability to set aside

emotional or

cognitive

predispositions

before conversing

PROGRAM DEVELOPMENT

• Reviewed existing assets from other successful, evidence-

based programs.

ADAPTED FROM…

Theory-based, multimedia program for 7th & 8th

graders

Evaluated in two randomized controlled trials

Results showed IYG

• Delayed initiation of sex

• Increased condom use

• Increased positive beliefs about abstinence

• Increased confidence to refuse sex

• Increased intentions to abstain from sex

N a t i o n a l l y R e c o g n i z e d

E f f e c t i v e H I V / S T I a n d

P r e g n a n c y P r e v e n t i o n

P r o g r a m f o r M i d d l e

S c h o o l Yo u t h

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.

Strategies:

Information transfer Refusal Skills Training

Peer modeling Condom Skills Training

PROGRAM DEVELOPMENTLevel Content Domain Virtue

1 Communication Communication Respect

2 Character & Goals Possible Me Vision

3 Friendships Friendship

4 Select, Detect, Protect - Friendships Persistence

5 Developing Body & Reproduction My Body

6 Intentions - Sex Select, Detect, Protect Caring

7 Healthy Dating Dating

8 Healthy Dating

9 Consequences of Sex Consequences

10 Select, Detect, Protect - Sex Select, Detect, Protect Responsibility

11 HIV Consequences

12 Dating Violence Dating

13 Pregnancy Consequences

14 Sex Refusal Select, Detect, Protect

15 Intro. to Condoms Safeguards Courage

16 Condom Negotiation & Contraceptives

17 Getting Tested for HIV/STDs

18 The Future My Future Integrity

GAME DESIGN

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.

THE STORY: CHRONOTITANS

Zeroun

Respect

Iksha

Vision

Humiel

Persistence

Jampa

Caring

Netis

Responsibility

Rith

Courage

Karama

Honor

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

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

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.

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.

• Get Wisdom, Skills, and Support battle cards

• Battle to liberate the townspeople and demonstrate skills

8. User fights

Battle

THE ‘BATTLES’

… you have to start here …

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.

PEP TALKS

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

PARENT WEBSITE

• Monitor youth’s progress and

review game content

• Prepare for PEP Talks

• Get tips and resources

STATUS

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).

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.

USABILITY TESTINGYouth Ratings for Prototype Levels 1 & 2

USABILITY TESTING

Parent Ratings for Parent Website and Prototype Levels 1 & 2

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)

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

Methods

STUDY PARTICIPANTS

Youth Parents

Demographics n % n %

Youth Age (11-14) 83 12.4 (+/-1.0) -- --

11-12 years 44 53 -- --

13-14 years 39 47 -- --

Gender

Male 46 55 5 6

Female 37 45 78 94

Race / Ethnicity

Caucasian 35 42 41 49

African American 27 33 26 31

Hispanic/Latino 18 22 16 19

Asian/Pacific Islander 3 4 0 0

American Indian / Other 0 0 0 0

IMPLEMENTATION

• Intervention families provided with recommended ‘prescribed’ dose of 2 hours game play per week over 12 weeks.

• Progress through game monitored weekly.

1 P1 2 3 P2 4 5 P3 6 7 8 9 P4 10 11 12 13 14 P5 15 16 17 P6 18 P7

A24

A33

A5

A27

A7

A28

A21

A81

A22

A20

A2

A37

A34

A35

A16

A82

C08

A31

A29

A40

A19

A17

A1

A32

A88

A84

A38

A9

A12

A23

A14

A86

ID

Levels & PEP Talks

EVALUATION

• Baseline (T1) in completion; 3-month follow-up (T2) data collection in progress.

Constructs Variables

Parent-child

communication

Frequency and content of parent-child communication about sex

Self-efficacy and outcome expectancy toward communication about sex

Parent-child connectedness, communication, communication ability and openness

Parental involvement, oversight, and monitoring

Sexual initiation Youth beliefs and intentions toward sex

Youth perceived friends’ and parents’ beliefs about sex

Youth self-efficacy to refuse sex and/or use condoms

Usability SSS likeability, ease of use, credibility, perceived impact, motivational appeal, and suggestions

for improvement.

Gaming for education.

YOUTH FEEDBACK

“I understand [puberty] better and know what to expect… it taught me how to say no [to sex] if I don’t want to do it.”

- Female, 12yo, Caucasian, 18 levels

“I did like some of the animation. The videos were long and sometimes I got bored. It made it hard to finish [the game] in time.”

- Female, 13 yo, Hispanic, 18 levels“The battles were fun. It was

something to look forward to.”- Male, 13yo, Hispanic,14 levels

PARENT FEEDBACK

“I’ve always [said] you need to wait [to date] and I don’t think she really understood why. It helped her [know] this is what I can expect in my life from my mom and this is what I should do to stay out of this bad situation.”

- Mother, 45yo, Caucasian,18 levels

“He complained… the graphics were elementary, but as he kept playing the game… it sparked better conversation. It makes you communicate.”

- Mother, 45yo, African American,3 levels

“[SSS] has opened a lot of doors and I’m hoping they will stay open... It’s given us a point to engage.”- Father, 48yo, Caucasian,18 levels

ADJUNCT IMPACT: DYAD A37 … THE 40

YEAR OLD VIRGIN

“It hasn’t opened the door [for conversations] any wider, for me

anyways. I’m kind of blunt. I tell it like it is. But for him, it has. So our

conversations [about sex] have gotten a little more [open]. He’s

more willing to talk. Before he wouldn’t say anything about it. ”

- Mother, 42yo, Hispanic, 14 levels

• SSS made a son (13yo)

more willing and open to

talk about sexual health

with his Mom.

ADJUNCT IMPACT: DYAD A5… SPARKED

CONVERSE, THE GRAY OF ‘TOXIC’ FRIENDS,

“It’s his personality. There’s not a lot of gray in the way he views the

world. They’re a friend or not. They’re trustworthy or not. But he got a

view into what other kids are going through which gave him a point of

empathy that he might not have had otherwise. Having the discussion put

him in a position to understand some of his friends that are dealing with

these difficulties.”

- Father, 48yo, Caucasian, 18 levels

• The PEP Talks in SSS

opened the door for new

discussions and allowed

father to connect with

son (14yo) with Autism

Spectrum Disorder.

ADJUNCT IMPACT: DYAD A24 … RELIEF

OF SELF-BLAME

• SSS helped a daughter

(12yo) come to terms with

parents divorce and her

insecurities about lack of

relationship with her father.

“Here’s an important point that I think you need to know about

the game … [SSS] talked about how to recognize bad

characteristics… and she saw that in her Dad. She was very upset

when she realized and put those two things together but I think it

gave her a sense of what really happened between me and her

Dad. She’s always felt bad about their relationship and I think she

blamed herself so I think the game gave her that extra lesson that

was not anticipated.”

- Mother, 45yo, Caucasian, 18 levels

CONCLUSIONS

The Secret of Seven Stones (SSS) is designed to be an intergenerational (dyadic) adventuregame to encourage parent-child communication that goes beyond “the sex talk” to impact healthy and responsible decisions about friendships, dating, and sex.

• SSS is a feasible delivery channel.

• Play progress is highly variable.

• Initial youth reactions to the game appear mixed.

• Initial parent reactions appear positive.

• Adjunct impact appears positive though main effects need to be formally determined.

IMPLICATIONS

This work will inform developers and researchers on the development, implementation, and evaluation of an innovative intergenerational computer game to impart life skills education and enhance parent-youth communication.

QUESTIONS?

Ross.Shegog@uth.tmc.edu