Parents’ Perceptions of a Serious Game for Educating Families on Prescription Opioid Safety: Qualitative Pilot Study of MedSMARxT: Adventures in PharmaCity

Background: Opioid misuse is a pervasive, worsening problem that affects the health of people throughout the United States, including adolescents. There are few adolescent-focused interventions designed to educate them about opioid medication safety. The MedSMARxT: Adventures in PharmaCity, is a serious educational video game that teaches parents and their youths about safe opioid practices. Objective: This study aimed to elucidate parent’s perceptions of MedSMARxT: Adventures in PharmaCity and its potential use by parents and their adolescents. Methods: Parents of adolescents aged 12 to 18 years who live in the United States were recruited from April to October 2021 via Qualtrics research panels, social media, email listserves, and snowball sampling. The study participants played MedSMARxT: Adventures in PharmaCity for 30 minutes and then participated in a 30-minute postgame interview via WebEx (Cisco). Questions were developed and piloted to examine adults’perceptions of the game. Participants were asked three sets of open-ended questions: (1) questions about the game and elements of the game, (2) what they learned from the game, and (3) questions about their experience with games. Audio recordings were transcribed verbatim. Interview transcripts were coded using content and thematic analysis by study team members to identify major themes and subthemes from the data. Results: Parent participants (N=67) played MedSMARxT


Background
The opioid crisis has palpable impacts throughout the United States across all demographics.Seldom can one go a significant amount of time without hearing about the epidemic's dire impacts on health and well-being.Death rates from opioid misuse have nearly tripled since 1999, and opioids were involved in an estimated 80,816 deaths in the United States in 2021 alone [1,2].Curbing opioid misuse has been a long-standing focus of policy and governmental efforts, with the White House declaring the opioid epidemic a public health emergency in 2017 [3].
Youths are just as vulnerable to the growing opioid crisis as adults.In a survey collected by the Centers for Disease Control and Prevention in 2019, approximately 14% of high school students reported misuse of prescription opioids during their lifetime [4].Opioid misuse encompasses taking opioids outside of their prescribed regimen, such as taking more than prescribed, using them in the absence of pain, or taking them after expiration.Among adolescents, misuse often begins at home, where leftover opioid medications enable misuse [5,6].Adolescents tend to model the behaviors of their parents regarding their opioid prescription usage [7].Research shows that the proportion of adolescents and young adults with opioid-related health problems has increased over time despite a decrease in the total number of adolescent and young adult personal opioid prescriptions during the same period [8].Out of all the adolescents and young adults who experienced an opioid-related problem, 40% had received a personal prescription for opioids in the past year while 48% had a family member prescribed an opioid in the past year.Even adolescents who are prescribed opioids and take them appropriately are 33% more likely to develop problems such as opioid dependence or lifelong patterns of misuse [1].
However, research has shown that educating parents can improve their behavioral intentions and reduce the likelihood that they will store unused opioid medications in the home [9][10][11].Alongside rising rates of adolescent opioid misuse, youths have reported misconceptions about safe opioid use practices, including inaccurate identification of medications that are opioids, improper storage and disposal techniques, and inappropriate sharing of prescribed opioids with others [12].Due to the vulnerability of adolescents and their limited knowledge about opioid medication safety, it is essential to create tailored, educational interventions that teach youths and families about the importance of safe prescription opioid use.
Currently, there is a lack of interventions tailored to adolescent education on opioid medication safety [13][14][15][16].Previous literature suggests that parents and youths are receptive to game-and web-based opioid misuse prevention programs, citing a belief that gamified educational methods would improve adolescent engagement [17,18].These studies have also shown that serious educational games may enhance the retention of information, accelerate learning, and increase accessibility to educational material.Other health-focused games have shown effectiveness in improving key behavioral intentions and improving education for youths [18][19][20][21].Novel approaches to engaging youths can be effective and are paramount in combating the opioid crisis [22,23].One such approach is the use of a serious game.Serious games are video games designed to impart knowledge or improve social-behavioral outcomes for players wherein the primary objective is not entertainment [24].

Overview
MedSMARxT: Adventures in PharmaCity is a theory-driven, adolescent-focused serious game developed to educate adolescents and their families on how to safely manage complex, real-life situations involving prescription opioid medications [25,26].By playing the game, youths and their family members (such as parents) are able to identify best practices for the safe and responsible management of opioid medications with a focus on appropriate disposal, proper storage, and preventing medication sharing.The game scenarios were created with the interdisciplinary study team comprised of game designers and developers, health services researchers, pharmacists, an adolescent health physician, and an addiction medicine physician.The scenarios were further assessed by adolescents and young adults who overall found the scenarios to be realistic and relevant.The game content, game design, and scenarios were informed by several extensive studies previously conducted by the study team to understand opioid safety knowledge games of adolescents and their preferences for game-based education [9,[14][15][16]25,26].Findings from these studies showed that adolescents significantly lacked information on safe opioid storage and disposal; hence, a critical knowledge gap that needed to be addressed via game-based learning.Parent involvement in medication-related behaviors (such as medication storage and disposal) remains an important protective factor against adolescent prescription medication misuse [27].Therefore, the inclusion of parents in the feedback and development was key to creating an intervention that would facilitate adolescent education and promote family medication safety.The game's format was a responsive narrative wherein players make choices that affect the game's outcomes, such as choosing their own adventure.Players play as an anthropomorphized sheep, Shan, who recently broke their arm.Players must use critical thinking and decision-making to select the correct (safest) choices regarding opioid use through 5 levels simulating real life.If players make a decision that is unsafe, they are presented with an opportunity to replay the level.The game is played using an internet-enabled computer via a web browser.

Level 1
A Quiet Sunday Afternoon focuses on teaching the player about the safe storage of opioids and requires the player to appropriately store opioids in a locked cabinet before Shan's friends gain access to the medications and overdose (Figure 1).

Level 2
Monday Morning Bus Ride, in this scene, the player is in pain and forgets there was an important assignment due that day (Figure 2).

Level 3
A Persuasive Speech at School teaches the player not to take others' pain medications through peer pressure from a friend and discusses the negative consequences of taking someone else's prescription medication (Figure 3).

Level 4
Bus Ride Home teaches the player not to share their medication with others and reinforces the risks of sharing medications.This game level also introduces the use of Narcan through an encounter with a stranger on the bus who acts as if they are in pain and needs relief (Figure 4).

Level 5
Last Minute Chore shows the player the correct approach to dispose of opioid medication and that medication disposal drop boxes are available at local pharmacies (Figure 5).

Study Objectives
The purpose of this study was to examine parents' perceptions of the MedSMARxT: Adventures in PharmaCity game.Specifically, the study assesses parents' perceptions of the game features, what participants learned from the game, and their gaming experience.

Ethics Approval
This study was approved by the University of Wisconsin-Madison's institutional review board (2020-1638) on January 5, 2021.

Sampling and Recruitment
From April to October 2021, a national sample of parents was recruited via Qualtrics research panels, social media, email listserves, and snowball sampling.The study team partnered with Qualtrics to identify and recruit from preexisting research panels.Social media sites included Facebook (Meta Platforms), Instagram (Meta Platforms), Reddit, and Twitter.Listserves came from the University's mass email system and the study team's own list of youths and parents.Eligible participants were parents of adolescents aged 12 to 18 years who live in the United States, could read, speak, and understand English, and had access to a computer with a working webcam.After screening for eligibility, parents were asked to provide consent and their contact information for scheduling purposes.Parents were then contacted to partake in the study and screened for eligibility by the research staff.

Data Collection
Study sessions were held via WebEx.Parents were told that the study was being conducted by a team of researchers interested in adolescent opioid misuse prevention and that they were looking for data to help refine their game.Parents were asked to play the MedSMARxT: Adventures in PharmaCity game for 30 minutes (or until they completed all 5 levels, whichever happened first), and answer follow-up interview questions.Data were collected through 30 minutes of gameplay and a 30-minute semistructured interview.Only participants and a member of the research staff were present during the data collection.The research team created interview questions to examine parent players' feedback on the game.Participants were asked three sets of open-ended questions: (1) about the game and elements of the game, (2) what they learned from the game, and (3) about their experience with games.Interview questions were developed for the purpose of understanding parents' perceptions of the game, confirming the salience of educational content, and characterizing the gaming experience of parents of adolescents.The study team used interview questions that had previously been pilot-tested and proved to be effective for examining adults' use of the game.The interview ended with, "Is there anything else you'd like to add?" to allow the participant to share any other thoughts or details that were not previously captured.Parents were compensated US $30 via an Amazon gift card for their participation in the study.Interviews were professionally transcribed verbatim using audio recordings collected through WebEx.The interview guide is shown in Multimedia Appendix 1.

Data Analysis
Two research team members (GAN and LLS) independently analyzed each interview transcript using NVivo (Lumivero) [28].The main themes from participant responses were coded using content analysis followed by a thematic approach [29].The coding members of the study team first familiarized themselves with the data by reading through each transcript in detail and then independently extrapolated codes.The research team members met regularly to discuss coding differences and develop a master codebook.The codes were then exported to Excel (Microsoft Corp) for further thematic analysis using an inductive and deductive approach to identify salient themes [30].The primary investigator (OA) met with the coders to address any coding discrepancies and prevalent themes identified.Each coder identified themes and subthemes from XSL • FO RenderX the data based on code prevalence, and then the research team met to compare and finalize the results reported below.

Participant Demographics
Feedback was elicited from 67 parent participants who played MedSMARxT: Adventures in PharmaCity.Participant characteristics are described in Table 1.Notably, 92.5% (n=62) of them identified as female, 77.6% (n=52) of them identified as White, and the mean age was 46.03 (SD 5.75) years.
As depicted in Textbox 1 below, four major themes were identified: (1) participant gaming experience, (2) perception of game features, (3) educational purpose of the game, and (4) future use of the game.A detailed description of the themes and prevalent subthemes that emerged from the data analyses is described below.a Three options were presented to the participants to select for their sex assigned at birth: "male," "female," and "other: please specify." b If participants only selected 1 category, that was their defined race; all other combinations of selections were defined as "More than once selected."

Overview
Parents had a wide range of experience with games.Overall, participants preferred games that required strategy and discrete tasks to accomplish.Study participants enjoyed games that foster family or social interaction.Most parents reported at least some experience with video games and favorable impressions of educational games.

Experience With Educational Games
Most participants (n=44, 66%), reported previous experience playing an educational game.Some of these participants (n=11, 16%), reported playing an educational game with their child in the past, and other parents (n=11, 16%), stated that educational games were a part of their career.Participants listed 36 unique educational games that they had previously played, which commonly included math games, crossword puzzles, early learning games, and trivia games.
Most parents (n=43, 64%), had a positive perception of educational games.Study participants perceived game-based learning as an appealing modality that is more engaging than traditional learning methods.Features such as the ability to learn from mistakes within the game and entertainment features were important to parents.A few participants (n=7, 10%), stated that educational games would be more beneficial for youths than adults.Theme 2: Perception of Game Features

Levels
The most frequent positive descriptors of game levels included "cute" and "engaging."Participants appreciated the variety of game levels, which they reported represented real life.Parents appreciated the responsive narrative format which allowed the player to choose from multiple available actions, learn the consequences of wrong (unsafe) actions, and replay scenes to discover the appropriate actions.
A total of 35 (52%) participants reported that game levels were realistic.Some participants (n=10, 15%), specifically stated that the levels were applicable to the lives of adolescents.Only 3 (4%) participants reported that game scenes were not realistic due to the severity of the consequences portrayed.Some parents expressed uncertainty about whether adolescents encountered opioid misuse frequently.A small number of 3 (4%) participants noted that in the game a child's character performs actions they would not have their own child perform, such as medication disposal.
In level 1, some participants reported uncertainty around the correct actions to take, though many benefited from the educational content of this level.Level 3 was well-received by participants due to its depiction of an opioid misuse scenario with peer pressure which they felt adolescents may encounter.Level 4 was sometimes viewed as being unlikely, as participants felt that a stranger would not ask for pain medication from another person. We

Characters
Parents responded positively to the game's characters.Parents' positive impressions of the characters were mentioned 166 times, whereas negative impressions of characters were noted only 38 times.Characters were described as cute, realistic, and sincere in their interactions.Some participants mentioned that the use of cartoon characters or animation-style graphics may be better suited for younger adolescents rather than older teenagers.Fifteen (22%) participants noted a preference for animal characters, while 4 (6%) participants preferred human characters.Participants appreciated that characters were gender-inclusive with neutral names and presentation.According to parents, animal characters contributed to this inclusivity.
And so, I think that it was, it was a good, you know, they had the things that the kids could find in common with them, you know.

Graphics
Parents stated that the graphics were cute and interesting but may have been designed for younger children.Only 4 (6%) participants stated that the game graphics were outdated.Participants also stated that the graphics may be basic for adolescents who often play games with advanced graphics.
In comparison to games and apps that kids use right now.They're pretty, it was pretty basic.And the, the

Navigation
Some parents (n=38, 57%), had difficulties with navigation, especially in level 1. Eleven (16%) participants sought more in-game directions for navigation while playing and suggested that keyboard controls (W, A, S, D keys) were difficult to use.For most parents, the game navigation became easier as the participants continued to play the game.Some participants (n=10, 15%), suggested gameplay may be more intuitive for a child rather than a parent.

Pace
Participants mentioned that the game had a slow pace with opportunities to repeat the game scene when the wrong action was selected.Time burden was reported due to the amount of dialogue the participant had to read throughout the game. There

Overview
Many participants expressed positive opinions about using a video game to educate their children on opioid medication safety.The parents reported that game-based learning would help their children remain engaged with the content.They also noted that the game would be a beneficial way for children to share what they learned with friends.

Perceived Main Idea of Game
When asked what they perceived to be the main educational point of the game, 23 (34%) participants reported the promotion of safe use of opioids and

Reading Level
Parents believed that the game's reading level was more appropriate for older adolescents than elementary-aged children.
And so, it seemed like it was designed for much younger than the characters in it, which was fine, but some of the things they were saying, I don't think the younger kids would be able to read.[Parent 131]

Target Audience
Participants reported that children of elementary or middle school age would be the primary target audience.Participants thought children 5 to 15 years of age would benefit most from the game but mentioned that the educational points are important for all ages.Dialogue and game scenes were perceived as more appropriate for older teenagers than younger children.Parents stated that their older teens may think the game less engaging due to its slow pace.However, parents reported that their children would learn from the game and gain confidence in safe prescription opioid behaviors.

I think that it can be valuable and not just the game itself, but […] perhaps the kid and parents could play it together, or the parent could watch the child playing it and it could help fill in any missing pieces or answer questions that the kid might have. I think it's a nice way to introduce the topic for a family discussion in a way that could be more engaging and that could hold the kid's interest a bit more than just straight laying it out there. [Parent 137]
I definitely would recommend it to others because it obviously is extremely important and needs to be, it needs to be brought up to anyone who will listen.But I would recommend it to a younger crowd, I think.

Participant Learning Experiences
Some (n=27, 40%), participants reported that the game confirmed their existing knowledge, while 22 (33%) others reported that the game did not provide novel educational points.Two frequently reported educational outcomes included medication storage recommendations and awareness of medication disposal options.Specifically, participants realized that they do not typically store medications in a locked area and do not have a locked area available in their homes.A substantial number of participants (n=15, 22%), were not aware of available pharmacy medication disposal drop boxes until playing the game.The game also emphasized the importance of parent-to-child medication safety education wherein participants discussed improved awareness of medication safety scenarios, such as when friends of their children visit the home.Parents were also motivated to increase communication about medication safety with their children after playing the game.Theme 4: Future Use of Game

Overview
Over half of participants (n=39, 58%), stated they would recommend MedSMARxT: Adventures in PharmaCity, and 17 (25%) other participants would provide a conditional recommendation.A small number of 5 (7%) participants mentioned that they would not recommend the game, 1 (1%) participant would conditionally not recommend it, 1 (1%) participant was indifferent, and 2 (3%) participants had mixed recommendations.Two (3%) participants did not provide a recommendation for or against the game.

Suggested Improvements
Improved navigation was cited as a future improvement 39 times.Participants recommended a tutorial, in the beginning, to explain navigation, pop-ups throughout the game to encourage exploring the scene, or adding a hint button.They also endorsed the use of keyboard arrow keys, a computer mouse, or touchscreens over current W, A, S, D keyboard controls.

I would have benefited from like, a little simple, like, practice round at the beginning, just a simple like, this is, I mean, this is how you move and how you jump and how you do these things. [Parent 183]
To increase the pace of the game, participants desired an option to skip over dialogue especially if repeating a game scene.Participants would prefer less text dialogue and more direct questions to prompt user action.Participants recommended the incorporation of social media, live video clips, and customizable characters to increase engagement for older teens.
Participants sought additional educational content, including a scene in the beginning of the game where the main character discusses information and instructions about their medication with a physician or a parent.Participants suggested this scene could include exposure to the medication package insert, a display of warning labels found on the medication bottle, or background information on the character's injury.More education regarding the recognition and treatment of opioid overdose was requested.Participants emphasized the importance of all users being able to see the consequences of wrong actions, even if they choose the correct actions in the game.

Principal Findings
Parental feedback demonstrates the acceptability and appropriateness of MedSMARxT: Adventures in PharmaCity as evaluated through parent perceptions of game design, navigation, educational purpose, and future game applications.
The study findings indicate that most parents support the use of educational games to teach adolescents about opioid medication safety, emphasizing that this approach is more appealing and engaging for youths as compared to traditional learning methods.Moreover, many parents stated that they would recommend the game to others, showing its appropriateness in engaging parents and garnering their support in using the game to educate their children.Despite being a serious game directed toward use by youths, MedSMARxT: Adventures in PharmaCity also taught parents of adolescents important opioid medication safety practices, including safe storage and disposal.

Comparison to Prior Work
Video games, specifically serious games, demonstrate the potential to improve key behavioral intentions and knowledge related to positive outcomes in various health conditions [31][32][33].
MedSMARxT is the first serious game to address opioid safety XSL • FO RenderX in adolescents [14].As such, it is critical that the game be evaluated with relevant stakeholders to ensure key quality criteria [34][35][36].Prior research has elucidated some key quality criteria in the development of serious games including the salience of the overarching goal of the game, appropriateness of the game content, enjoyment, and acceptable media presentation [37].In order to best tailor the game to the target players, the study team has rigorously evaluated the game among groups of stakeholders.For example, the study team has conducted research with pharmacists to validate the educational content and their perceptions of using the game in pharmacies when opioid medications are dispensed.Pharmacists reported that the information presented in the MedSMARxT is accurate and age-appropriate while potentially useful for populations aside from adolescents such as parents or older adults [38].
Previous work by the study team has focused on the development of MedSMARxT wherein community-based participatory research was used to elucidate adolescent knowledge gaps and preferences for education on medication safety [39].Adolescents most frequently reported web searches, parents, health care providers, and web-based videos as resources for medication safety information, which highlights the integral position of parents and health care professionals such as pharmacists in ensuring appropriate and correct education for adolescents [39].In prior studies on adolescent receptiveness to using educational games to improve medication knowledge, nearly 80% of adolescent participants indicated they would be receptive to using an educational game [40].
Concordantly, this study demonstrates that parents are also receptive to the use of an educational game to educate their adolescents on opioid safety.Moreover, parents of adolescents in this study reported experience with video games at elevated levels (84%).In conjunction with previous studies, this study indicates sufficient receptiveness toward MedSMARxT for families with adolescents.
Existing research also indicates that serious games contain realistic scenarios that engage and motivate participants more than traditional learning approaches [41].Parents in our study offered positive feedback on the game features including the media presentation (graphics) as well as the characters and individual gameplay levels.Coupled with the correct identification of the game's overarching goal, these findings describe the potential balance of serious and game elements in the MedSMARxT game.
Although the original, intended audience is adolescents, parents likewise reported new learnings.Parents most often reported newfound knowledge about proper disposal and storage.
Research has demonstrated the importance of educating patients on safe disposal.When patients are taught the proper method of disposal, they are more likely to dispose of their medications in a safe manner [42,43].Beyond the use of a serious game to provide education to adolescents, parental involvement in adolescent medication use practices has been a protective factor against prescription drug misuse [27].Parents can act as useful resources for information about opioid safety and important models of proper opioid use when they themselves have the requisite education.Recognizing the vital role that the family plays in the development of medication use behaviors, the National Institutes of Health [44] recommends family-based prevention programs as an effective means to reduce rates of opioid misuse among youths.Parental exposure to topics their children are learning about can promote discussions foundational to future safe medication use behaviors.Parent responses suggest that this intervention could foster family conversations around opioid and prescription medication safety by providing parents with an educational resource for both them and their children.
This study of MedSMARxT: Adventures in PharmaCity showed a perceived educational benefit for adolescents and a reported gain in parental exposure to opioid medication safety topics.Parents were able to explore realistic scenarios that their child may experience.For example, through playing level 1, parents realized that proper opioid storage in the home is not only important for their child but also for their children's friends who may visit the home.

Future Directions
While overall perceptions of the MedSMARxT game were positive, findings from this study suggest further improvements including a navigation tutorial, an option to skip through dialogue when repeating scenes, and explicit hints or objectives.While iterative improvement of the game itself is vital to future uptake, implementation effectiveness studies are integral to determining the best location and means for implementing this novel educational technology.Future studies will work to evaluate the effectiveness of MedSMARxT in different health care and non-health care settings to determine fit and implementation.

Strengths and Limitations
Strengths of this study include sampling a significant parent population from across the United States, which provided a representation of many parenting opinions and styles.Second, the use of open-ended questions during the interview provided participants ample opportunity to discuss all aspects of MedSMARxT: Adventures in PharmaCity that they perceived were important.Third, analysis was carried out by 2 research team members for triangulation (GAN and LLS), guided by the principal investigator for reflexivity (OA), and validated through peer debriefing and an audit trail to support trustworthiness in terms of credibility, transferability, dependability, and confirmability.
There are limitations to this study.The first is that of self-selection bias in this sample.While this study uses a considerably large sample size for a qualitative study, parents' self-selected participation could be present in terms of those who favor the use of educational games being more likely to participate.Second, there are limitations surrounding demographic homogeneity in this sample.The format of study activities would exclude families without access to high-quality internet or those without a computer in the home.Therefore, our study sample, while a national sample, is homogenous in terms of socioeconomic status and education level.Hence, findings of acceptability may be less generalizable to those in more difficult socioeconomic situations and those who discontinued education after high school.Recruitment was carried out across multiple streams (Qualtrics panels, social media, listserves, snowball) across a few months in order to create a sample that was as robust as possible.The study team used practices such as investigator triangulation, peer debriefing, and reflexivity to improve the trustworthiness of the data collected.
Third, social desirability bias could play a role in the positive perceptions of the parents.It is possible that when asked about their perceptions, parents were more likely to offer a positive response than a negative response.To account for this potential, the interview guide was designed and piloted to ensure neutrality in questions and prompts.Future work could use anonymous surveys to remove the researcher from data collection and decrease social desirability.The findings of this study are trustworthy given that questions were tailored to touch on multiple parts of the intervention and questions regarding potentially threatening topics were not used.

Conclusions
The creation and use of serious educational games to teach adolescents about opioid medication safety could be an effective approach to improving youths' knowledge of opioid prescription safety.This study investigated parent perceptions of MedSMARxT: Adventures in PharmaCity and found that parents believe this game would be beneficial for youths.MedSMARxT: Adventures in PharmaCity could be used in various non-health care and health care settings in the future to educate adolescents and inspire meaningful parent-adolescent conversations about safe opioid use.
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