Early in her career as a physician-researcher focused on improving outcomes for adults struggling with addiction and mental health issues, internist Lynn Fiellin, MD, kept hearing the same comment from her patients: “If only I knew then (as a teenager) what I know now, I’d have made different choices.”
“During that time, I also had three kids at home (between the ages of 9 and 19) and everybody was full-on engaged in video games—not only commercial games but also some great learning games,” she recalls. “I saw the power of digital games and started thinking, ‘If I could create interventions that would engage a younger population around prevention, it would be a win-win.’”
Soon after, Fiellin secured the first of many grants from the NIH and other funding organizations, allowing her to establish (in 2009) the play2PREVENT Lab—an innovative space whose expertise now spans game design, research, evaluation, and implementation to create impactful, evidence-based interventions.
Today, Fiellin, who serves as a professor with faculty appointments within the Departments of Biomedical Data Science, Medicine, and the Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, is renowned for her work in developing and testing novel video game interventions to promote health and reduce risk in youth and young adults. In the following Q & A, she talks about her research, her most recent published work, and future goals.
Q: What specific health risk areas have you developed games for?
Fiellin: To date, our team of researchers, game developers, youth, and community partners have created and evaluated five interactive evidence-based digital games addressing mental health, opioid misuse, smoking/vaping, and sexual health and HIV/STI prevention. Each has its own dedicated age group, depending on what we’re looking to accomplish and what the epidemiology is telling us.
Q: What are some of the strengths of your research program and your approach?
Fiellin: I think the youth-centeredness has been key. You know, back when we started, after about six months we realized as a group of adults that we had no idea what teenagers thought. We needed to stop and start again, involving them in the whole process. So, one huge asset is that these games are created by and with and for young people.
Another huge asset is we publish on everything we do, on the process by which we design and develop these games, and on all the outcomes. Our methods are strictly, rigorously scientific—we do randomized controlled trials, which are the gold standard of evaluation. As a result, we’ve been able to demonstrate that our interventions have a positive impact on health risk behaviors.
Also, most of our research is done in health classes in schools, which provide an environment that kids and teens are familiar and comfortable with. We bring everything to them—iPads, headphones, even snacks.
Q: Your games are very popular among kids and young adults. What elements give them lasting impact?
Fiellin: They’re designed to imitate real life, presenting the many, complex pressures young people experience. The games are story-based and employ role-playing, so players become a character and, first, must navigate a path that leads to negative health outcomes. They’re then taken backwards through moments of decision-making and explore what might have happened if they’d made different choices.
The approach takes lessons that are embedded in the games beyond simplistic messaging like “just say no,” which we now know doesn’t work, into the domain of less apparent behavioral choices that can nudge a young person in either a riskier or healthier direction.
Our game development starts with our team bringing together focus groups of teens. From those meetings, we’re able to gather stories about healthy and unhealthy decision-making and identify blind spots in the teens’ health knowledge. We use stories from the real lives of our adolescent partners to build the games, working with our experienced video game developer, Schell Games, and use feedback from the teens to make the games as relatable to our target audience as possible.
Q: Can you tell us about your most recent research paper, published in Nature Health this month?
Fiellin: As part of an NIH initiative known as HEAL (Helping to End Addiction Longterm), my lab was one of 10 projects around the country that was tasked with developing and testing an intervention around opioid misuse and mental health.
The study involved a diverse group of 532 teenagers from 15 different high schools across the state of Connecticut. To be part of the study, the teenagers had to report never having tried an opioid and to have at least low levels of mental health issues (depression or anxiety) or substance use (not opioids). Half were assigned to play our game, half to play a set of control games.
We knew from previous research that adolescents tend to have, generally speaking, low perceived risk of harm from drug use. In other words, they don’t perceive drug use, including misuse of opioids, as being dangerous, and therefore are more likely to experiment with them. Similarly, there is strong evidence that a greater perceived risk of harm from drug use translates to a lower likelihood of using drugs. Therefore, our goal was, by having them play the game, to increase their perceived risk of harm around opioids, thereby decreasing the likelihood they would misuse them.
We found that overall, our game produced significant short-term increases in perceived risk of harm from opioids (the goal of our study) and improvements in knowledge and attitudes related to opioid misuse. However, the risk perception effect diminished by three months, suggesting the potential benefit of booster interventions to sustain impact over time. We’ll be reporting on our mental health findings in an upcoming paper.
Q: Looking ahead, what are some of your goals for your research?
Fiellin: There’s a huge movement towards family mental health, so we’re expanding to include parents and families in the work we do. We’re finding that, like their kids, parents also often struggle with how to navigate different situations. And games are a great way to engage people with other people, like in their families, because they can play them together.
Recently, we started a new project working with the family foundation Proof Positive to develop a game for kids with autism. Our goal is to engage these kids and their families and other stakeholders in the design and development process, with the focus really being on increasing their happiness, well-being, and sense of agency.
And then, another project that we’re just launching is one where we’re going to be doing the formative work to develop a game that focuses on social media and kids’ experience with social media. We know that there are a lot of potential mental health harms, especially for young girls in social media environments. So, we’ll again be working with young people to develop a game in which they can learn how to negotiate and navigate these environments in healthier ways.
