The Game of Scienceand

the Science of a Game

The Development of an HIV Prevention Video Game

Lynn E. Fiellin, M.D.

Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development grant: R01HD062080

The ProblemNo change in HIV incidence = 48,100

new cases in 2009

Those most affected:–Younger age groups = 39% between

ages 13-29 years –Ethnic minorities = 115 cases/100,000

blacks/Hispanics vs. 15 cases/100,000 whites

–Sexual risk = 85% due to sex

An Opportunity

Early teen years are a window of opportunity to intervene on sexual risk:

48% of high school students reported sex

ONLY 7% before age 13 (Youth Risk Behavior Survey 2007)

An Interactive Video Game

For HIV Prevention in At-Risk Adolescents

Part I Overview I nformation

Department of Health and Human Services

Participating Organizations

National Institutes of Health (NIH), (http://www.nih.gov)

Components of Participating Organizations

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD),

(http://www.nichd.nih.gov)

Title: Using Proven Factors in Risk Prevention to Promote Protection from HIV Transmission (R01)

Request for Applications (RFA) Number: RFA-HD-08-010

Why a Video Game?

• 15 million play interactive video games – 63% of 11-14 year-olds play on a given day

• Extends across racial and economic lines– 60% of Blacks, 55% of Hispanics, 61% of Whites– 58% with household incomes < $35,000

• Video game play has been found to affect change in health behaviors– Asthma– Diabetes– Eating habits/obesity– Physical activity– Smoking prevention

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

The Team• Collaborators:

– Scientists:• HIV risk behaviors (sex and drug-related)

– Lynn Sullivan, M.D.– David Fiellin, M.D.– Jen Edelman, M.D.

• Child development– Linda Mayes, M.D.– Marjorie Rosenthal, M.D.– Deepa Camenga, M.D.– Brian Forsyth, M.D.– Gail Slap, M.D.

• Health behavior change– Kimberly Hieftje, Ph.D.– M. Zachary Rosenthal, Ph.D.– Carl Lejuez, Ph.D.– Lindsay Duncan, Ph.D.

• Prospect theory/message framing– Peter Salovey, Ph.D.

– Game Developers:• Ben Sawyer—Digitalmill • Noah Falstein—The Inspiracy• Robin Hunicke--Thatgamecompany• Alex Seropian—Disney Interactive Studios• Schell Games

– Community Programs:• Elizabeth Gambardella—Farnam Neighborhood House

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

Theoretical Constructs

• Proven factors in behavior change/risk reduction:– Social learning theory/self-efficacy– Social competency– Prospect theory– Delay discounting– Message framing

13

Know Power

Refuse Power

People Sense

Social Context/

Situations

Others’ Behavior

& Approval

Social Bonding/ Attachment

Family School Neighborhood Peers

Others’ Expectations

Desire to Please

Social Normative

Beliefs

INTENTIONS/DECISIONS

BEHAVIORExperiences from

Behavior

Epilogue Collages

Socio-Cultural

Environment

Information Environment

General Values

Expected

Consequences

Evaluation of Outcomes

Mass Media Regulations Religion Economy

Attitudes Toward the Behavior

IntraPersonal (Individual)

Social Competence

Sense of Self

Social

Skills

Self- Determination

Self-Efficacy

Genetics Biology Personality

My Future is My Life Components and Minigames

Priority Sense

Future Sense

Trouble Sense

Aspirational Avatar

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

Creating a Design Document: The “Game”

• “Aspirational Avatar”– Goals and values

• Mini-games tied together– Pre-visualization – Sexual health education– HIV education– Refusal, persuasion (negotiation) skills– Handling negative situations– “Reading” individuals, reading groups– Delay discounting – Risk literacy– Prospect theory/ message framing

Aspirational Avatar• Move beyond physical representation of

players in a virtual environment• Expand to include aspirations,

goals, dreams • Future orientation & decisions

Initial Visualization

The Game

• A 2D "RPG" (role-playing game)-style game:– How the choices one makes in life impact both short-

term and long-term life goals– Target audience = inner-city youth ages 11 to 14

years– The goal = to improve youth’s understanding of risk

and risky behaviors associated with the acquisition of HIV 

– Player’s engagement in game play will provide opportunities to practice skills:• Navigating situations and negotiating decision-making to

avoid risk

How to Play the Game

• The player plays as their Aspirational Avatar

• Multiple “trips” through their life with different “choices”– Iteratively experiencing impact of choices on

their life plan• 8-12 45 minute sessions• Data captured through game play and by

standardized instruments during trial and at 12 and 24 months

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

Content Development

• Working with community program with at-risk youth:– Interviews and focus groups:

• Purposeful sample of African-American and Latino young adolescents

• Participating in an after-school or summer enrichment program

• 21 boys and 20 girls, ages 10-15 years

Established in 1943

Fair Haven section of New Haven

Serves inner-city at-risk population

Provides after-school and weekend programs

Over 900 youth ages 6 -18 years

In-depth Individual Interviews

– Audiotaped– 15 final interviews

• Domains:– Extracurricular activities– Video game play– Life plan– Risk-taking– Decision-making– Peer influences– Future orientation– Demographics

In-depth Individual Interviews

– Interviews professionally transcribed

– Text reviewed by 3 reviewers for themes in an iterative fashion

– Results informed focus groups

– Coded transcripts to be entered into Atlas Ti:• Qualitative data analysis software• Output is a comprehensive identification of key themes

Focus Groups

• Onsite at Farnam Neighborhood House• Used themes elicited from interviews• 6 focus groups: 3 boys-only, 3 girls-only• Audiotaped• Professionally transcribed• 5 reviewers coded transcripts• A grounded theory approach

Focus Group Themes• Video Game Play

– Reality– Alternate reality/fantasy

• Success– Self– Others– Environment

• Party Scene– Risk-taking– Future orientation– Consequences

• Message framing– Positive– Negative– Combined

Results• Main themes from individual interviews:

– Avatar• Often represents “ideal self”• Protective • Ownership in decisions, choices

– Game play• Kids know what they like• Not educational; not too hard, not too easy• Be able to control character’s choices and actions• Develop mastery (self-efficacy)• Able to translate to both real life and alternate life

Results• Main themes from focus groups:

– 1) Boys and girls both described pregnancy and its associated impact as the major consequence of sexual risk-taking behavior with very limited discussion of sexually transmitted infections, including HIV

– 2) Risk-taking behaviors described by both boys and girls included sexual violence, gun violence and bullying

– 3) Factors associated with avoiding high-risk behaviors included internal strength, a connection with a mentor figure, and a supportive, safe environment

– 4) Both boys and girls preferred sexual risk reduction and HIV prevention messages that included positive and negative message framing.

Content Development <- -> Game Development

Content Development (qualitative data)

Game Development

Avatar has ownership in choices/decisions

Embody these features in the “Aspirational Avatar”

Videogame play based in both a reality and an alternate reality world

Integrate both reality- and fantasy-based play

Focus on pregnancy vs. STI/HIV Connect risk for pregnancy with risk for HIV

Importance of internal strength Creation of “Refuse” power, “Know” power, “People” sense

Importance of mentor figure Mentor/guide in the game

Influence of combined positive and negative framing

Choices in the game should be posed with combined framing

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

Hiring a Studio• Request for Information (RFI) from 10

studios• Narrowed to 5 studios to send Request for

Proposal (RFP)• Created a 30-page design document to

send to studios with RFP• 3 studios responded• 2 proposals—reviewed by commercial

game consultants• Awarded project to Schell Games of

Pittsburgh

Schell GamesFounder Jesse Schell: Assistant Professor at Carnegie Mellon’s Entertainment Technology Center

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

Contracts and Negotiations

• Interface with the Office of Cooperative Research (OCR)

• Secured a patent on concept of the “Aspirational Avatar”

• Work with Grants & Contracts to draft additional language addressing intellectual property

• Met with Yale’s Office of General Counsel • Met with Schell Games

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

People

Places

Stories

Project PhasesForming a team/forging collaborations

Content Development:

• Individual interviews

• Focus groups

Game Development:• Identification and

integration of established theoretical constructs

• Creating a design document/How to play the game

• Hiring a video game studio

• Contracts/Negotiations

Pre-Production

Randomized Clinical Trial

Study Design• Randomized Clinical Trial: HIV Prevention Video

Game vs. commercial video game – 2 sessions/week of assigned game for 4 weeks– 2 booster sessions at 6 months– Educational materials

• Subjects– 330 minority adolescents

• Ages 11-14 years• Attend after-school or other youth program

• Outcomes:– Primary: delay initiation of sexual activity – Secondary:

• HIV risk behavior knowledge• Prevention of drug/alcohol use

– Improved self-efficacy and social competency

Conclusions

• HIV incidence is unacceptably high, especially among young minorities

• Young teens offer a window of opportunity

to intervene on sexual risk

• Video game play offers a unique vehicle as an intervention

Conclusions• The development process involves:

– Multi-faceted approach with multi-disciplinary teams– Incorporating qualitative data into development of an

intervention– Parallel and intersecting efforts in game development

and content development• Success requires coordination between science,

community, technology, and law• Development of a video game for HIV

prevention:– If effective, will serve as a model for other technology-

based interventions targeting prevention and health promotion

– Can translate to mobile technologies such as smart phones for broader dissemination (including international)

Acknowledgements

Science Side:• Kimberly Hieftje, PhD• E. Jennifer Edelman, MD• Deepa Camenga, MD• Marjorie Rosenthal, MD• Linda Mayes, MD• David Fiellin, MD• Peter Salovey, PhD• Brian Forsyth, MD• Lindsay Duncan, PhD• Gail Slap, MD• Maria Mezes

Game Side:• Ben Sawyer

• Noah Falstein

• Alex Seropian

Legal/Contracts Side:• Kimberly Muller

• Lauren Pite

The Community Side:

Elizabeth Gambardella

Thank You!