The Impact of Playing Super U on Pre-adolescents' Body Image
Condition: Body Image
Study type: Interventional

Summary: 
      Body image concerns can have serious physical and psychological consequences on young people,
      including anxiety, depression, risk taking behaviours, eating disorders and suicidal
      ideation.

      Micro-interventions (brief, low intensity interventions), offer an alternative to
      traditional, intense interventions that aim to immediately improve specific symptoms. Body
      image micro-interventions have proven effective at providing immediate and short-term
      improvements in body image among adolescents within digital and community settings. To date,
      utilising micro interventions in the world of gaming remains unexplored. Specifically, the
      Roblox platform which is hugely popular among young people (Roblox, September 2022).

      As such, the aim of the present study is to conduct a randomised controlled trial (RCT) to
      evaluate the immediate and short-term impact of a Roblox game, Super U story, on American
      children and adolescents' body image, mood, internalisation of appearance ideals and social
      media literacy. The primary outcome is immediate change in state-based body satisfaction.
      Secondary outcomes include immediate changes in state-based mood and body functionality and
      short-term changes in trait body esteem, body appreciation, internalisation of appearance
      ideals and social media literacy.

      The Super U story was developed through a collaboration between Dove (Unilever), Toya (game
      developers) and The Centre for Appearance Research. It was specifically designed to target
      sociocultural risk and protective factors for body image including social media literacy,
      appearance comparisons, positive body image and teasing/bullying around appearance.

      The comparison control conditions include an active control; an alternative Roblox game;
      Rainbow Friends story which has been matched to the intervention on style, length, and age
      appropriateness (omitting body image messaging) and an attention control whereby participants
      complete a series of word searches.

      To undertake the main trial, 1,479 girls and boys will be recruited through an external
      research agency. Participants will be randomised to one of three conditions: 1) the Super U
      story intervention, 2) alternative Roblox game or 3) attention control. All participants will
      be encouraged to play the game/word search for a maximum of 30 minutes, where they will be
      assessed on state-body image and mood immediately before and after completing the game/word
      search. All participants will be assessed on trait body esteem, body appreciation,
      internalisation of appearance ideals and social media literacy at baseline (one week
      pre-intervention) and again at one-week post intervention.

      At the end of the study, all participants will receive a debrief form, outlining the study
      aims and objectives, and additional resources for body and eating concerns.
    

Detailed description: 
      Background:

      Extensive research has established that body image issues are evident in early adolescence
      and can have far-reaching negative consequences for young people. For instance, poor body
      image is predictive of various negative outcomes, including disordered eating, low
      self-esteem and mood, and risky health behaviours in early adulthood, such as smoking and
      drug use.

      Micro-interventions are designed to deliver content that aims to immediately improve specific
      symptoms, and they have been applied to adolescent and adult samples with body image and mood
      symptoms in community and digital environments. Digitally delivered micro-interventions have
      shown promise in improving some body image outcomes in the moment. Importantly, interactive
      micro-interventions that require active engagement with its content appear to be more
      effective than didactic or passive micro-intervention styles.

      Super U intervention:

      As such, this project involves the evaluation of 'Super U', a video game-based
      micro-intervention designed for American girls and boys. It was created in collaboration with
      the Dove Self-Esteem Project and Toya, a gaming studio that creates games for the Roblox
      platform, a hugely popular gaming platform among young people with over 57 million daily
      users (Roblox, September 2022). Super U is a narrative-based game, which centres around The
      Academy - a school for kids with superpowers - under siege by a group of rogue students bent
      on spreading negativity. The mission is to help players find their unique superpower of
      flight, fire, water, or speed, to dodge and destroy poisonous negativity to help save The
      Academy from being overcome. Through the engaging story of Super U, players receive messages
      that address known risk factors for poor body image and provide them with strategies that
      promote positive body image, such as learning to focus on what their body can do, instead of
      what it looks like; recognising that making comparisons can lead to body dissatisfaction;
      understanding the importance of critically evaluating messages on social media; and learning
      how to deal with appearance-related bullying.

      Research questions:

        1. Is the intervention acceptable (liked/recommended/children want to continue playing)
           among girls and boys in the US?

        2. Is the intervention effective in eliciting immediate state-based changes in body image
           and mood among girls and boys in the US?

        3. Is the intervention effective in eliciting short-term (one week) trait improvements in
           body image and related factors among girls and boys in the US?

      Design:

      To execute this study, the Centre for Appearance Research are collaborating with a research
      agency (C&R) based in the US. To test the effectiveness of Super U, we will conduct an online
      three-arm randomised controlled trial (RCT) among an equal number of girls and boys from a
      range of cities in the US.

      Participants:

      Recruitment will be outsourced to C&R, a US-based research agency. The research agency will
      recruit 90 participants for the pilot and 1479 participants for the main trial. The pilot and
      main trial samples will be composed of 50% girls and 50% boys, be evenly split among the age
      group (i.e., 9-13 years), and be representative of socioeconomic status and ethnicity. The
      research agency will recruit participants via their own recruitment panels of participants
      (children and teens) as well as through trusted and fully vetted national sample suppliers
      that they have successfully used in the past for research with this target group. Parental
      consent will be obtained.

      Sample size calculations:

      For the pilot, a minimum of N = 30 participants per arm (total sample N = 90) will be
      recruited. This recruitment objective was informed by the recommendations by Whitehead and
      colleagues, stating that for a main trial designed with 90% power and two-sided 5%
      significance, the pilot sample sizes per arm should include a minimum of 25 participants for
      standardised effect sizes that are expected to be small (0.2), as the ones of similar online
      micro-interventions have been.

      For the main trial, the investigators will aim to recruit 1,479 participants (N = 493 per
      arm). Considering one primary outcome (state body satisfaction), and one primary end point
      (i.e., post-test), an a-priori power analysis based on an ANCOVA model with 3 groups and 3
      covariates found that a total sample size of 967 participants would be necessary to detect
      small effects (F = 0.10) when considering 80% power and alpha levels of 0.05. Similar studies
      testing micro-interventions online show dropout rates at post-test up to 34.39%. The
      investigators have therefore inflated the initial sample of 967 by 35% to ensure sufficient
      power at post-test. Said inflation resulted in our target sample of 1479 participants, for
      which the investigators will aim to have a balanced distribution of gender identities and age
      across arms.

      Procedure:

      All participants will be asked to complete an online questionnaire of trait-based measures
      one week prior to receiving the intervention. Participants will complete these trait-based
      measures from their home and they will take approximately 30 minutes to complete. The
      questionnaires will be hosted on C&R's secure survey platform. Participants who complete the
      first questionnaire will then be randomised, into one of 3 groups:

        1. Intervention condition: One third of participants will be randomised to receive the
           intervention (Super U story) described above.

        2. Active control condition: One third of participants will receive an active control
           activity in the form of an alternative Roblox game; Rainbow Friends story which has been
           matched to Super U in terms of length, age appropriateness, story type and challenges.

        3. Attention control condition: One third of participants will receive an attention control
           activity (complete word searches).

      All participants will have a maximum of 30 minutes to play the game/complete word search.

      Outcome measures (described in detail elsewhere):

      To assess the immediate impact of playing Super U on body image and mood, all participants
      will complete state-based measures for body satisfaction, body functionality, and mood
      immediately prior to game play. At the end of game play, participants will complete the same
      state-based measures of body satisfaction, body functionality, and mood. Participants will
      also complete trait-based measures at follow up (one week after the completion of the
      intervention).

      Other measures:

      Demographics: The baseline questionnaire will capture information on age, gender, ethnicity,
      socio-economic status and Roblox game play frequency.

      Acceptability: At post-intervention, intervention group participants will answer quantitative
      and qualitative questions regarding acceptability of the intervention directly following the
      state-based items.

      Levels of engagement: At post-intervention, intervention group participants will respond to
      questions regarding which parts of the Super U story intervention they engaged with to track
      individual engagement with the active ingredients of the intervention.

      Data quality measures: Items will be embedded within the surveys to assess data quality
      (e.g., questions to evaluate participants' attention).

      Pilot study:

      Initially, a pilot study will be run in the same format as the main trial (described above)
      with the intent to test and confirm the following to refine and validate the research design:

        -  Confirm recruitment strategy

        -  Assess the attrition rate for each phase

        -  Analyse acceptability data

        -  Assess any other elements that can help support the smooth running of the main trial

        -  Identify how many people engage with key elements of the game
    

Intervention name(s): Super U Story intervention; Alternative Roblox game; Online word search
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Participants in this condition will be asked to play a Roblox adventure video game called 'Super U Story'. They will play the game once and have between 6 - 30 minutes to complete the game.; Participants in this condition will be asked to play an alternative Roblox adventure video game called Rainbow Friends Story (colour story). They will play the game once and have between 6 - 30 minutes to complete the game.; Participants in this condition will have 20 minutes to complete a series of word searches online.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention