Barriers to Effective Infection Prevention in the Neonatal Intensive Care Unit: A Qualitative Study.

BACKGROUND: Infection prevention (IP) behaviors such as hand hygiene (HH) and mobile device disinfection are important to reduce the risk of infection transmission from both family members and hospital staff to critically ill neonates. PURPOSE: To inform the design of educational interventions to improve both patient family and staff IP behaviors, we engaged separate groups of nurses and family members to understand perceptions about the spread of infection and barriers to implementing effective IP strategies. METHODS: This was a qualitative study using focus groups to gather data from neonatal nurses and patient family members. Data were triangulated with hospital-wide survey data and analyzed using inductive content analysis. RESULTS: Twelve nurses and 4 patient family members participated. Themes related to communication about IP between staff and family members emerged: stakeholders expressed discomfort with the timing and nature of just-in-time HH education. These communication challenges contributed to stress levels within the neonatal intensive care unit. This finding was reflected in the hospital-wide survey. IMPLICATIONS FOR PRACTICE AND RESEARCH: Steps should be taken to improve communication about IP behaviors between patient family members and frontline staff. Reducing nurse burden of providing just-in-time HH reminders to patient family members through increased IP education may decrease stress and facilitate IP behaviors. This has the potential to decrease infection spread and improve patient outcomes. The development of interventions targeting stakeholder communication is therefore warranted, but additional research is needed to understand the timing and process for delivery of the educational material.

Perspectives of Adolescents and Young Adults With Sickle Cell Disease and Clinicians on Improving Transition Readiness With a Video Game Intervention.

We aimed to learn the experiences of clinicians and adolescents and young adults with sickle cell disease (AYA-SCD) with managing their disease at home and making medical decisions as they transition from pediatric to adult care, and their perceptions of a video game intervention to positively impact these skills. We conducted individual, semistructured interviews with patients (AYA-SCD ages 15 to 26 years) and clinicians who provide care to AYA-SCD at an urban, quaternary-care hospital. Interviews elicited patients' and clinicians' experiences with AYA-SCD, barriers and facilitators to successful home management, and their perspectives on shared decision-making and a video game intervention. To identify themes, we conducted an inductive analysis until data saturation was reached. Participants (16 patients and 21 clinicians) identified 4 main themes: (1) self-efficacy as a critical skill for a successful transition from pediatric to adult care, (2) the importance of patient engagement in making medical decisions, (3) multilevel determinants of optimal self-efficacy and patient engagement, and (4) support for a video game intervention which, by targeting potential determinants of AYA-SCD achieving optimal self-efficacy and engagement in decision-making, may improve these important skills.

Black Adolescent Females' Perceptions of PrEP for HIV Risk Reduction.

Preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention is approved for use in adolescents, though uptake remains low. Black adolescent females experience higher rates of HIV transmission compared to adolescent females of other racial/ethnic groups. Increasing PrEP awareness and education among this population may be an effective strategy to mitigate disparities in HIV transmission among Black adolescent females. Twenty-seven Black adolescent females participated in focus groups which were coded using the constant comparative method of qualitative analysis to identify major themes: (1) PrEP is not commonly framed as an HIV prevention strategy for heterosexual Black adolescent females, (2) PrEP use among peers is perceived as mostly positive, (3) Adoption of PrEP among Black adolescent females is impeded by perceived barriers such as stigma, negative side effects, and adherence concerns. These findings may inform the development of targeted culturally tailored marketing and educational campaigns centered on Black heterosexual adolescent females to increase PrEP awareness and uptake in this population disproportionately affected by HIV.

A Pilot Randomized Controlled Trial to Evaluate a Cognitive Behavioral Videogame Intervention: empowerED.

Objective: To design a cognitive behavioral videogame intervention and to evaluate its preliminary effect on improving youth's perceptions about themselves, their future, and their ability by incorporating skill development in cognitive reappraisal, an emotion regulation strategy to change perceptions. Materials and Methods: We conducted a pilot RCT to evaluate the preliminary efficacy of a videogame intervention, empowerED, in enhancing cognitive reappraisal skills. We also assessed beliefs/attitudes, self-efficacy, and emotional self-efficacy as well as user experience and feasibility. Youth (N = 100) aged 14-19 years from one school were enrolled in a pilot RCT assigned either to play empowerED or a control condition. Results: Improvements were noted in cognitive reappraisal in the empowerED group compared to the control group (LSM difference = 1.33, P = 0.01). There were no significant differences observed between treatment groups for beliefs/attitudes, self-efficacy, and emotional self-efficacy; however, the empowerED group reported improvements in beliefs/attitudes from pretest to posttest survey responses (M = 1.33, P = 0.01). Conclusion: Overall, the intervention was deemed easy to use and beneficial among youth, and feasibly delivered in a high school setting. Given the growing youth mental health needs in schools and the importance of school climate on healthy development, empowerED may offer an effective and innovative student-level approach to improve cognitive reappraisal and later empower youth to enact change in their school climate. Clinical Trials.gov Identifier: NCT04025294.

How Black Teen Girls Navigate Social Media to Form Romantic Relationships.

The purpose of this study was to explore the use of social media within the context of heterosexual Black teen girls' romantic partner selection processes. To better understand Black teen girls' experiences, five focus groups (N = 27; aged 14-18 years) were conducted over Zoom. An inductive thematic analysis revealed four major themes: (1) the use of different platforms to gather different types of information, (2) the rules of social media scouting, (3) detecting partner qualities through social media, and (4) exploring Black teen girls' experience with social media and dating. Participants in our study primarily used Instagram to understand a potential partner's true self, while Twitter was used to assess a potential partner's political leanings. Our participants shared numerous "rules" related to the partner-scouting process. Black teen girls in our study explained that photos index a potential partner's style and hygiene, while memes were used to gauge sense of humor compatibility. More specific to Black teen girls, across all focus groups, participants shared their experiences of racism and bias, such as being associated with Black stereotypes, cultural invalidation, and being accused of "acting White." Although teen girls of various racial and ethnic groups may use social media to vet romantic partners, findings reveal that Black teen girls navigate social media in a unique way, including being highly attuned to signs of bias. Our findings suggest that in the first few months of COVID-19 social distancing had little impact on our participant's practice of using social media to vet potential romantic partners.

Evaluation of a virtual reality E-cigarette prevention game for adolescents.

OBJECTIVE: To test preliminary efficacy and acceptability of Invite Only VR: A Vaping Prevention Game (Invite Only VR), an electronic cigarette (e-cigarette) prevention game that uses virtual reality (VR) hardware. METHODS: 285 adolescents (146 boys; ages 11-14; M = 12.45 years; SD = 0.57) were enrolled in this non-equivalent control groups design through their middle school. Participants who played Invite Only VR for 1.5 h were compared to treatment as usual at 4 timepoints: baseline, post gameplay, 3 and 6 months. Evidence of the efficacy of the game to influence e-cigarette use, e-cigarette knowledge, nicotine addiction knowledge, perceived addictiveness of e-cigarettes, perceived likelihood of using e-cigarettes, perceptions of harm, self-efficacy to refuse, social approval of e-cigarettes, and e-cigarette social perceptions was assessed using mixed between-within subjects ANOVAS. Intervention acceptability was indicated by measures of gameplay experience/satisfaction, VR experience, and perceived responsibility for game-based decisions. RESULTS: From baseline to 6 months, Invite Only VR players improved in e-cigarette knowledge, nicotine addiction knowledge, perceived addictiveness of e-cigarettes, perceptions of harm, and social perceptions about e-cigarette use compared to the control group. No significant changes were observed for the other dependent variables, including e-cigarette use. Ratings of gameplay experience and satisfaction, VR experience, and game-based decisions were high. CONCLUSIONS: Invite Only VR may help players develop knowledge about e-cigarettes and nicotine addiction, as well as encourage the development of healthy harm and social perceptions regarding e-cigarette use that persist 6 months beyond gameplay. Adolescents' satisfaction with the VR gameplay indicates preliminary intervention acceptability.

Effectiveness of a web-based tobacco product use prevention videogame intervention on young adolescents' beliefs and knowledge.

BACKGROUND: Preventing tobacco product initiation in youth is a critical need. While cigarette smoking among youth has been on the decline, tobacco use in other forms, such as e-cigarettes and vaping, continue to be a major concern. The purpose of this study was to conduct a real-world, quasi-experimental test of the effectiveness of a web-based videogame, smokeSCREEN, aimed at developing healthy beliefs and knowledge associated with tobacco product use prevention, including electronic cigarettes. Methods: Adolescents (N = 560) aged 10-16 years were enrolled from schools and afterschool programs in a single-group pre-post study. Measures included a pre- and post-survey of beliefs and knowledge about tobacco product use. At post-survey, participants were asked questions regarding their gameplay experience. Paired responses for the tobacco product use in the beliefs and knowledge survey before and after the smokeSCREEN videogame intervention were compared using McNemar's test. Descriptive statistics were generated to assess overall participant gameplay experience. Results: McNemar's test showed significant differences in the proportions of correct answers before (pre-survey) and after (post-survey) the intervention in seven out of eight belief questions (p < . 0001). It also suggested significant differences in the proportions of correct answers before (pre-survey) and after (post-survey) the intervention in all six knowledge questions (p < . 0001). Several gender and age differences were noted for belief and knowledge questions related to e-cigarettes and vaping. There was no association between gameplay duration at post-survey or to the answers of the beliefs or knowledge questions. Overall, participants reported that they enjoyed playing the game. Conclusions: Findings suggest that the videogame intervention, smokeSCREEN, has a promising effect on participants' beliefs and knowledge about tobacco product use, including electronic cigarettes and vaping, and is well accepted by adolescents.

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.

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.

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).

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.

Game playbooks: tools to guide multidisciplinary teams in developing videogame-based behavior change interventions.

As mobile technologies and videogaming platforms are becoming increasingly prevalent in the realm of health and healthcare, so are the opportunities to use these resources to conduct behavioral interventions. The creation and empirical testing of game style interventions, however, is challenged by the requisite collaboration of multidisciplinary teams, including researchers and game developers who have different cultures, terminologies, and standards of evidence. Thus, traditional intervention development tools such as logic models and intervention manuals may need to be augmented by creating what we have termed "Game Playbooks" which are intervention guidebooks that are created by, understood by, and acceptable to all members of the multidisciplinary game development team. The purpose of this paper is to describe the importance and content of a Game Playbook created to aide in the development of a videogame intervention designed specifically for health behavior change in young teens as well as the process for creating such a tool. We draw on the experience of our research and game design team to describe the critical components of the Game Playbook and the necessity of creating such a tool.

The use of message framing to promote sexual risk reduction in young adolescents: a pilot exploratory study.

Few studies have explored the application of message framing to promote health behaviors in adolescents. In this exploratory study, we examined young adolescents' selection of gain- versus loss-framed images and messages when designing an HIV-prevention intervention to promote delayed sexual initiation. Twenty-six adolescents (aged 10-14 years) participated in six focus groups and created and discussed posters to persuade their peers to delay the initiation of sexual activity. Focus groups were audio-recorded and transcribed. A five-person multidisciplinary team analyzed the posters and focus group transcripts using thematic analysis. The majority of the posters (18/26, 69%) contained both gain- and loss-framed content. Of the 93/170 (56%) images and messages with framing, similar proportions were gain- (48/93, 52%) and loss-framed (45/93, 48%). Most gain-framed content (23/48, 48%) focused on academic achievement, whereas loss-framed content focused on pregnancy (20/45, 44%) and HIV/AIDS (14/45, 31%). These preliminary data suggest that young adolescents may prefer a combination of gain- and loss-framing in health materials to promote reduction in sexual risk behaviors.