Acceptability Evaluation of the Use of Virtual Reality Games in Smoking-Prevention Education for High School Students: Prospective Observational Study
Authors: Guo Jong-Long , Hsu Hsiao-Pei , Lai Tzu-Ming , Lin Mei-Ling , Chung Chih-Ming , Huang Chiu-Mieh 
Published: September 2021

Background
Alternative forms of cigarettes, such as electronic cigarettes (e-cigarettes), are becoming increasingly common among adolescents. Many high schools now provide smoking-prevention education in an attempt to minimize the potential negative health effects and illness burdens e-cigarettes may induce in adolescents. However, it is often difficult to motivate young students to engage with traditional education regarding the harmful effects of tobacco; thus, the development of alternative approaches may be required.

Objective
In this study, we aimed to conduct an acceptability evaluation of educational virtual reality games designed to support smoking-prevention measures. We based the acceptability evaluation on the following two experience types: game-playing and content-learning experiences. The paths by which these experience types affect the intention to abstain from smoking were also examined.

Methods
We applied a prospective observational study design. We developed educational games based on three-dimensional virtual reality technology, in which participants operated joysticks to complete challenge tasks. To increase the possibility of the games fostering motivation to abstain from smoking, the ARCS motivational model (comprising attention, relevance, confidence, and satisfaction) was used as a framework during the games’ design. We measured the participants’ game-playing experiences by inquiring about the strength of the ARCS elements; content-learning experiences were measured using overall knowledge improvement and the perceived persuasiveness of the content. A total of 130 students participated in the program. Study hypotheses for this evaluation were derived from a literature review. We used partial least squares structural equation modeling to examine the proposed hypotheses.

Results
Based on the responses of the students to questionnaire items concerning attention, relevance, confidence, and satisfaction in the context of the games, most students agreed or strongly agreed that the educational games were motivational, and that their game-playing experiences were positive. Regarding content-learning experiences, there was a significant improvement in knowledge (t129=25.67, P<.001), and most students perceived themselves as being persuaded to abstain from smoking. Attention, relevance, and satisfaction significantly influenced perceived persuasiveness (t=3.19, P<.001; t=4.28, P<.001; and t=3.49, P<.001, respectively); however, confidence did not (t=0.42, P=.67). Perceived persuasiveness, relevance, and satisfaction significantly influenced the intention to abstain from smoking (t=3.57, P<.001). In addition to directly affecting the intention to abstain from smoking, indirect effects were observed from both relevance and satisfaction to intention via perceived persuasiveness (t=2.87, P=.004 and t=2.11, P=.04, respectively). However, intention was not significantly influenced by knowledge improvement.

Conclusions
Our findings revealed that the educational games were positively accepted by the participating students. This indicates that the integration of the ARCS framework and persuasive strategies is applicable for smoking-prevention education. We recommend that the games be included as teaching materials for smoking-prevention education.