The document outlines various public health research and interventions aimed at improving adolescent sexual health and parental communication through technology and serious games. It emphasizes the importance of involving parents in sexual health education and developing a home-based game that enhances parent-youth interactions while addressing sexual health topics. The study aims to test a game called 'Secret of Seven Stones' to educate youth aged 11-14 and support parents in facilitating discussions around sexual health.

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 …
“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

3. “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

4. 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

5. 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

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?
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.

12. [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
❑ 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

13.  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

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.  Year 1 (Summer / Fall 2013)
 Literature review and needs
assessment
 Focus groups
 Evaluate existing activities
 Build prototype of The Secret of
Seven Stones
 UsabilityTesting 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 ControlTrial
efficacy testing of SSS in
homes with 80 dyads
(ongoing)
PHASE 1: Create andTest a
Prototype
PHASE 2: Create andTest
Complete Program
STUDY OVERVIEW

18. 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

19. LITERATURE REVIEW: CONCEPTUAL
FRAMEWORK

20. 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 experience
D’Cruz et al., Games For Health, 2015.

21. RESULTS: Focus Groups
Qualitative Needs Assessment Data
Table: 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

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

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.
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

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
• 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 ve H I V / S T I a n d
P r e g n a n c y P r eve n t i o n
P ro 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.

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

28. PROGRAM DEVELOPMENT
Level 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

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
Jampa
Caring
Netis
Responsibility
Rith
Courage
Karama
Honor

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. SKILLSTRAINING
• Train up in the Dojo to learn and build skills
• Take a Challenge to test knowledge, skills, and wisdom
6. User takes

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

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. 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

51. 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

52. 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

53. 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.

54. 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

55. 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

56. ADJUNCT IMPACT: DYAD A37 … THE 40
YEAR OLDVIRGIN
“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.

57. 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.

58. 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

59. CONCLUSIONS
The Secret of Seven Stones (SSS) is designed to be an intergenerational (dyadic) adventure
game 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.

60. 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.

61. QUESTIONS?
Ross.Shegog@uth.tmc.edu