Liyuan Wang

BACKGROUND Despite recent declines in unintended teen pregnancies attributed to family planning services, socioeconomically disadvantaged and highly mobile youth (HMY)—those experiencing frequent residential transitions—remain disproportionately at risk. Traditional teen pregnancy prevention (TPP) programs often fail to effectively engage these youth due to their unstable life circumstances and limited access to conventional prevention resources. OBJECTIVE This paper describes the design, usability testing, and key lessons learned from the development of gamification elements involving interactive narratives for "My Future-Self (MFS)," an innovative, hybrid intervention tailored specifically for HMY. This manuscript highlights the experience of interdisciplinary collaboration in the development of gamified elements of behavioral change interventions. METHODS We employed a User-Centered Design (UCD) framework, emphasizing iterative collaboration among adolescent unintended pregnancy prevention intervention scientists, game designers, and HMY advisors (N=96; mean age=19.86, SD=1.41). Initial surveys assessed HMY’s game aesthetics preferences, technology access, intimate relationships, and specific life experience with medical professionals and use of contraception in order to guide prototype development of gamified interactive content. Two 10 minute gaming activities were developed; one around visiting a physician office to discuss contraception and one using scenarios to practice healthy communication with an intimate partner. Iterative usability testing involved structured playtesting sessions with 12 youth with HMY experience utilizing think-aloud protocols, semi-structured interviews, and thematic feedback analysis. Throughout development, distinct goals representing a) intervention developers (i.e. contributions to behavior change) and b) game designer/producers (i.e. user engagement) were clarified, aligned, and operationalized to optimize gaming elements’ contribution to the small group intervention’s behavior change effectiveness. RESULTS Playtesting revealed high user appreciation for realistic and immersive scenarios; however, feedback also underscored the necessity for clearer context and increased user agency within the intimate partner gaming element. Iterative refinements resolved usability barriers and significantly enhanced gaming elements’ acceptability. Key lessons learned included the critical importance of clearly defining and aligning interdisciplinary goals early in the design process, positioning intervention scientists as lead designers, adapting gamified interventions to realistic user-engagement expectations, and proactively integrating cultural relevance throughout inclusive content. CONCLUSIONS Explicitly addressing interventionists’ and game designers’ distinct goals was crucial to achieving successful interdisciplinary alignment. Employing a collaborative, iterative UCD approach significantly strengthened interdisciplinary understanding of the gaming elements’ purpose, enhancing the design relevance and usability of the MFS gamified intervention for HMY. The identified lessons learned provide valuable insights for future development and production of gamified health interventions through the partnering of intervention developers with game designers and end users of resultant intervention program.

Background: A just-in-time adaptive intervention (JITAI) is “designed to address the dynamically changing needs of individuals via the provision of the type or amount of support needed, at the right time when needed.” If and how rumination-focused cognitive behavioral therapy (RFCBT), the gold standard, blocks emotional cascades underlying rumination is unclear. Furthermore, cognitive behavioral therapy has been successfully used as a mobile variant, but RFCBT has not been adapted for a mobile variant (mobile RFCBT [MRFCBT]) or for a JITAI variant. Objective: This study aimed to pilot-test a fully automated JITAI leveraging RFCBT and ways to identify and block cascading depressive rumination. Methods: Patients in therapy for clinical depression were recruited for a randomized controlled trial (RCT). After consenting to be part of the RCT, they were randomly assigned to either of the 2 mobile versions of the RFCBT conditions personalized to the individual’s rumination timing patterns (JITAI-MRFCBT) or a no-treatment control condition through a double-blind procedure. Although the initial design was to have a 3-armed trial with 2 JITAI conditions (a JITAI and a narrative JITAI condition), we later opted to collapse those 2 conditions into 1 JITAI condition because of the low number of participants. All participants were recruited and participated through their smartphones, receiving 5 SMS text message reminders on each of the 35 days to self-report their rumination-related symptoms (eg, rumination episodes and duration). In the JITAI-MRFCBT condition, they also received treatment materials. The first 7 days provided a rumination baseline, and the last 7 days provided a postintervention rumination value. In total, 42% (25/59) of volunteers were eligible and provided their phone numbers, 20% (5/25) of whom never replied to the SMS text message reminding them to start the RCT. A total of 90% (18/20) of volunteers completed it (ie, finishing, as prespecified, 80% of the questionnaires and training tasks) and, therefore, were included in the analysis. Results: Using independent 2-tailed t tests with bootstrapping, results showed that participants in the JITAI-MRFCBT condition, compared with those in the control condition, reported a greater reduction in counts of rumination episodes (mean −25.28, SD 14.50 vs mean 1.44, SD 4.12, P<.001) and greater reduced average time (minutes) spent in rumination (mean −21.53, SD 17.6 vs mean 1.47, SD 1.5; P=.04). Results also suggest that, compared with those in the control group, those in treatment reduced ruminative carryover from one episode to the next. Conclusions: The results suggest that JITAI-MRFCBT may reduce negative rumination by providing RFCBT just in time following rumination, thereby blocking the next rumination episode using the same trigger. This study supports a subsequent, full-scale JITAI and the importance of leveraging mobile smartphone technology with MRFCBT to curb depressive symptoms. Trial Registration: ClinicalTrials.gov NCT04554706; https://clinicaltrials.gov/ct2/show/NCT04554706

BACKGROUND A just-in-time adaptive intervention (JITAI) is "designed to address the dynamically changing needs of individuals via the provision of the type/amount of support needed, at the right time… when needed." If and how Rumination Focused Cognitive Behavior Therapy (RFCBT), “the gold standard”, blocks emotional cascades underlying rumination is unclear. Further, CBT has been successfully used as a mobile variant (MCBT) but RFCBT has neither been adapted for a mobile variant (MRFCBT) nor for a JITAI variant. OBJECTIVE To pilot-test a fully automated JITAI intervention, leveraging rumination-focused CBT (RFCBT), and ways to identify and block cascading depressive rumination. METHODS Patients in therapy for clinical depression were recruited for the randomized controlled trial (RCT). After consenting to be part of the RCT, they were randomly assigned to a mobile version of RFCBT condition personalized to the individual’s own rumination timing patterns (JITAI- MRFCBT) or a no-treatment control condition through a double-blind procedure. All were recruited and participated through their smartphone and received five text-message reminders per each of 35 days to self-report their rumination-related symptoms (e.g. rumination episodes and durations). In the JITAI-MRFCBT condition, they also received treatment materials. The first 7-days provided a rumination baseline; the last 7-days a post-intervention rumination value. Out of 59 volunteers, 25 were eligible and provided their phone numbers. Five out of 25 of volunteers never replied to the text-message reminding them to start the RCT. Among the twenty participants who logged on the RCT. Eighteen of the remaining 20 accomplished the current RCT (i.e., finishing, as pre-specified, 80% of the questionnaires and training tasks) and were therefore included in the analysis. The intensive within-person design measures daily rumination symptoms and change within each of the 18 individuals. RESULTS Using independent t-tests with bootstrapping, results showed that participants in the JITAI-MRFCBT, compared to the control condition, reported greater reduction of counts of rumination episodes (M=-25.28, SD=14.50 versus M=1.44, SD=4.12, p<.01, 95 CI [14.25, 33.67]) and in average time (minutes) spent in rumination (M=-21.53, SD=17.6, versus M=1.47, SD=1.5; p=.04, 95 CI [10.58, 32.00]). Results using Group Iterative GIMME suggest that compared to the control, those in the JITAI-MRFCBT condition reduced ruminative carryover from one episode to the next . CONCLUSIONS Results suggest that JITAI-MRFCBT may reduce negative rumination by providing RFCBT just-in-time following rumination and by, thereby, blocking the next rumination episode with the same trigger. This study supports a subsequent, full-scale JITAI intervention, and the importance of leveraging mobile smartphone technology with MRFCBT to curb depressive symptoms. CLINICALTRIAL NCT04554706

The current study assessed whether vicariously experiencing story characters granting a small favor can induce similar intentions from its audiences. Acting upon the perspectives of story characters, audiences may agree to a subsequent larger request to the same cause, as in the case of vicarious foot-in-the-door (VFITD). Study 1 found that a VFITD story was more effective in eliciting prosocial intentions than a non-VFITD story and a non-narrative message. That is, the VFITD condition generated greater intentions to volunteer in a series of activities, with attitudes mediating this process. Study 2 replicated this result. It also showed that when a VFITD story can generate sufficient levels of identification, it is more effective than a non-VFITD narrative in eliciting prosocial intentions. Implications of this study are also discussed.

Avatars or agents are digitized self-representations of a player in mediated environments. While using agents to navigate through mediated environments, players form bonds with their self-agents or characters, a process referred to as identification. Identification can involve automatic, but temporary, self-concept “shifts in implicit self-perceptions” (Klimmt et al., 2010, p. 323) of the media user by adopting or emphasizing the action choices on behalf of the social expectation of the avatar in the mediated environment. In the current study, we test the possibility that users' identification with video game avatars–a bond built between avatars and players- would account for subsequent behavior changes. We did so by using 3-month longitudinal data involving a narratively-based serious game: Socially Optimized Learning in Virtual Environments (SOLVE), a 3D-interactive game designed to reduce risky sexual behaviors among young men who have sex with men (n = 444). Results show that video game identification predicts both the reduction of risky sexual behaviors over time, and reduction in the number of non-primary partners with whom risky sex occurs. And when players identify with the game character, they tend to make healthier choices, which significantly mediates the link between video game identification and reduction of risky behaviors.

Social support differs for depressed and non-depressed individuals. However, the structural features of social supports, as represented via social networks and how they are related to depression, and its mitigation, are unclear. Here, we examine associations between personal support network structures and self-reports of depression and depression mitigation behaviors. Cross-sectional data were collected from participants (n = 1002 adults) recruited from a research volunteer website. Personal support networks were elicited by asking participants to nominate up to six people (i.e., confidants) that they talk to about interpersonal problems (e.g., unpleasant social encounters) and to indicate who knows whom among their confidants. Results show that the confidant networks of depressed and non-depressed participants did not differ in network size or in constraint—i.e., the degree to which confidants’ ties overlap with the ties of the participant. However, depressed participants’ confidants had significantly fewer average ties with one another (mean degree). Irrespective of depression diagnosis, lower network constraint and size predicted greater engagement in depression mitigation behaviors. That is, having relatively large confidant networks within which one can freely navigate one’s personal information can contribute to improvement in depressive outcomes. Implications are further discussed in the discussion section.

Causal inference and generalizability both matter. Historically, systematic designs emphasize causal inference, while representative designs focus on generalizability. Here, we suggest a transformative synthesis – Systematic Representative Design (SRD) – concurrently enhancing both causal inference and “built-in” generalizability by leveraging today’s intelligent agent, virtual environments, and other technologies. In SRD, a “default control group” (DCG) can be created in a virtual environment by representatively sampling from real-world situations. Experimental groups can be built with systematic manipulations onto the DCG base. Applying systematic design features (e.g., random assignment to DCG versus experimental groups) in SRD affords valid causal inferences. After explicating the proposed SRD synthesis, we delineate how the approach concurrently advances generalizability and robustness, cause-effect inference and precision science, a computationally-enabled cumulative psychological science supporting both “bigger theory” and concrete implementations grappling with tough questions (e.g., what is context?) and affording rapidly-scalable interventions for real-world problems.

A just-in-time, adaptive intervention (JITAI) is an emerging type of intervention that provides tailored support at the exact time of need. It does so using enabling new technologies (e.g., mobile phones, sensors) that capture the changing states of individuals. Extracting effect sizes of primary outcomes produced by 33 empirical studies that used JITAIs, we found moderate to large effect sizes of JITAI treatments compared to (1) waitlist-control conditions (k = 9), Hedges’s g = 1.65 and (2) non-JITAI treatments (k = 21), g = 0.89. Also, participants of JITAI interventions showed significant changes (k = 13) in the positive direction (g = 0.79). A series of sensitivity tests suggested that those effects persist. Those effects also persist despite differences in the behaviors of interests (e.g., blood glucose control, recovering alcoholics), duration of the treatments, and participants’ age. Two aspects of tailoring, namely: (1) tailoring to what (i.e., both people’s previous behavioral patterns and their current need states; with these effects additive) and (2) approach to tailoring (i.e., both using a human agent and an algorithm to decide tailored feedback; with these effects additive), are significantly associated with greater JITAI efficacy.

A secondary analysis investigated the influences of verbal stigmatization from family members on the psychological well-being of Latino homosexual males. A model was proposed to explain effects of being exposed to labeling stigma messages that supported both Stigma Communication Model and Revised Labelling Theory. Results showed exposure to verbal stigma messages, especially those with labeling and name calling, was associated with low self-esteem, perceived social support, and highly stigmatized beliefs. Such effects were also related to one’s emotion reactions, especially the feeling of shame, toward verbal stigmatization. Implications for interpersonally communicated stigma messages in general and further study directions were discussed.