The Power
of Play

In the games, players must first navigate a trajectory for their character that leads to the more problematic health outcomes. Then, the game takes them backward through moments of decision-making and explores what might’ve happened if they’d made different choices. This allows them to see many possible branching trajectories.

This approach takes the lessons embedded in the gameplay beyond simplistic messaging such as ‘just say no’ (to drugs, sex, violence, cheating on a test, or any other seriously harmful behavior), and into the realm of the less obvious behavioral choices that can nudge a person in a riskier or healthier direction.

For example, in one scenario, a character is being offered opioid pain medication for wisdom tooth extraction. The game offers the player a way to role-play a common experience for adolescents, navigating a conversation with their dentist about pain management, cluing the player into the risks of potential addiction to opioids when prescribed.

“This gives [players] an opportunity to gain accurate knowledge, as well as learning skills” for difficult conversations, Fiellin says. “How do you talk to a healthcare professional without feeling like you’re being rude? How do you develop the sense of agency that, ‘I’m allowed to ask these questions, and I’m allowed to gently and respectfully push back and say, let’s do something besides opioids?’”

Players also aren’t given just one way to say no to unhealthy choices, an acknowledgement, Fiellin says, of the complex social consequences and pressures a young person faces. For example, a player might be given the option to use humor to deflect from peer pressure, or to use a parent saying ‘no’ as an excuse so as not to risk a friendship—much like Fiellin herself remembers doing when she was a child and she didn’t want to sleep over at a friend’s house, so as not to hurt her friend’s feelings.

“None of these experiences are in a vacuum. Kids want to maintain their social circles, they want to maintain their friends,” Fiellin says. “That’s why the whole ‘just say no’ approach doesn’t work. They need to do it in such a way that they save face.”

Although the gameplay is largely geared toward learning healthy decision-making around drugs and alcohol, sexual health, mental health, and other specific healthcare topics, the games also more subtly include ways to work on social skills and critical thinking in other contexts. For example, in one game, a player engages in hurtful gossip behind a friend’s back, and experiences social consequences of a rift caused by breaking their friend’s trust.

Games That Transcend: Signs of Success

The games are not available on any app stores. Rather, they’re deployed largely by request. In most instances, they’ve been offered as part of health class curricula in schools.

Requests to use the games come from educators, youth organizations, clinicians, parents, and even kids. Modifying them for distinct cultural contexts and needs, Fiellin and her team are meeting requests for the games around the globe, including in Australia, South Africa, Vietnam, Rwanda, and more countries.  She says they’ve given out more than half a million logins since the games have been available.

“They transcend geography,” Fiellin says. “Kids everywhere love to play.”

But the games’ popularity isn’t their only measure of success. Randomized controlled trials of the games suggest that they increase players’ attitudes, beliefs, perceptions, and knowledge of a given behavioral health area. In one study, participants were tested on their beliefs and knowledge about tobacco use after playing the play2PREVENT Lab’s game smokeSCREEN. After just four hours of play over four weeks, players demonstrated a notable increase in knowledge and aversion to tobacco use. Another randomized control trial focusing on a risk reduction and HIV prevention game called PlayForward: Elm City Stories found that one year after completing an average of 10 hours of play, test subject players demonstrated a significant increase in sexual health knowledge and attitudes compared with players in a control group.

The games already launched by the play2PREVENT Lab address vaping and smoking (smokeSCREEN), opioid misuse and mental health (PlaySmart), STI/HIV testing and sexual health (PlayTest!), risk reduction and HIV prevention (PlayForward: Elm City Stories), and mental health and overall well-being (empowerED). They are all distributed by Playbl, Inc., a startup Fiellin created in response to significant demands for the games to support their marketing and distribution.

Fiellin and her Playbl team have been participating in this year’s cohort of the Dartmouth Innovations Accelerator for Digital Health (DIADH), which provides Dartmouth innovators access to support, entrepreneurial guidance, and the infrastructure and tools to shepherd their innovations in digital health into the marketplace. Playbl won the top prize in the DIADH pitch competition earlier this month, and the team was awarded $75,000 to expand marketing and distribution of the play2PREVENT Lab games.

Game development begins with Fiellin and her team gathering focus groups of teens. From those dialogues, the team gleans stories about healthy (and unhealthy) decision-making and identifies blind spots in the teenagers’ health knowledge. They use stories from the real lives of their adolescent partners to build the games, in partnership with experienced video game developer Schell Games, and incorporate feedback from the teens to make the games as relatable to the target audience as possible. They even give the focus group disposable cameras to document what they see in their daily lives. These images are used by the game developer to ensure everything in the virtual world, including neighborhoods, schools, bedroom décor, fashion, and hairdos, reflects the real-world spaces where players spend time.

Fiellin’s research has been funded in great part by the National Institutes of Health, most recently through the National Institute on Drug Abuse-funded Helping to End Addiction Long-term (HEAL) Initiative. The play2PREVENT Lab has also received funding from the Food and Drug Administration, the CVS Health Foundation, and the Best Foundation.

In her new position at Dartmouth and CTBH, Fiellin is building out her focus on mental health in youth and its interface with substance misuse, as well as translating her video games research to specific populations in other parts of the world.

“What CTBH does is exactly what I have been doing in my lab for the past 15 years,” Fiellin says. “It is a natural place for me to be and only acts to enhance all of my current and future work.”