Developing a Serious Videogame for Preteens to Motivate HPV Vaccination Decision Making

"Offering information and cues to action through a serious videogame for preteens may foster HPV vaccination awareness, information seeking, and communication."

Vaccination against human papillomavirus (HPV) is routinely recommended for ages 11-12, yet in 2016 only 49.5% of women and 37.5% of men had completed the 3-dose series in the United States (US). A group of researchers created a "serious game" whose goal is to increase HPV vaccination knowledge, promote communication with parents and providers, and influence a decision toward initiating the vaccine. The purpose of this article is to report on the input the researchers received from preteens and parents that helped contribute to the initial development of this video game.

The video game is part of a larger intervention, Protect Them, which uses communication tools to normalise discussion about sexually transmitted infections (STIs), cancer, and the benefits of preteen HPV vaccination. Practices and providers receive posters and brochures and online interactive training, parents receive reminder texts for HPV vaccine appointments and web-based information about HPV, and preteens play a web-based video game, Land of Secret Gardens (LOSG), which is designed to increase their self-efficacy to participate in the decision-making process.

Rather than didactic presentations, serious video games promote "situated learning", where players can learn through exploration and experimentation. An immersive story is often used to enhance motivation to play the game and to allow for deeper information processing. These games often incorporate behavioural theory; in the case of LOSG, the design was informed by the Self-Determination Theory (SDT), which holds that intrinsic motivation for health behaviour change is enhanced when a game is entertaining and engaging. In addition, the development of game messages was informed by the Health Belief Model (HBM), which considers perceptions of susceptibility to HPV infection, severity of HPV-related disease, benefits of vaccination to prevent HPV infection, and possible barriers, including questions of safety, duration, and cost. The researchers also used gain framing over loss framing (you can grow up healthy vs. you can get diseases).

The intention of LOSG was to foster: (i) in-game autonomy by posing creative choices in planting a thriving garden, (ii) in-game competence by challenging the preteen to master the path to planting a healthy garden shielded from disease by a potion (vaccine), (iii) narrative presence through an engaging story line of nurturing seedlings when they are young, and (iv) motivation to learn about HPV disease and prevention. The design includes gamification features with rewards and levels, and it excludes elements of competition and peer pressure. Players learn facts about HPV and the benefits of vaccination via messages that briefly flash on screen without interrupting play. "The key element is fostering preteen self-efficacy so that the preteen feels empowered to question an adult (parent or provider) about a sensitive sexual health subject (STI and vaccine)."

The researchers used an iterative process to develop the video game. They worked in partnership with professional game developers over a 7-month period, they employed a user-centred approach by recruiting dyads of preteens and parents to provide feedback on game development, and they conducted focus groups with both preteens and their parents (in parallel) to understand perceptions and motivations for a proposed HPV vaccination game. The focus groups revealed that:

• Both preteens and their parents shared the desire to know about HPV transmission, how to avoid the virus, and whether HPV vaccination was safe. Parents wanted to have a trustworthy source for preteens to consult, and they were acutely aware that sources other than parents themselves were often helpful.
• Preteens wanted to be able to protect themselves against the virus. Parents were mostly favourable about HPV vaccination but acknowledged that some parents were hesitant.
• Preteens recognised their risk of getting HPV and also admitted their dislike of shots. Parents tended to accept preteen HPV vaccination but also wondered whether additional infectious diseases would require vaccination in the future.
• Preteens said they would play the game with parents but not with friends because of the sensitive STI topic. Parents seemed eager to have their children learn the facts, noting that "with age comes more responsibility of individual decision making".
• Preteens preferred a videogame that was both entertaining and instructional, that provided an opportunity to earn tokens, and that offered advancing levels. Some parents expressed hesitancy around games as motivational tools.

The qualitative data collection allowed the researchers to refine their approaches before developing the software for the game.

LOSG went on to be evaluated in a research study funded by the National Institutes of Health to determine whether it is effective in stimulating preteen/parent/provider conversations and decision making about HPV vaccination.