mHealth video gaming for human papillomavirus vaccination among college men—qualitative inquiry for development

Introduction

Over the past few decades there have been promising progress concerning human papillomavirus (HPV) vaccination (1,2). While recent emphasis has primarily focused on vaccinating adolescents prior to sexual activity onset, previous vaccination recommendations varied. There were distinct differences concerning vaccination uptake for men and women and priority groups were also segmented by age. When HPV vaccination recommendations were first adopted in 2009, priority groups identified only included women aged 15 to 26, men up to 21 years, and men ages 22–26 if they identify as a man who has sex with men (MSM) (3). Since then vaccination recommendations have been expanded for all persons through age 26 years old with 2- or 3-dose series dosing depending on age at initial vaccination or condition (4). Therefore, college-age males have been constituted as a catch-up vaccination group (5).

To remedy the low uptake of HPV vaccination among males, several studies have been conducted. They have explored college male knowledge and perceived risk (6), vaccine patterns and perceptions (7), challenges (8) vaccine intentions and behaviors (9) stigma (10) and even racial and ethnic differences (11). Even more recently, research has also been extended towards understanding influencers towards HPV vaccine uptake (12), use of health behavior theory towards intervention development (8,13-16) and the use of some technological advances to improve vaccination rates such as electronic medical record alerts, social media messaging, web-based interventions and mHealth based vaccine reminders (17-19). However, many of the communication technology-based approaches have and continue to focus on females and adolescents (20) indicating a need for more efforts focused on college age men.

Within the public health realm, opportunities to utilize information communication technologies (ICTs) like digital gaming as a behavior change tool are evident. Digital gaming as a public health intervention shows great promise due to the increased gaming behaviors of young adults (women and men). Generally speaking, research indicates that males prefer racing, sports, fighting, survival, action, and collection games whereas females prefer life simulation, dancing, singing, sports, puzzle/strategy and racing games to name a few (21). However, the genre of games played can evolve as age differences emerge (22). Gaming has been used in other public health interventions, focusing on topics such as physical activity/exercise, diabetes prevention and management, smoking prevention, anxiety/depression and broadly sexual health (23-25). While there have been some game-based interventions developed in the area of vaccinations (26). very few games have explored digital gaming specifically for HPV vaccination (27-29). Of the HPV games developed, one focuses on adolescents as a target population group, and the other explores implications of modifying an existing vaccination game to test the effects of avatar customization on HPV vaccine outcomes (29,30). Among the two that were developed and tested in the Unites States, none focused on tailoring video games for college men.

College-age men play video games at significant levels. Not only do they engage in game play but receive feedback through mechanics such as health messages (31). College age men are a population demographic that historically have been gamers. Because of this coupled with game play behaviors, men immerse themselves and take on the attributes of the characters they play. This can impact not only their gaming behaviors but real-world behaviors as well. They see the video game as a form of entertainment and fun, but also as an environment to socially interact with others as well as experience things within the video game that they may never be confident to engage in real life. Video games are a form of education entertainment, influencing health knowledge, attitudes and behaviors while also serving as a form of entertainment. Because they do not detract from the enjoyment of using this health education channel, they are the optimal platform for an HPV intervention or program (32).

There are many benefits of using gaming-based interventions for college age men. According to psychology research, gaming among men promotes cognitive skill development, faster and more accurate attention allocation, enhanced mental rotation abilities, problem solving and neural processing (33). Engaging in game play also encourages intrinsic motivations and therefore real-world motivations and behavior change (34). Therefore, when designing a vaccination-based game specific gaming mechanics should be taken into consideration. Current research identifies role playing, rewards and simulations as common mechanics that contribute to favorable study outcomes. In a recent systematic review, it was identified that in all of the vaccination-based video games studies published between 2013 and 2019, role play and rewards was an evident characteristic among all. Four (n=4) of the seven (n=7) studies indicated that favorable outcomes such as positive attitude and intention to get vaccinated increased and three (n=3) studies reported increased knowledge and literacy (24).

Digital gaming technology as an HPV vaccination programmatic tool can be influential among college age men. Furthermore, we believe that the formative data collected can be guiding tool towards app development for uptake. Therefore, the research questions that guided this exploratory qualitative study included:

• “How should a digital game be designed for male college students on HPV and the HPV vaccine?”
• “How should a digital game be implemented for male college students on HPV and the HPV vaccine?”
• “How should a digital game be evaluated for male college students on HPV and the HPV vaccine?”

We present the following article in accordance with the Standards for Reporting Qualitative Research (SRQR) reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-21-29/rc).

Methods

Focus group interviews were conducted with a convenience sample of college-age men at one large research-intensive university in the south. To be included in the study, individuals had to meet the following inclusion criteria: cisgender male, between the ages of 18–26 years old, full time students and non-recipients of the HPV vaccine. Additionally, because previous vaccination recommendations extend for males up until the age of 26 if they have a compromised immune system or identify as MSM, the inclusion criteria were set to obtain data from college males up to the age of 26. Recruitment was conducted via informational study fliers throughout the campus and blasts on departmental email list-serves. All departmental list serve administrators throughout the University were contacted and agreed to distribute study information. The study flier included information relevant to the inclusion criteria, compensation information, days, dates and times focus group sessions would be held, as well as contact information for the Principal Investigator so that they could reserve their spot and confirm participation.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Approval for this study was granted through the University of Florida Institutional Review Board 2 (No. 2015-U-1488). All students completed an informed consent prior to participating in a focus group session. Focus group participation was voluntary and participants received compensation for participating. Because researchers were more interested in gaming behavior insights, a demographic survey was not used to collect demographic data on focus group participants. Focus groups were conducted by asking open-ended qualitative questions by trained research team members. Questions were developed to college information on how an HPV vaccination digital game should be designed, developed, and evaluated for college-age males. The Focus Group Protocol was developed by the study’s principal investigator and lead author and implemented in all sessions (see Figure 1). The protocol was guided by recommendations and suggestions elicited in conversations with subject matter experts in a previous study (not published). The questions that were asked of focus group participants solicited information on (I) current knowledge of HPV and the HPV vaccine; (II) video game preferences and usage trends; (III) openness/willingness to playing games for health; (IV) video game character customization beliefs and practices; and (V) what features or characteristics should be included in a video game designed for college-age men on HPV.

Figure 1 Focus group facilitation protocol and interview guide. HPV, human papillomavirus.

The interview guide protocol was piloted with a convenience sample of college age men (n=5) prior to the first focus group session to ensure comprehension and clarity of questions and optimal response elicitation. The pilot session was conducted as a focus group session. Participants were able to provide feedback to the interview guide through in-depth interviews. Based upon feedback provided changes were made prior to full implementation of data collection activities. Four focus group sessions were conducted with recruitment goals of six to eight students total participating in each focus group session. A convenience sample of college men were recruited to participate in the focus group sessions. While familiarity with video games were not formally and quantitively assessed, all participants were vocal prior to and during the focus group sessions about their gaming behaviors and experiences. All participants indicated that they were gamers, with great variation in mobile, computer and console gaming. This was confirmed with the depth and variety of information provided during conversation with the sample.

The focus groups were conducted until saturation of ideas was gathered. In total twenty-five participants participated in the focus group sessions which averaged 1.5 to 2 hours in length. Each session was moderated by different team member and to ensure that no ideas were missed, each session was audiotaped for transcription. To ensure consistency among moderators and note-takers, each researcher moderating the focus group sessions was trained and provided with a focus group protocol. During each session, one facilitator moderated the focus group session with one other individual assisting with note-taking. Refreshments were provided, and participants were compensated with a $10 Visa debit card for the feedback provided during the focus group session.

Interview transcripts were transcribed by the research staff. Using the focus group protocol as a guide, a codebook was developed for thematic coding. After transcription, interview transcripts were input and coded using NVivo 10 software to identify emergent themes. To establish inter-rater reliability of emergent codes, three independent researchers independently coded each transcript and meet to discuss the codes identified until 100% agreement was achieved. The codebook assisted in the identification of emergent themes relevant to HPV game development for college-age men. Differences were discussed until a consensus on the coding scheme. Grounded theory was used to develop a codebook for thematic coding and data analysis (35). This coding scheme assisted researchers with identifying emergent frames or themes relevant for HPV game development for college-age men. Results were condensed and organized based upon major themes and subthemes with accompanying quotes provided. Each theme or subtheme was organized in a table format, relative to the research question it addressed (see Table 1).

Results

Game design & development

While there was no demographic data collected on gaming study participants, all focus group participants indicated that they were gamers and engaged in game play on a variety of platform channels. This proved to be beneficial in soliciting feedback and understanding of how to developed a tailored and appropriate game relevant to men. When asked about game design and development, there were several factors that were discussed among the participants. Since a large percentage of the participants identified as gamers, they felt as though a game that was more role playing in nature, and had the same level of action experienced in similar games played would appeal most to college age men. Creative freedom was also emphasized in conversation. Creative freedom for a digital game, can be explored in several ways. This included skill customization and the use of a sandbox (having each player experience something different when playing the game.

“… just that creative freedom and not being tied down to play a game in one specific way. If everyone at this table were to play the same game it would be unlikely that we would all play it the same way. I like that freedom. Usually it’s like an open world sandbox thing where you can just go and draw even when it has no purpose to the game” (FG1, M1).

While avatar customization was brought up, it was emphasized that this type of customization and its effect would be heavily influenced by the type of game itself. While some games commonly played by men, such as Halo and Call of Duty would not be a natural fit, if designed contextually to be an online simulation game, then the use of an avatar may be more appropriate. Additionally, participants felt as though besides being relevant to their population, the game should be informative, include subtle messaging and include a strong storyline. Nearly one third of our participants reported in conversation with focus group facilitators having seen health messages before and during game play; and were open to receiving messages in the future. By incorporating these components, college age men felt as though the game could be more impactful at increasing awareness of the HPV virus and HPV vaccine. This is exemplified below:

“I think something very informative for people who do not know what HPV is; something very interactive, not just flip pages but a character with the disease and then this happens. Even if I spend 15 minutes, I’m 60 percent more educated.” (FG3, M5).

Besides the characteristics, gaming platform was also deemed important. While there were many advantages and disadvantages of each mentioned, ultimately our participants highlighted mobile app-based games as optimal platform due to its increased access and use among the population. They also discussed the ease of play and ease of dissemination but acknowledged that sometimes traditional computer and platform only games do not translate as easily into a mobile format (see Table 1).

Implementation

Besides mobile apps being an optimal channel for game dissemination and uptake, the participants also offered up several ways to actually get college age men to play the HPV vaccine game. While they acknowledged that they would not automatically pick up an HPV game just to play naturally, they offered up many options to consider. This included integrating HPV messaging into already existing popular video games that men already play or creating a game that could be used in conjunction with a health course curriculum. The game could be associated as an assignment and would ensure that the men enrolled would play. A third option also included health care providers/health departments prescribing the game for patients.

“And building off his idea, you know, at health departments or any kind of primary care visit, maybe the type of game would be effective for like practitioners or umm providers to give kids.” (FG1, M2).

Evaluation

Participants gave great insight on how to categorize a digital game as being successful and effective among their peers for HPV vaccine uptake. Because several participants had very to no knowledge about the HPV virus and vaccine, they felt as though measuring knowledge outcomes would be important. In particular, themes such as “Not an issue/not on radar” and “If women get the vaccine then men are covered” emerged. Conversations further highlighted the issue of the HPV vaccine being framed as a woman’s issue impacting the general awareness among men. This is exemplified in the quotes below:

“That it’s not as pertinent to men as it is to women. Being framed as a sexual promiscuous lifestyle. Because it is more frequently covered as causative to cervical cancer, it’s not as noticed.” (FG2, M5).

“… Several different like strains of the HPV and that the vaccination doesn’t cover all of them but I think it covers like the most prominent ones or the most prevalent ones I guess. Um but same thing, as he said, you know I knew that it could cause cervical cancer, and like I said before it just really wasn’t on my radar because I don’t have a cervix.” (FG3, M4).

In a digital game, besides knowledge it was important to assess other aspects of impact. These included (I) increased self-efficacy of the player (increased confidence of the player during game play to prevent spread of HPV and receive the vaccine in the game); (II) increased engagement and interaction with the game itself; and (III) game to real world behavior change (i.e., HPV vaccine initiation and completion with a healthcare provider or health agency). Participants thought the only way to increase the impact would be through the use of simulated real-world experiences, especially for a game centered on HPV (see Table 1).

Conclusions

There was a great wealth of data collected from this qualitative study, as focus group participants provided insight concerning game mechanics, design and implementation. They suggested rather than developing an HPV-specific game, that researchers should consider embedding messages into popular games already played or developing a game to be used as part of a course curriculum. Although there were many benefits and challenges associated with each platform type, college-age men in our study indicated that they preferred towards the use of a mobile app or some type of downloadable technology for an HPV game. Computer games were seen as a middle ground platform (easy to pick up and play for all types of gamers) however, the extensive opportunities that existed for the downloadable technology emerged to be the key advantage for use among college-age men. With the continual advances in technology and particularly mobile phones, a gaming intervention can be tailored to the specific preferences of the user; and emphasized that the ability to tailor in-game experiences or experience different things each time they played (creative freedom) was also important. This tailoring can personalize the experience for the users while addressing cultural factors that can be influential on sexual health outcomes (36).

Based on a consumer research theory premise called the “extension of the self” (37) many college students also view the mobile phone as an extension of themselves due to their increased utilization of the object and their perceived control and power over it. Because the possession of a mobile phone can assist in the reflection of one’s identity a mobile game can have immense saliency and effect on HPV vaccine uptake among college-age men. Focus group participants also highlighted that the game should be role-playing in nature to capture the attention of the targeted audience. According to Prensky (38), when intending to change or alter behaviors, digital games should be role-playing in nature and integrate learning activities that incorporate imitation, feedback, coaching, and practice. A mobile based HPV game or HPV messages imbedded in games played can have immense benefits for encouraging not only vaccination behaviors among men, but other behaviors relative to their overall health. This is increasingly promising as research literature has highlighted that men use less preventative health care services and generally do not seek treatment when experiencing health issues (39). These negative behaviors, are even more extended to those who identify with the sexual and gender minority (LGBTQ+) population group (40).

Although mobile app or mobile technology games were seen as most favorable among players, many of our focus group participants were not convinced that college age men would intentional play a game centered about the HPV. Participants communicated that there should be some incentive or motivation attached to encourage initial engagement and interaction.

Primary care providers are cited as one of the most influential factors impacting vaccine imitation and completion among adolescent and young adult populations (41). However, there can be many disparities with the implementation of practice standards including the strength and quality of the provider recommendation, where it is emphasized as a cancer prevention strategy or linked to sexual health, the use of reminder systems or technology, the nurse/clinical staff interaction, same day vaccine initiation practices and educational tools used to supplement provider recommendation (42,43). When patients go to healthcare providers to seek care, they are often provided a variety of patient education tools which can include brochures and handouts, fact sheets, videos, posters, infographics and websites (44,45). This may not resonate with younger populations, therefore increasing the opportunity for the provider to “prescribe” the video gaming so that they can learn more after leaving or as they are waiting to be seen by a healthcare provider. The prescription of mHealth HPV game by healthcare providers could provide dual opportunities for motivation for game play and improving health system improvement, specifically related to HPV vaccination. This innovative strategy also has additional benefits. Not only does it decrease the uncomfortableness and uncertainty of healthcare providers addressing or communicating with males about HPV but it also allows for males to seek further health information in a gaming format privately about something that can be seen as a stigmatizing topic. Overall this strategy will increase current missed opportunities for knowledge gain/education increase by the target population relative to an important issue. As gaming literature supports, “Opportunities exist through simulation and Internet-based training modules to advance clinical competence in knowledge acquisition, patient education, and processes, such as prescription guideline adherence to address the opioid crisis and other urgent health concerns” (46). By optimizing the patient educational experience as a “play as you wait” option, it would encourage game play of the mobile HPV game since participants in our study identified that young men may not naturally pick up and play an HPV vaccination game outright.

A digital health game designed for HPV vaccination uptake among college age men should match in the game mechanics similar to off the shelf games already played by college age men. There should be a balance of content and design. In addition to the excitement, graphics and technological appeal, an HPV digital game should focus on HPV knowledge gains, and address the pre-conceived notions surrounding the HPV vaccine and virus. Messages of the game should be brief and highly relevant but subtle enough to be informative. Additionally, the HPV game should include characters involved in some type of storyline or narrative and allow for interaction. Overall, consensus gathered communicates that the mobile-based digital game can be influential as an education and communication tool for reaching college age men.

Based upon the feedback gathered for our study participants, combined with preliminary data collected in an experimental study implemented and evaluated on the feasibility of customization on HPV outcomes (30), next steps for game development include (I) the creation of game design including gaming mechanics, narratives and decision tree; (II) game prototype development; (III) feasibility/beta testing; (IV) revisions; (V) patent and copyright protections; and (VI) pilot testing to determine impact among priority population prior to market release. While game design can be an iterative and lengthy process, our team is confident that utilizing a mobile-based approach to game design is the optimum strategy towards increasing HPV vaccine initiation and completion rates among young men.

Acknowledgments

The results discussed in this study are part of a larger dissertation study conducted at the University of Florida. While the results have not been published elsewhere, the entire dissertation study has been made available online via the Library Services at the University of Florida.

Funding: This work was supported by UF STEM Translational Communication Research Program (UL1 TR000064) NIH/NCATS Clinical and Translational Science Grant.

Footnote

Reporting Checklist: The authors have completed the Standards for Reporting Qualitative Research (SRQR) checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-21-29/rc

Data Sharing Statement: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-21-29/dss

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-21-29/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Approval for this study was granted through the University of Florida Institutional Review Board 2 (No. 2015-U-1488). All students completed an informed consent prior to participating in a focus group session.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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