A Video Game Promoting Cancer Risk Perception and Information Seeking Behavior Among Young-Adult College Students: A Randomized Controlled Trial

Background Risky behaviors tend to increase drastically during the transition into young adulthood. This increase may ultimately facilitate the initiation of carcinogenic processes at a young age, highlighting a serious public health problem. By promoting information seeking behavior (ISB), young adults may become aware of cancer risks and potentially take preventive measures. Objective Based on the protection motivation theory, the current study seeks to evaluate the impact of challenge in a fully automated video game called Re-Mission on young adult college students' tendency to perceive the severity of cancer, feel susceptible to cancer, and engage in ISB. Methods A total of 216 young adults were recruited from a university campus, consented, screened, and randomized in a single-blinded format to 1 of 3 conditions: an intervention group playing Re-Mission at high challenge (HC; n=85), an intervention group playing Re-Mission at low challenge (LC; n=81), and a control group with no challenge (NC; presented with illustrated pictures of Re-Mission; n=50). Measurement was conducted at baseline, immediate posttest, 10-day follow-up, and 20-day follow-up. Repeated-measures mixed-effect models were conducted for data analysis of the main outcomes. Results A total of 101 young adults continued until 20-day follow-up. Mixed-effect models showed that participants in the HC and LC groups were more likely to increase in perceived susceptibility to cancer (P=.03), perceived severity of cancer (P=.02), and ISB (P=.01) than participants in the NC group. The LC group took until 10-day follow-up to show increase in perceived susceptibility (B=0.47, standard error (SE) 0.16, P=.005). The HC group showed an immediate increase in perceived susceptibility at posttest (B=0.43, SE 0.14, P=.002). The LC group exhibited no changes in perceived severity (B=0.40, SE 0.33, P=.24). On the other hand, the HC group showed a significant increase from baseline to posttest (B=0.39, SE 0.14, P=.005), maintaining this increase until 20-day follow-up (B=−0.007, SE 0.26, P=.98). Further analyses indicated that perceived threat from virtual cancer cells in the game is related to the increase in perceived severity (B=0.1, SE 0.03, P=.001), and perceived susceptibility is related to changes in ISB at 10-day follow-up (B=0.21, SE 0.08, P=.008). Conclusions The feature of challenge with cancer cells in a virtual environment has the potential to increase cancer risk perception and ISB. The results are promising considering that the Re-Mission intervention was neither designed for cancer risk communication, nor applied among healthy individuals. Further research is needed to understand the theoretical framework underlying the effects of Re-Mission on ISB. The findings call for the development of a Web-based, game-based intervention for cancer risk communication and information seeking among young adults. ClinicalTrial International Standard Randomized Controlled Trial Number (ISRCTN): 15789289; http://www.controlled-trials.com/ISRCTN15789289 (Archived by WebCite at http://www.webcitation.org/6jGYZC3lZ)


IRB Approval, Informed Consent Process, Recruitment, and Survey Administration
The study involving these surveys has been approved by the institutional review board. The initial contact with potential participants was made face-to-face through an announcement. One month before the experiment, the research team attended classes at the University at Buffalo, to announce the study and invite participation. The announcement reached as many as 500 students.
In addition to the verbal announcement, an announcement was posted online through the class websites. The class website can only be visited by the young adult students attending the class. The website already pre-selects this group, which forms the population of interest.
The online and the face-to-face announcements explained the purpose of the study, the length of the study, method of accessing the study sign-up sheet, risks/benefits of the study, and statement of voluntary participation. The announcements included a link to the baseline survey.
The baseline survey began with an electronic consent form specific to the survey. The baseline survey was closed to the subsample of young adult students who were interested in the study and who have approved the electronic consent form. This consent form was also provided in hard copy for the students to keep for their own records, after they arrived at the experimental site. At the experimental site, participants were provided with an informed consent form for the rest of the study, which was verbally explained. All other surveys were also closed surveys that were only open for participants who continued in the study.
For all the surveys, no personal information was collected, except for e-mail addresses. However, all data was retrieved from the cloud and stored in a password protected hard drive and locked in a data storage room. Only the principal investigator had access to the data.
Participation in the study was voluntary, and participants were not required to complete the surveys. Participants were compensated by receiving additional course credits for completing the surveys and taking part in the intervention.
The baseline survey was open for a period of two months. The post-test survey was taken at the intervention site immediately after game play. The 10-day and 20-day followup surveys were sent to each participant via e-mail. Each survey had between 1 and 13 items per page. The surveys did not allow for the participants to review answers. The participants could not go to a previous page to change their answers.

Response Rate
Considering the need for full privacy, IP addresses were not collected for participants. Instead, a unique participant was determined based on the university e-mail address they provide on the first page of the survey. The participation rate for all surveys was 100%. The completion rate for the baseline survey was 99%. The completion rate for the post-test survey was 100%. The completion rate for the 10-day follow-up survey was 81.02%. The completion rate for the 20-day follow-up survey was 57.71%.

Preventing Multiple Entries
While the surveys were closed, they did not involve a login to prevent duplicate entries. For all surveys, IP addresses were not collected based on the requirements of the institutional review board. However, duplicate database entries having the same user ID were eliminated before analysis, such that the first entry was kept and the second entry was eliminated.