An Interactive Narrative Intervention to Increase Adolescents' Knowledge and Self-Efficacy to Reduce Alcohol Use: Pre-Post Study.

Background: Accidents and injuries are the leading causes of preventable death among adolescents and are often related to substance use. About 60% of US high school students have tried alcohol and 22% report current alcohol use. Preventing and reducing adolescent alcohol use would contribute to substantial health benefits and prevent major health morbidity and mortality. Advances in interactive narrative learning technologies hold promise for designing games for health that effectively deliver age-appropriate and personalized behavior change interventions. The Interactive Narrative System for Patient-Individualized Reflective Exploration (INSPIRE) is designed to serve as an extension to clinical preventive care, engaging adolescents in a theoretically grounded alcohol prevention intervention by leveraging the dual mechanisms of interactive narrative and 3D game technologies. Objective: This pre-post study aims to examine the impact of INSPIRE on adolescents' self-efficacy to avoid risky alcohol-related behavior and knowledge about alcohol risk. Methods: A total of 44 adolescents in high school (aged 14-16 years; mean 15.16, SD 0.95; n=22, 50% female) were recruited using convenience sampling from an after-school program in the San Francisco Bay Area. The largest proportion of participants identified as Hispanic or Latine (n=15, 34%), followed by White, Asian, and multiple racial or ethnic backgrounds. Participants completed two 20-minute web-based interactive narrative episodes. We compared pretest and posttest data to examine changes in adolescents' self-efficacy and knowledge using a combination of questionnaire and computer interaction trace log data. Self-efficacy was measured using a 24-item scale (α=.95; 0-10 rating). Knowledge was assessed using 10 multiple-choice items derived from in-game content. Pre-post changes were analyzed using Wilcoxon signed-rank tests (α=.05), with rank-biserial correlation effect sizes and 95% CIs. Results: Approximately 25% (n=11, 95% CI 14.6%-39.4%) of study participants reported having consumed alcohol at least once, and 23% (n=10, 95% CI 12.8%-37.0%) reported alcohol use within the past year. Self-efficacy scores significantly increased from 7.97 (SD 2.24) at pretest to 8.72 (SD 1.58) at posttest, with a mean difference of 0.75 (95% CI 0.59-0.91; P<.001; r=0.89). Knowledge scores also significantly increased from 5.09 correct (median 5.0, IQR 4.0-6.0) at pre-test to 6.11 correct (median 7.0, IQR 5.0-8.0) at posttest, with a mean increase of 1.02 (95% CI 0.31-1.74; Wilcoxon signed-rank test, P<.001; r=0.57). Reflection tool clustering revealed 4 behavioral strategy endorsement profiles. Conclusions: As a first of its kind interactive narrative intervention, INSPIRE offers an innovative theoretically grounded model for supporting adolescent health behavior change. This study enhances our understanding of how to use innovative learning technologies to reduce risky alcohol use. Extending prior research in the field through using personalized narrative adaptations, this study indicates that through reinforcing goals and decisions to avoid risky behavior, adolescents can enhance their self-efficacy beliefs to avoid risky alcohol use and increase their knowledge about alcohol risk. Implications of these outcomes include the potential to facilitate the generalization of preventive behaviors to real-life situations.