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Keywords:

  • serious educational game;
  • alcohol;
  • drug;
  • video game;
  • computer

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Issues

Serious educational games (SEG) have been shown to be effective in educating young people about a range of topics, including languages and maths. This paper identifies the use of computerised SEGs in education about alcohol and other drugs and reviews their impact on the prevention of alcohol and drug use.

Approach

The Cochrane Library, EMBASE, MEDLINE, ERIC, Scopus, psychINFO, pubMED and DRUG databases were searched in February 2013. Additional publications were obtained from the reference lists of the relevant papers. Studies were included if they described an evaluation of a computerised SEG that targeted alcohol and/or other drugs and had been trialled with adolescents.

Key Findings

Eight SEGs were identified targeting tobacco, alcohol, cannabis, methamphetamine, ecstasy, inhalants, cocaine and opioids. Six reported positive outcomes in terms of increased content knowledge and two reported increased negative attitudes towards the targeted drugs. Only one reported a decrease in the frequency of drug use.

Implications and Conclusion

This is the first review of the efficacy of computerised SEGs for alcohol and other drugs for adolescents. Results suggest that SEGs can increase content knowledge of alcohol and other drugs. Evidence concerning impacts on negative attitudes and alcohol and drug use is limited, with few studies examining these outcomes.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Use of alcohol and other drugs is associated with considerable burden of disease, social costs and harms, especially in young people [1–4]. Nearly three-quarters of young Australians aged 12–17 years have had a full serving of alcohol, 6.4% have consumed alcohol at levels that put them at risk of injury at least once in the past seven days (defined as more than four drinks on a single occasion), and approximately one in six (15.6%) have tried an illicit substance [5]. Considering that early initiation into drug use is a risk factor for the development of substance use disorders, comorbid health problems, juvenile offending and impaired educational performance, it is important that evidence-based drug and alcohol education and prevention be initiated and implemented early [6–9].

Video gaming is a method of education that is gaining attention due to its popularity with younger audiences [10]. A video game is played on a digital device and can be described as a mental contest with a goal or objective, played according to rules that determine what a player can and cannot do inside the game world [11]. The use of video games is evidently becoming increasingly common with the younger population, with a recent study finding that out of a sample of 974 secondary school students in Australia, 95% had played video games in their lifetime [12]. Additionally, studies have suggested that playing video games can contribute to positive emotions, emotional stability and better attachment to school as compared to non-players [13,14].

Serious games, which are video games developed primarily for reasons other than entertainment [15,16], have been developed in the areas of education, rehabilitation, therapy, and medical and public health training [10,17–23]. Serious educational games (SEGs), which are developed primarily for educational purposes [15,16], have shown they can be effective in increasing the knowledge of adolescents in the areas of languages, maths, geography and computer science [10,23–28]. In some cases the use of SEGs were shown to be as effective in knowledge acquisition as non-gaming controls and to maintain higher motivation in learners [24,28]. Aside from increasing motivation and knowledge, other benefits found from SEGs include the promotion of general problem-solving skills, goal-oriented behaviour, strategic thinking, cognitive skills and visual attention [13,29–34]. However, exactly what aspect of playing these games promotes these outcomes is uncertain, and whether it can apply more specifically to SEGs on alcohol and other drugs has not been explored.

Modern theories of learning suggest that learning is most effective when it is active, experiential, situated, problem-based and provides immediate feedback, and games can be argued to offer more of these than traditional approaches to teaching [35]. The use of computers to deliver SEGs has its own potential benefits, as the use of computers has been shown to accelerate learning, develop more positive attitudes to learning and result in a longer retention of information when compared with traditional methods of teaching [36–38]. Furthermore, the medium of a computer means that the game is easily accessible, is consistent, requires minimum preparation time for teachers and can be easily updated [39,40].

A recent review by Connolly [15] explored the empirical evidence on the positive impacts and outcomes of computer games and serious games. Results showed that SEGs have been developed across a range of curricular areas, but mainly in tertiary and secondary education; however, none of the studies covered included SEGs on alcohol and other drugs. Regarding the serious educational games included, knowledge acquisition was a frequent outcome, although randomised controlled trials were uncommon. Nevertheless, Connolly's review highlights the potential benefits of SEGs, though also the need for further studies.

Taking into account the positive impacts SEGs can have on knowledge and behaviour change, as well as the importance of early implementation of drug and alcohol education, this paper will report a systematic review of computerised SEGs for alcohol and other drugs that have been trialled with adolescents.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Data sources

The Cochrane Library, Embase, MEDLINE, ERIC, Scopus, psychINFO, pubMED and DRUG databases were searched in February 2013 using the following keywords: ‘alcohol OR drug OR cannabis OR ecstasy OR marijuana OR amphetamine OR psychostimulant’, ‘prevention OR education OR schools’, ‘game OR gaming OR interactive OR application’ and ‘internet OR computer OR web OR online OR virtual’. The titles and abstracts of the 1180 articles identified were independently reviewed, and full copies of potentially relevant papers were obtained to determine if they met the inclusion criteria. Publications were also obtained from the reference lists of the relevant papers and by contacting authors via email where the full text was not available. Articles were excluded if they did not describe a computer-based game on the topic of alcohol or other drugs or were published before the year 2000. Studies were included if they described an evaluation of a SEG which targeted alcohol and/or other drugs and had been trialled with adolescents. Figure 1 displays a flowchart of the search strategy and study selection process.

figure

Figure 1. Flowchart of search strategy and study selection.

Download figure to PowerPoint

Outcome measures

The main measure evaluated was gains in content knowledge from baseline to post-test. Differences between baseline and post-test were also reported for a range of other measures, including drug-related attitudes and drug use.

Analysis

Due to the limited number of studies included and the heterogeneity of study design and outcome measures, it was not possible to combine the results into a meta-analysis. Consequently, results have been reported in a systematic review.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Overall, eight computerised SEGs were identified. All eight of the games were universal, that is, they were delivered to all participants regardless of their level of risk for alcohol or drug use. The games adopted either an educational (n = 6) or social influence approach (n = 2). The games that adopted an educational approach presented the students with knowledge about the science of alcohol and other drug use, assuming that this knowledge would contribute to better decision-making regarding alcohol and other drugs. The games that adopted a social influence approach taught students to resist drugs by providing drug-related information, resistance skills training and normative education [41,42].

Of the eight games, four were delivered online, three were available via CD-ROM and one was presented on an autostereoscopic 3D display on a computer. All trials were conducted in the USA, except for one that was conducted in the UK. All trials were mixed-gender and were conducted on students in early adolescence (10–14 years of age). Of the identified trials, the Head On and Thinking Not Drinking trials were the only randomised controlled trials with a control group, which received an alternate alcohol prevention program called Life Skills Training and no program at all, respectively [43,44]. Four of the trials had pre- and post-test delays of a minimum of two to three days [45–48]. One study [49] took only post-test measures, immediately after participants played through the game.

Table 1 shows the outcomes for each trial. Of the six games that took an educational approach, the results for five showed a quantitative increase of content knowledge from the game, data for four of which were collected at a follow-up of at least three days after playing the game [45–48]. Two of the educational games were also associated with more negative attitudes towards the targeted drugs [45,50]. The other two games, Head On and Thinking Not Drinking, adopted a social influence approach. The first was associated with retention of content knowledge as well as reduced frequency of smoking, drinking and marijuana use, while the latter appeared to produce an increased perception of the harm of alcohol as well as increased assertiveness skills [43,44]. Qualitative data were collected in one study through interviews, which were conducted immediately after playing through the game [49].

Table 1. Outcome data for identified trials
Game nameAuthorsSubstanceLocation, sample age (years), sample size (n)Game componentsTheory/orientationTypeControlAssessmentOutcomes
  1. aSignificant difference at P < 0.01 between baseline and post-test. bResults stated to be significant, but no P value given. NA, not applicable.

N-Squad Web AdventureKlisch et al. (2011) [46]AlcoholUSA, 11–18, 355Online, 3 episodesEducationalUniversalNABaseline measured 3 days before the first episode was played; post-test at least 3 days after the final episodeIncrease in content knowledge from baseline mean of 18.36 to post-test mean of 22.32a
Thinking Not Drinking: A SODAS City AdventureSchinke et al. (2005) [44]AlcoholUSA, mean 10.83, 489CD-ROM, 10 lessonsSocial influenceUniversalPre-test and post-test measures onlyPretest and post-test measures; time frames not specified.Intervention group showed an increased perception of the harm of alcohol use and increased assertiveness skillsa
NACheng et al. (2012) [50]MethamphetamineUSA, 11–14, 982 parts presented on an autostereoscopic 3D displayEducationalUniversalNABaseline and post-test measured immediately before and after playing the gameMean increase of correct-answer rate for understanding of brain structures and their function of 54.48%a; understanding of the impact of methamphetamine use on the brain increased by 28.06%a; more negative attitudes towards methamphetamine useb
The Reconstructors: Uncommon ScentsKlisch et al. (2011) [45]InhalantsUSA, 11–14, 444Online, 3 episodesEducationalUniversalNABaseline measured 3–5 days before the first episode was played; post-test measured 3–7 days after the final episodeIncrease in content knowledge from baseline mean of 13.60 to post-test mean if 17.63a; more negative attitudes towards inhalants (baseline mean 1.79, post-test mean 1.65)a
The Reconstructors: Nothing to Rave AboutMiller et al. (2006) [48]MDMAUSA, 12–13, 289Online, 3 episodesEducationalUniversalNABaseline taken a minimum of 3 days before playing the first episode; post-test measured a minimum of 3 days after the last episodeIncreases in percentage of correct answers: mean increase of 7% after episode 1,a 17% after episode 2,a 28% after episode 3a
The Reconstructors: A Plaguing ProblemMiller et al. (2002) [47]OpioidsUSA, 12–13, 148Online, 5 episodesEducationalUniversalNABaseline taken a minimum of 2 days before playing the first episode; post-test measured a minimum of 2 days after the last episodeIncreases in percentage of correct answers: mean increase of 12% after episode 1,a 14% after episode 2a
Head OnMarsch et al. (2007) [43]Tobacco, alcohol, cannabisUSA, 12, 272CD-ROM, 15 lessonsSocial influenceUniversalAn alternate prevention program (Life Skills Training program)Baseline taken before and post-test taken after playing through the lessons, time frame not specified.Significant increases in knowledge about drug abuse prevention; reduced frequency of smoking, drinking and marijuana use; effect greater in intervention group than control groupa
NANoble et al. (2000) [49]CocaineUK, 10–11, 101CD-ROMEducationalUniversalNAPost-test onlyQualitative data suggested that the majority of students felt they had learnt something about cocaine; common responses indicated participants learnt about some of the negative effects cocaine can have

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

This is the first review of computerised SEGs targeting alcohol and other drug use in adolescents. Eight trials of computerised SEGs were identified, seven of which showed quantitative evidence for positive outcomes, including the reduction of alcohol and drug use for one game which adopted a social influence approach. The most frequently measured outcomes were content/knowledge acquisition and increased negative attitudes towards the targeted drug. Results show that SEGs on this subject can be a potentially effective method for teaching and perhaps even for changing attitudes and behaviours towards alcohol and other drug use. If further studies show SEGs can be effective in changing attitudes and behaviours towards alcohol and other drug use, they could potentially reduce the significant harm and costs associated with alcohol and other drug use by young people, especially if they are able to delay the initiation of drug use [6–9].

Although the number of trials identified in this review is very small, the results have implications for the use of SEGs for educating people and preventing the use of alcohol and other drugs. The results of this study, indicating that playing SEGs about alcohol and other drugs can lead to knowledge acquisition and potential changes in attitudes and behaviour, parallels the effects shown for SEGs on other educational topics [10,23–28]. However, evidence suggesting that SEGs on alcohol and other drugs are more effective than traditional methods of teaching is still needed due to the absence of comparable control groups. Future studies should seek to include control groups where participants would be taught the content provided in the game through traditional teaching methods or have only the outcome measures recorded and receive no educational material.

A limitation to this study is the small number of trials included in this review and the inconsistency of the outcome measures assessed. It would be useful to investigate whether the content knowledge gained and changes in attitudes also accompanied changes in behaviours in the studies that did not already measure this. On top of this, in the selected studies, the longest delay before taking the post-test measures was three days; a more delayed follow-up at post-test would be useful in determining whether the measured outcomes were lasting. Additionally, none of the games were evaluated more than once, highlighting the need for cross-validation and replication studies of these existing games to provide further support for the effectiveness of SEGs about alcohol and other drugs for adolescents.

Overall, the results from the trials identified in this study and the evidence of effectiveness from SEGs on other educational topics suggest that computerised SEGs may have the potential to educate young people about and prevent the use of alcohol and other drugs. Further studies are needed to examine whether this approach can also change behaviours and if these changes persist in the long term. The further investigation and development of successful SEGs has the potential to lead to a new teaching method that engages students, can easily be implemented in schools and, importantly, addresses the significant harm and cost caused by alcohol and other drug use among young people.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Funding for this paper was supported by the Department of Health, Australian National Health and Medical Research Council Centres of Research Excellence in Mental Health and Substance Use and a National Health and Medical Research Council research fellowship to MT.

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  3. Introduction
  4. Methods
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  6. Discussion
  7. Acknowledgements
  8. References
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