Kimberly Hieftje, PhD, Yale University School of Medicine*
At my lab, the play4REAL Lab at the Yale Center for Health & Learning Games, we develop and evaluate videogame interventions focused on health promotion and behavior change using virtual/augmented/mixed reality technology. Most recently, we partnered with Oculus Education and PreviewLabs, Inc., to create, and then rigorously evaluate Invite Only VR, a virtual reality-based videogame focused on JUUL/e-cigarette prevention in teens. Why JUUL/e-cigarettes? Sadly, e-cigarette use in teens is increasing at an alarming rate. There has been a 78 percent increase among high school students (11.7% to 20.8%) and 48 percent increase among middle school students (3.3% to 4.9%) from 2017 to 2018.1 E-cigarettes, including the popular brand JUUL, often contain high levels of nicotine and other harmful substances. Teens who use e-cigarettes are more likely to smoke cigarettes in the future and are at an increase risk for future addiction to other drugs.2
In Invite Only VR, the player must navigate different types of peer pressure, including the pressure to vape (specifically JUUL) in various social situations such as in the school bathroom, in the back of a classroom, and at a party. As the game progresses, the player develops new powers he can use to help him successfully navigate these high-pressure situations, including the power to observe his environment, the power to apply his newly-gained knowledge about vaping in conversations with others, and the power to refuse his peers in an effective way. Invite Only VR uses voice recognition software, which allows the player to practice refusing peers in real time. The game is played on the Oculus Go and takes approximately 1.5 hours to complete. Invite Only VR was developed by teens FOR teens – teens from all over Connecticut helped us to design the game, write the narrative, and even did the voice acting.
Last summer, we conducted a feasibility study of the game with 60 teens, which resulted in some encouraging preliminary data in relation to important changes to teens’ knowledge, harm perceptions, attitudes, and intentions regarding JUUL/e-cigarettes. Perhaps most importantly, we received a small but significant glimpse into our immediate future of what a VR intervention might look like when implemented in the classroom. My review? I’m optimistic, but still cautious.
Many teachers were excited to see us come into their school with VR headsets. They were excited for the students, who were anxious to experience VR (many for the first time). We were bringing something new and innovative into schools while delivering an important and much needed intervention on JUUL/e-cigarette prevention. I felt (and still feel) optimistic about VR and its potential for impacting students’ health behaviors.
But I am still cautious. While teachers were excited about our presence, few were eager to consider incorporating the intervention (or VR in general) in their classrooms. Teachers have enough on their plate as is, so I totally understand the initial hesitancy. And while the Oculus Go is easy to set up and use, I think the idea of VR in general may be daunting for those who do not have a much, if any, experience with using it. Many teachers probably don’t have access to VR headsets in the first place.
During our pilot, we also experienced some hurdles that could easily deflate any teacher’s enthusiasm about incorporating VR in the classroom. For instance, the Oculus Go headsets didn’t stay charged as long as we’d hoped, so by the end of the second gameplay session we had almost all of the students lined up against walls plugged into outlets to keep their headsets from dying. The batteries in the controllers also gave out after only a few uses, which was another continuous hassle. Oh, and teens are still teens no matter what the situation –students without headsets on couldn’t resist the temptation to poke at or scare their classmates that were immersed in the game.
This fall, we are conducting a randomized controlled trial to test the efficacy of Invite Only VR with over 300 8th grade students in three Connecticut middle schools and will follow them for six months to see if playing our game can reduce the uptake of JUUL/e-cigarettes. This means we will be bringing our VR game into health classes that have on average about 20-30 students in each class. Given this is a research study, we will be there to help students login to the game, provide technical help, and ensure they finish playing the game. We will work alongside teachers, but our team will do the heavy lifting.
We started conversations with middle school administration and faculty last fall and didn’t come to a final plan for our partnership until this past Spring for the research study. Together, we decided that our partnership should extend beyond just testing the VR intervention itself, given all the reasons I mentioned previously. So, after we’ve collected research data from students on the efficacy of the game, we plan to stay around the rest of the year to help train teachers on how to implement VR in their classrooms once we are gone. We will be leaving each school with 30 Oculus Gos, packed with education games and ongoing tech support as needed. At the end of the school year, we will spend some time with teachers learning about their experience with VR. Did they use the headsets in their classrooms? What were the high and low points? Where did they struggle? Where did they succeed?
As I said, I’m optimistic, but cautious. Creating innovative interventions using AR/VR/XR that help teens make healthier choices around behaviors is fulfilling and exciting work. But what is the value of having these interventions if teachers or other program leaders that work with teens aren’t able to implement them? As researchers we can’t just collect our data and leave. We owe it to the schools, the teachers, and the students we work with to continue our partnership with them beyond the data collection – it’s not enough just to leave 30 VR headsets behind and hope they will be used. We have to provide the support they need, and want, if VR is ever going to make it into the classrooms in a sustaining and meaningful way.
1Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Increase in use of electronic cigarettes and any tobacco product among middle and high school students — United States, 2011–2018. MMWR Morbid Mortal Wkly Rep. 2018;67(45):1276–1277.
*About the Author
Kimberly Hieftje, PhD, is a Research Scientist at the Yale School of Medicine and the Deputy Director of the Yale Center for Health & Learning Games, which focuses on the development and evaluation of videogame interventions for health prevention and promotion, behavior change, and education in adolescents and young adults. Dr. Hieftje is also the Deputy Director of the play2PREVENT Lab and Director of the play4REAL Lab at the center, which focuses on the use of VR/AR/XR in games. She is currently involved in the development and testing of several health behavior changes videogames and has published frequently on developing, evaluating, and implementing serious games. She has worked on games that have focused on topics including JUUL/e-c-cigarette prevention, tobacco use prevention, risk reduction in adolescents, HIV/STI prevention, HIV/STI testing, empowering young women around sexual health, bystander intervention, LGBTQ bullying, school climate, and increasing math skills in first graders.
Most recently, Dr. Hieftje received a gift from Oculus to fully develop and evaluate Invite Only VR, a VR videogame intervention focused on JUUL/e-cigarette prevention in teens developed by the play4REAL Lab in partnership with PreviewLabs, Inc. Created for the Oculus Go, the game uses voice recognition software to allow players to practice refusing peers in real time. With her team at the play4REAL Lab, she will conduct a randomized controlled trial with 230 teens, following them for six months to see if playing Invite Only VR impacted their behaviors, attitudes, intentions, and social perceptions of JUUL/e-cigarettes. Additionally, the team will explore how VR can be leveraged to create the feeling of social pressure in simulated high-risk social situations involving peers.
Dr. Hieftje is also a K12 Scholar in the Yale Implementation Science program (YSIS), where she will collect and analyze qualitative and quantitative data from teachers and students on the implementation of a web-based videogame intervention focused on tobacco use prevention with the goal of better understanding the factors associated with successful implementation of videogames in schools.