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A Web-Based Escape Room to Raise Awareness About Severe Mental Illness Among University Students: Randomized Controlled Trial

A Web-Based Escape Room to Raise Awareness About Severe Mental Illness Among University Students:... Background: People with severe mental illness (SMI) face discriminatory situations because of prejudice toward them, even among health care personnel. Escape rooms can be a novel educational strategy for learning about and empathizing with SMI, thus reducing stigma among health care students. Objective: This study aimed to examine the effect of the Without Memories escape room on nursing students’ stigma against SMI. Methods: A pre- and postintervention study was conducted with a control group and an experimental group. A total of 306 students from 2 Andalusian universities participated in the study. Data were collected through a pre-post study questionnaire, consisting of an adapted version of the Attributional Style Questionnaire and a questionnaire on motivation for cooperative playful learning strategies. The control group carried out an escape room scenario without sensitizing content, whereas the experimental group carried out an escape room scenario on SMI, with both escape rooms being carried out in a 1-hour session of subjects related to mental health. To answer the research questions, a 2-way analysis of variance with repeated measures, a linear regression, and a 2-way analysis of variance were performed. Results: After the intervention, a significant reduction (P<.001) was observed in the experimental group in stigmatizing attitudes compared with the control group, in which no statistically significant changes (P>.05) were observed. In contrast, the linear regression (t =−22.15; P<.001) showed that there was an inverse relationship between flow and the level of reduced stigma. When controlling for having or not having a close relative, the intervention was also shown to be effective (P<.001) in reducing the stigma displayed, both for people with affected and unaffected relatives. Conclusions: Our findings suggest that the Without Memories escape room can be used as an effective tool to educate and raise awareness about stigmatizing attitudes toward SMI in university students studying health care. Future testing of the effectiveness of educational escape rooms should be designed with new programs through playful strategies of longer duration to evaluate whether they can achieve a greater impact on motivation, acquisition of knowledge, and awareness. In addition, the feasibility of implementing the Without Memories escape room in other careers related to health and community should be investigated. (JMIR Serious Games 2022;10(2):e34222) doi: 10.2196/34222 KEYWORDS escape room; severe mental disorder; higher education; nursing education; mental health; mental disorder; serious games https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al observed that the students perceive that it helps them to learn, Introduction consider that these types of activities are fun, and believe that they should be included in their training curricula [12]. Owing Background to the situation caused by the COVID-19 pandemic, the daily Severe mental illness (SMI) refers to different nosological face-to-face use of escape rooms has had to be transformed to entities with certain common severity criteria, lasting more than apply it during web-based teaching. Previous studies [13-15] 2 years, and is associated with a loss of functionality [1]. show that playful strategies have broad benefits in motivation Formally, it includes diagnoses such as schizophrenia, bipolar and academic performance in massive web-based open courses. disorder, or severe personality disorders. The main difficulty Objectives faced by this group is stigma. People who are affected from stigma face discriminatory situations that prevent them from University students in health care and social work studies are fully participating in society. Stigma is a multifactorial especially concerned that they are empathic with the population phenomenon that thrives on stereotypes and prejudices toward affected by mental disorders because they are one of the people with mental disorders. The most common stereotypes vulnerable groups in their professional future that they will have toward people with SMI are, for example, that they can be to attend to. The objective of this study was to evaluate the dangerous and commit more crimes than the general population impact of a web-based escape room on raising awareness of [2]; they can be violent, unpredictable, and dependent; and they SMI among university students in the health care branch during are responsible for their illness [2]. Stigma has severe the 2020-2021 academic year in web-based mode. The specific consequences on the quality of life and self-esteem of people objectives of this study were (1) to determine whether through with mental disorders, hindering their social inclusion [3], a web-based escape room, it is possible to modify the which, in turn, has a negative effect on finding work, being stigmatizing attitudes of university students taking a nursing economically independent, and having a solid circle of close degree regarding SMI; (2) to study the influence of the friends and supporters [4]. immersion (flow) experienced during the escape room experience and on the awareness of the participants toward To reduce stigma, different proposals for socioeducational stigma; and (3) to determine whether the degree of stigmatizing programs have been made, including the dissemination of attitudes is different between students with family members information, leisure activities such as sports or art, and contact with severe mental disorders and students without family with people with mental disorders. For example, in a members with SMI and to analyze whether the program has the meta-analysis study [5], through the analysis of 72 articles, it same effects on these people. was observed that educational and social programs had positive effects in reducing stigma in adults and adolescents with mental Methods illness. With the arrival of serious games and educational video games, Participants the possibilities of electronic resources in socioeducational All the participants were first-semester nursing students. The intervention are also beginning to be studied. For example, in participants were chosen based on the purpose of the research, the video game Stigma-Stop, which aimed at reducing stigma consideration of the resources available when performing the toward people with mental disorders, its characters had various intervention with web-based escape rooms, and the willingness mental disorders, with whom participants could empathize. The of the university teachers to carry out the intervention in their results of 552 students aged between 14 and 18 years showed class schedule. a statistically significant decrease in the levels of stigma toward Both the escape room of the control group and the escape room people with schizophrenia [6]. of the experimental group were used during class time in Playful strategies, such as video games, have the potential to subjects that had some content related to mental health. Students be widely motivating for students, making them pivotal to the enrolled in the first semester of their nursing degree could acquisition of social skills among young people with mental participate in the research if they gave their written consent. disorders [7] and to the reduction of stigma [8]. The escape room did not score on the average of the course, and no financial reward or any other type of incentive was In recent years, new forms of games have emerged and offered (Figure 1; Multimedia Appendix 1). established themselves as a leisure alternative, including escape rooms [9]. Escape rooms consist of being locked in a room, A total of 306 nursing students participated in the study, with solving a series of puzzles, unlocking locks, and finding hidden a mean age of 23.34 (SD 8.37) years, comprising 57 (18.6%) clues to escape from that room. Using a variety of settings and men and 249 (81.4%) women. They were selected through challenges, escape rooms create an experience that manages to cluster sampling, where a particular batch of students were be both motivating and educational for participants [10]. selected as participants, dividing them by participating classrooms. They were randomly allocated between the control The results of recent studies [11] show that games and the use group and the experimental group. The experimental group of escape rooms have been effective in engaging students in the consisted of 197 students with a mean age of 22.93 (SD 7.93) learning process and helping them retain information. In higher years, comprising 37 (18.8%) men and 160 (81.2%) women; education, specifically in the health care field, games have been the control group consisted of 109 students with a mean age of used to evaluate the theoretical and practical knowledge of nursing students and study their motivation, where it can be https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al 24.1 (SD 9.10) years, comprising 20 (18.3%) men and 89 questions were asked of the students before beginning the (81.7%) women. intervention about whether they had relatives who had SMI. The data showed that 67 students had relatives with SMI, with To fulfill the third objective of this study—to determine whether a mean age of 22.78 (SD 4.27) years. Of these 67 students, 23 the degree of stigmatizing attitudes is different between students (34.3%) belonged to the control group, 19 (82.6%) women and with family members with severe mental disorders and students 4 (17.4%) men, with a mean age of 23 (SD 4.62) years, and 44 without family members with SMI and to analyze whether the (65.7%) belonged to the experimental group, 38 (86.4%) women program has the same effects on these people—demographic and 6 (13.6%) men, with a mean age of 22.7 (SD 4.07) years. Figure 1. Flowchart followed for the selection of participants. from 1 to 9. It has a Cronbach α of .87. A higher score on this Ethics Approval questionnaire indicates a greater number of stigmatizing attitudes This study was conducted in accordance with the Declaration toward people with SMI. It measures the following four factors: of Helsinki. All participants provided written informed consent. Dangerousness—measures whether people with SMI pose Ethics approval was obtained from the Research Ethics a threat or create feelings of fear. An example question is, Committee of the University of Almería (Ref. UALBIO “Do you feel that people with SMI are dangerous?” 2021/01). Solidarity—measures the willingness to help a person with Instrument SMI; for example, “If I owned an apartment, I would rent it to people with SMI.” Attributional Questionnaire Coercion—people with SMI are required to participate in The 14-item abbreviated version of public stigma in mental treatment. An example of an item for this factor is “I think health (Spanish) was used, adapted from the Attributional it is in the best interest of the community where a person Questionnaire (AQ) 27 [16], with 14-point Likert-type questions with SMI lives to be placed in a psychiatric facility.” https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al Avoidance—indicates the willingness to live or work near were designed and evaluated according to the intervention group someone with SMI. For example, “I will share my car every (Table 1). day with a person with SMI.” Owing to sanitary measures arising from the COVID-19 situation, both escape rooms were designed on the web. The Motivation Questionnaire for Cooperative Playful escape rooms were prepared using the Genially digital platform, Learning Strategies allowing the creation of Click and Point spaces, which is why The Motivation Questionnaire for Cooperative Playful Learning it favors creating an interactive experience that can favor student Strategies [17] was used to evaluate the learning process, degree immersion. To create the scenarios proposed in the escape room, of immersion, and motivation toward gamified activities. It is images and illustrations from the FreePik resource bank were a Likert scale, ranging from 1 to 7, with 1 being totally disagree used, owing to a premium license for free use (Figures 2 and and 7 being totally agree. The flow factor has been used in this 3). questionnaire, with a Cronbach α of .83. An example of the items contained in the factor is, “While playing, I was not aware The main advantage of placing the escape room on the web is of what was going on around me.” the ease of implementation in different universities through a link. The steps to carry out both escape rooms were as follows: For this study, an escape room has been designed based on SMI, namely, the Without Memories escape room. The narrative is 1. On the official platform of the university (Blackboard that the main character must remember his or her identity and web-based learning platform), the class began, and the game leave the apartment where he or she is to be on time for an master explained in a general way what an escape room appointment. In the escape room, the player wakes up with no was, how the Genially platform was used, and that this memory of who or where he or she is and, through solving tests escape room was cooperative. Once any questions among and exploration, discovers that he or she is a young man with the students had been resolved, the escape rooms were a mental disorder. Through different elements, such as distributed to the students in teams of 4 people. newspapers, mobile phones, social networks, and computers, a 2. Each team was housed in a web-based workroom so that normalized life is gradually presented together with the different they could share ideas and opinions about solving the escape barriers that people with SMI face because of the stigma and room. They had 2 options: either one of them shared a discrimination they face; for example, difficulties in health screen and they solved it together through that screen or services or difficulty finding work. each person solved the escape room simultaneously on their computer, maintaining the relationship between their The escape room features linear mechanics: one test allows the partners in both options. next to be solved and so on until the final task, which requires The game master was in the general room of the Blackboard the resolution of 2 tasks to obtain the code that ultimately allows platform during the entire escape room implementation the player to exit. The escape room is web-based and is designed time, in case a team contacted to request clues. There was within the Genialy digital platform, designed as a graphic no limit to the number of clues, as it was important that adventure (Click and Point). The difficulty of the escape room they felt they could receive feedback and were able to get is low because it is designed for a nonexpert audience in these out of the escape room even if they had never played before. activities, and its duration is approximately 1 hour. Once the team passed the last test and managed to leave Procedure the escape room, they completed the posttest questionnaire individually. To investigate whether web-based escape rooms could modify stigmatizing attitudes toward SMI, 2 web-based escape rooms Table 1. Investigation procedure. Pretest Intervention Posttest Control group Attributional Questionnaire [14] and Motivation Escape room Attributional Questionnaire [14] and Motivation Questionnaire for Cooperative Playful Learning Locked In Questionnaire for Cooperative Playful Learning Strategies [16] Strategies [16] Experimental Attributional Questionnaire [14] and Motivation Escape room Attributional Questionnaire [14] and Motivation group Questionnaire for Cooperative Playful Learning Without Memo- Questionnaire for Cooperative Playful Learning Strategies [16] ries Strategies [16] https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al Figure 2. Example of elements where you must search for clues. Figure 3. Example of awareness elements mixed with clues for other puzzles. To design the escape room Without Memories, interviews were must be solved in a particular order. The experiment was conducted with people with SMI and 2 professionals from a conducted on the web and synchronously. The average duration local mental health association with the aim of understanding of the escape room was 60 minutes. the difficulties people with SMI deal with daily and the reality The escape room narrative involves waking up in a room without they face as told from their own experiences. The game design any memories of who or where you are. You must overcome for an escape room has a linear structure. Solving one clue will different challenges until you know that your name is Enrique, provide the object necessary to solve the next clue, and so on you have an SMI, and you have a normal life. and so forth until the students escape. Tasks in a linear room https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al The different tasks of the escape room are presented in the 277 students. Therefore, the sample size for this study was following formats inside the game: considered sufficient. • Computer: in this game, there are elements hidden around Before starting the analyses to answer the research questions, the room (click and point) that allow the student to know the direct scores of the administered tests were calculated using the password of a computer. On the computer, Enrique’s the corresponding descriptive statistics. browsing history can then be accessed, where there are 2 To answer the first research question, an ANOVA (2×2) with videos of awareness campaigns on mental health and mental repeated measures was performed for each factor of the AQ14, disorders, and Enrique’s social networks can be accessed, as well as another test for the total result of the battery. The where 2 conversations with friends and a conversation with Bonferroni correction was used as the adjustment method for his family physician are observed, in which he mentions the comparison of post hoc tests. difficulties related to medication, such as the fear of not being able to have erections and to relate intimately with To determine the relationship between flow and the change in the woman he likes. Between these conversations, the key stigmatizing attitudes, a linear regression was performed, in for the next test is observed. which the differential scores were calculated. In other words, • Diary and mobile phone: more conversations with Enrique’s pretest scores were subtracted from posttest measurements. family and friends are reflected on the mobile phone. These With the differential scores and the score obtained in the flow, conversations reflect Enrique’s concerns and limited the linear regression was performed with the score of the flow relationships. Some responses to his messages can be as an independent variable. interpreted as condescension, childishness, and other To address the last research objective, a 3-way ANOVA was behaviors that people with SMI reported in previous carried out for each of the factors and the total score of the interviews. It is also narrated how these people may have AQ14. a perception of the world that is different from the norm and may display different concerns and hobbies. The analyses were carried out using the R programing language • Safe and door: the safe is opened by means of a phrase that with the R Studio development environment. The libraries used is encoded in the computer. To achieve this, it is necessary were ggplot2, tidyverse, emmeans, and rstatix. to find the decoding key located in one of the rooms. This coded information allows the safe to be opened using Results information contained in the mobile phone and in the The means and SDs are presented in Table 2. To better bedroom and allows you to remember that you are Enrique, understand these results, it should be clarified that higher scores you are an adult, you have an SMI, and you have met the on the questionnaire indicate a greater stigma expressed by girl you like for a coffee. The box finally gives you the key participants. to open the door. When you click on the door again, there is a concluding message. This message provides statistical Regarding the first research question, ANOVAs (2×2) were information about SMI and the possibility that the player performed with repeated measurements. The results of the tests may have an SMI or meet someone close with an SMI in between the groups are reported in Table 3, which shows the the future. results of the ANOVAs along with the effect size using generalized eta squared. Post hoc tests are reported in this table, For the control group, an escape room called Locked In was indicating the group in which there are statistically significant prepared. This escape room is a copy of the previous one in differences together with significance. This table shows that all which all the elements that had been prepared to raise awareness, statistical differences were found in favor of the experimental such as narrative texts and correspondence on social networks, group in the posttest measurements. Table 4 indicates that the were removed, replacing them with others without any burden starting groups had equivalent scores, and statistically significant of awareness, as they are logical tests, puzzles, and numerical differences were found after applying the program. Regarding locks. The narrative of this escape room assumes that you wake the effect sizes found in the variables, it can be indicated that up in bed with no memories and must leave the apartment you are in. The steps for resolution are the same as those carried out in all the variables there is a large effect size (η >0.14), except by the experimental group; that is, they follow a linear logic in in coercion, where the size is medium, and avoidance, where which one test leads to another until the final resolution is the size is small (η >0.01). reached. As for the second research question, as already mentioned, a Data Analysis linear regression was carried out between the flow variables Initially, a sample size calculation was performed using the (mean 18.4, SD 3.16), such as the independent variable, and G*Power 3.1 program [18]. The parameters used for the the differential scores (mean −16.7, SD 18.4), such as the calculation were α=.05 and statistical power (1−β)=0.80. For dependent variable. The results obtained in the analysis indicated the effect size reference, the scientific literature was reviewed that the predictor variables explained 84.5% of the total variance [6,14,19]. The effect size was moderate (d>0.20). Using these (r =−0.845) and a moderate slope of the curve (β=−0.145; data, the minimum sample size needed for ANOVA testing was t =−22.15; P<.001); that is, the higher the score obtained for flow, the more the stigma displayed was reduced. https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al Table 2. Mean and SD (pre- and posttreatment) of the control and experimental groups. Control, mean (SD) Experimental, mean (SD) Pretest Posttest Pretest Posttest Dangerousness 17.93 (6.78) 17.91 (6.76) 18.03 (7.57) 11.01 (6.17) Solidarity 11.14 (5.5) 10.99 (5.39) 10.2 (5.48) 6.04 (3.58) Coercion 8.63 (4.51) 8.87 (4.5) 8.18 (4.72) 5.65 (3.82) Avoidance 11.86 (4.51) 11.78 (4.69) 11.16 (4.99) 8.13 (5.05) Total 49.56 (16.03) 49.55 (16.02) 47.57 (16.7) 30.83 (14.79) Table 3. ANOVA tests comparing between groups with the variables AQ14. Pretest Posttest Post hoc 2 2 η η F test (df) P value (adjusted) F test (df) P value (adjusted) g g b c,d Dangerousness 0.01 (1,304) .91 0 81.81 (1,304) <.001 0.212 Exp -Cont Solidarity 2.04 (1,304) .16 0.007 92.61 (1,304) <.001 0.234 Exp-Cont Coercion 0.67 (1,304) .41 0.002 43.81 (1,304) <.001 0.126 Exp-Cont Avoidance 1.52 (1,304) .22 0 38.60 (1,304) <.001 0.011 Exp-Cont Total battery 1.03 (1,304) .62 0.003 106.16 (1,304) <.001 0.258 Exp-Cont Bonferroni adjusted. Exp: experimental. Cont: control. P<.001. Table 4. ANOVA tests comparing within groups with the variables AQ14. Control Experimental Post hoc 2 2 η η F test (df) P value (adjusted) F test (df) P value (adjusted) g g Dangerous- 0.01 (1,108) .90 0 196.13 (1,196) <.001 0.206 Pre-post ness Solidarity 2.12 (1,108) .15 0 104.81 (1,196) <.001 0.169 Pre-post Coercion 3.68 (1,108) .58 0 55.42 (1,196) <.001 0.08 Pre-post Avoidance 0.47 (1,108) .49 0 64.61 (1,196) <.001 0.084 Pre-post Total battery 0.01 (1,108) .98 0 163.19 (1,196) <.001 0.221 Pre-post Bonferroni adjusted. P<.001. The means and SDs before and after the intervention are a close relative. In other words, people with a close relative with displayed in Table 5, differentiating those who reported having SMI display a lower level of stigma than those without a close a close relative and those who did not, both for the control group relative with SMI. and the experimental group. With the intention of knowing how the program affects the fact The results of the ANOVA indicated that having a close relative of having or not having family members with SMI, the 3-way influences the level of stigma of the participants in all study ANOVA was continued, and the results of this are reported for the posttest measures. The ANOVA results are presented in variables (dangerousness: F =6.33, P=.01, η =0.01; 1.604 g Table 6. In addition, the post hoc tests are reported, indicating solidarity: F =30.8, P<.001, η =0.04; coercion: F =25, 1.604 g 1.604 only the statistically significant results. 2 2 P<.001, η =0.04; avoidance: F =49.5, P<.001, η =0.08; g 1.604 g As can be seen, statistically significant differences were found and total battery: F =42.2, P<.001, η =0.06), with 1.604 g between the control and experimental groups, especially in the statistically significant differences in favor of people who have https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al case of not having a family member affected by SMI. In this for the variables dangerousness and total battery, there were case, statistically significant differences were observed in all statistically significant changes between the people in the control study variables. However, when someone had a family member and experimental groups who had family members affected by affected by SMI, no statistically significant changes were found SMI. for the variables solidarity, coercion, and avoidance, whereas Table 5. Means and SDs of participants with and without relatives with severe mental illness in the control and experimental group. Control-pre, mean (SD) Experimental-pre, mean (SD) Control-post, mean (SD) Experimental-post, mean (SD) Family No family Family No family Family No family Family No family Dangerousness 15.43 (5.68) 18.59 (6.92) 16.48 (7.59) 18.46 (7.53) 15.95 (6.03) 18.43 (9.92) 11.48 (5.95) 10.87 (6.24) Solidarity 7.91 (4.36) 12 (5.47) 7.48 (4.52) 10.96 (5.49) 7.82 (4.03) 11.83 (5.40) 5.58 (3.43) 6.16 (3.62) Coercion 6.39 (4.08) 9.23 (4.45) 5.81 (3.58) 8.83 (4.79) 6.69 (3.94) 9.45 (4.48) 4.60 (2.87) 5.94 (3.99) Avoidance 8.30 (4.34) 12.81 (4.08) 7.6 (4.65) 12.14 (4.62) 8.34 (4.93) 12.69 (4.19) 6.90 (4.85) 8.46 (5.06) Total 38.04 52.63 (14.86) 37.39 (16.70) 50.40 (15.61) 38.82 (15.90) 52.41 (14.86) 28.58 31.45 (15.33) (15.23) (12.56) Table 6. Three-way ANOVA with the interaction between the control and experimental group and whether they have declared a close relative or not in posttest measures. Family No family Post hoc 2 2 η η F test (df) P value (adjusted) F test (df) P value (adjusted) g g b c d Dangerousness 6.41 (1,65) <.001 0.011 67.512 (1,238) <.001 0.101 Exp -cont (no family) /exp- cont (family) Solidarity 3.317 (1,65) .280 0.005 77.812 (1,238) <.001 0.114 Exp-cont (no family) Coercion 3.61 (1,65) .232 0.006 37.40 (1,238) <.001 0.058 Exp-cont (no family) Avoidance 1.45 (1,65) .916 0 46.028 (1,238) <.001 0.071 Exp-cont (no family) Total battery 6.79 (1,65) .036 0.011 105.88 (1,238) <.001 0.148 Exp-cont (no family) /exp-cont (family) Bonferroni adjusted. Exp: experimental. Cont: control. P<.001. Persons without family members affected by severe mental illness. Persons with family members affected by severe mental illness. However, as stated earlier, escape rooms are an increasingly Discussion used tool in the educational field [23,24] because of their playful contribution and proximity to the current language of young Principal Findings people. This study sought to provide new methodologies to raise In this study, we investigated the effectiveness of an escape awareness among the young adult population, especially room as an awareness tool based on empathizing or putting university students who in their professional future could work oneself in the role of a leading character with an SMI. The with people with severe mental disorders. There are very few intervention significantly reduced the stigmatizing attitudes of studies that have used a web-based methodology [20], and at university students in the experimental group compared with present, we do not know about any other study that has been the control group. It is worth highlighting the size of the large based on an escape room, despite being a methodology that is effect observed in the factors of danger, perceived fear, and in being used more and more in the educational field. A recent solidarity, variables in which the greatest reduction was systematic review on this topic did not identify any studies that obtained. applied this tool [21]. Applying them in a web-based format is also novel and, of course, was brought on by the effects of the Dangerousness is the most common stigma dimension in the pandemic, which resulted in a rapid adaptation to these methods general population [25], and it scored the highest in the [22]. pretreatment evaluation in this study. In contrast, because of https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al the characteristics of the sample, the intervention also had a interpretation of the effect size. Second, the specific great effect on solidarity. More specifically, providing characteristics of the participants and the possible confounding information about mental health problems in a participatory factors that may influence the results, such as their sociocultural way, such as in the escape room, favored the strengthening of origin, their level of knowledge, and their desire to work with this variable. patients with SMI, were not evaluated; the only exception was whether they had family members with SMI, in which case they The implementation of the escape room was carried out with were evaluated. Finally, another limitation was not conducting university students from the health sector, which is important a reevaluation months after the intervention to determine considering that some of these professionals will work directly whether the changes achieved in the experimental group could with people affected by SMI, and their expectations and beliefs be perpetuated over time. will affect the recovery of their patients [26]. Another aspect that should be highlighted is that professionals who work in the Conclusions field of mental health continue to have negative beliefs, Mental health awareness is a very important subject for the paternalistic attitudes, and even restrictive and directive attitudes proper professional development of health care students. It is on occasions [27]. These can have repercussions not only on the responsibility of university teachers to prepare students to recovery but also on the patients’ own perception of themselves, learn, understand, and know how to work with their patients. causing them to label themselves in a stigmatizing way, which The lack of theoretical knowledge and stigma toward people is known as self-stigma [28]. with SMI can contribute to discrimination toward this group, which, in turn, can influence their self-esteem and quality of In contrast, it has been proven how the narrative of the story life. Therefore, it is necessary to implement new strategies in and immersion in the activity encourage the re-elaboration of university education to improve the knowledge and awareness value judgments that alter the beliefs and attitudes of people of mental disorders. The integration of playful strategies such with SMI. Escape rooms have already been tested as active as escape rooms can be of great interest because of their methodological tools that promote motivation and student immersive and motivating capacity. commitment toward learning [10,29], obtaining good results when they have been applied. Similar studies [30-32] have found Without Memories, a web-based escape room where the narrative that it is possible to reduce stigma through other methodologies, is about a character with SMI, is an effective tool to promote and the interesting aspect of this study is that it is able to raise awareness around mental health because it favors learning by awareness through a playful activity that is easy to implement discovery and playful challenges through attractive dynamics and replicate. and mechanics, which can encourage students to learn about SMI and be more empathetic toward these people. As for other findings, a variable found to influence the results is whether the person has a family member with mental health Future studies could use this escape room not only in nursing problems. When a person has a family member with this type degree studies but also in other degrees related to health and of difficulty, we can observe that the stigma is lower and community education to promote awareness among other possibly owes to the greater knowledge and direct contact that professionals who also have direct contact with people with an individual has around these problems, which is fundamental SMI. Furthermore, future research could assess whether the in the reduction of stigma [33]. results on the impact of playful strategies for mental health awareness vary because of other sociodemographic factors. Limitations Finally, the duration of the escape room Without Memories is This study has several limitations. First, the sample is relatively very limited, and although this may have benefits for its small, it comes from 2 universities, and it is not representative replication, there is a need to plan future awareness programs of the general population. Furthermore, the sample of university through playful strategies of longer duration to evaluate whether students included only individuals from nursing schools. This they can achieve a greater impact on motivation, acquisition of may undermine the generalizability of the results and limit the knowledge, and awareness. Conflicts of Interest None declared. Editorial Notice This randomized study was not registered, explained by authors on the basis that the subjects were nursing students. The editor granted an exception from ICMJE rules mandating prospective registration of randomized trials, given that the subjects were undergraduate students. However, readers are advised to carefully assess the validity of any potential explicit or implicit claims related to primary outcomes or effectiveness, as retrospective registration does not prevent authors from changing their outcome measures retrospectively. Multimedia Appendix 1 CONSORT-EHEALTH checklist (V 1.6.1). [PDF File (Adobe PDF File), 381 KB-Multimedia Appendix 1] https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al References 1. Conejo Cerón S, Moreno Peral P, Morales Asencio JM, Alot Montes A, García-Herrera JM, González López MJ, et al. Opiniones de los profesionales del ámbito sanitario acerca de la definición de trastorno mental grave. Un estudio cualitativo. An Sist Sanit Navar 2014;37(2):223-233 [FREE Full text] [doi: 10.4321/s1137-66272014000200005] [Medline: 25189980] 2. Zhang Y, Kuhn SK, Jobson L, Haque S. A review of autobiographical memory studies on patients with schizophrenia spectrum disorders. BMC Psychiatry 2019 Nov 14;19(1):361 [FREE Full text] [doi: 10.1186/s12888-019-2346-6] [Medline: 31727046] 3. Galán Casado D, Castillo Algarra J, García Tardón B. Deporte e inclusión social en personas con Trastorno Mental Grave (TMG). 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[doi: 10.1016/j.cpr.2019.02.001] [Medline: 30908990] Abbreviations AQ: Attributional Questionnaire SMI: severe mental illness Edited by N Zary; submitted 12.10.21; peer-reviewed by N Gronewold, A Teles, X Wang; comments to author 23.12.21; revised version received 09.02.22; accepted 17.02.22; published 05.05.22 Please cite as: Rodriguez-Ferrer JM, Manzano-León A, Cangas AJ, Aguilar-Parra JM A Web-Based Escape Room to Raise Awareness About Severe Mental Illness Among University Students: Randomized Controlled Trial JMIR Serious Games 2022;10(2):e34222 URL: https://games.jmir.org/2022/2/e34222 doi: 10.2196/34222 PMID: ©Jose M Rodriguez-Ferrer, Ana Manzano-León, Adolfo J Cangas, Jose M Aguilar-Parra. Originally published in JMIR Serious Games (https://games.jmir.org), 05.05.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 11 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

A Web-Based Escape Room to Raise Awareness About Severe Mental Illness Among University Students: Randomized Controlled Trial

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Abstract

Background: People with severe mental illness (SMI) face discriminatory situations because of prejudice toward them, even among health care personnel. Escape rooms can be a novel educational strategy for learning about and empathizing with SMI, thus reducing stigma among health care students. Objective: This study aimed to examine the effect of the Without Memories escape room on nursing students’ stigma against SMI. Methods: A pre- and postintervention study was conducted with a control group and an experimental group. A total of 306 students from 2 Andalusian universities participated in the study. Data were collected through a pre-post study questionnaire, consisting of an adapted version of the Attributional Style Questionnaire and a questionnaire on motivation for cooperative playful learning strategies. The control group carried out an escape room scenario without sensitizing content, whereas the experimental group carried out an escape room scenario on SMI, with both escape rooms being carried out in a 1-hour session of subjects related to mental health. To answer the research questions, a 2-way analysis of variance with repeated measures, a linear regression, and a 2-way analysis of variance were performed. Results: After the intervention, a significant reduction (P<.001) was observed in the experimental group in stigmatizing attitudes compared with the control group, in which no statistically significant changes (P>.05) were observed. In contrast, the linear regression (t =−22.15; P<.001) showed that there was an inverse relationship between flow and the level of reduced stigma. When controlling for having or not having a close relative, the intervention was also shown to be effective (P<.001) in reducing the stigma displayed, both for people with affected and unaffected relatives. Conclusions: Our findings suggest that the Without Memories escape room can be used as an effective tool to educate and raise awareness about stigmatizing attitudes toward SMI in university students studying health care. Future testing of the effectiveness of educational escape rooms should be designed with new programs through playful strategies of longer duration to evaluate whether they can achieve a greater impact on motivation, acquisition of knowledge, and awareness. In addition, the feasibility of implementing the Without Memories escape room in other careers related to health and community should be investigated. (JMIR Serious Games 2022;10(2):e34222) doi: 10.2196/34222 KEYWORDS escape room; severe mental disorder; higher education; nursing education; mental health; mental disorder; serious games https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al observed that the students perceive that it helps them to learn, Introduction consider that these types of activities are fun, and believe that they should be included in their training curricula [12]. Owing Background to the situation caused by the COVID-19 pandemic, the daily Severe mental illness (SMI) refers to different nosological face-to-face use of escape rooms has had to be transformed to entities with certain common severity criteria, lasting more than apply it during web-based teaching. Previous studies [13-15] 2 years, and is associated with a loss of functionality [1]. show that playful strategies have broad benefits in motivation Formally, it includes diagnoses such as schizophrenia, bipolar and academic performance in massive web-based open courses. disorder, or severe personality disorders. The main difficulty Objectives faced by this group is stigma. People who are affected from stigma face discriminatory situations that prevent them from University students in health care and social work studies are fully participating in society. Stigma is a multifactorial especially concerned that they are empathic with the population phenomenon that thrives on stereotypes and prejudices toward affected by mental disorders because they are one of the people with mental disorders. The most common stereotypes vulnerable groups in their professional future that they will have toward people with SMI are, for example, that they can be to attend to. The objective of this study was to evaluate the dangerous and commit more crimes than the general population impact of a web-based escape room on raising awareness of [2]; they can be violent, unpredictable, and dependent; and they SMI among university students in the health care branch during are responsible for their illness [2]. Stigma has severe the 2020-2021 academic year in web-based mode. The specific consequences on the quality of life and self-esteem of people objectives of this study were (1) to determine whether through with mental disorders, hindering their social inclusion [3], a web-based escape room, it is possible to modify the which, in turn, has a negative effect on finding work, being stigmatizing attitudes of university students taking a nursing economically independent, and having a solid circle of close degree regarding SMI; (2) to study the influence of the friends and supporters [4]. immersion (flow) experienced during the escape room experience and on the awareness of the participants toward To reduce stigma, different proposals for socioeducational stigma; and (3) to determine whether the degree of stigmatizing programs have been made, including the dissemination of attitudes is different between students with family members information, leisure activities such as sports or art, and contact with severe mental disorders and students without family with people with mental disorders. For example, in a members with SMI and to analyze whether the program has the meta-analysis study [5], through the analysis of 72 articles, it same effects on these people. was observed that educational and social programs had positive effects in reducing stigma in adults and adolescents with mental Methods illness. With the arrival of serious games and educational video games, Participants the possibilities of electronic resources in socioeducational All the participants were first-semester nursing students. The intervention are also beginning to be studied. For example, in participants were chosen based on the purpose of the research, the video game Stigma-Stop, which aimed at reducing stigma consideration of the resources available when performing the toward people with mental disorders, its characters had various intervention with web-based escape rooms, and the willingness mental disorders, with whom participants could empathize. The of the university teachers to carry out the intervention in their results of 552 students aged between 14 and 18 years showed class schedule. a statistically significant decrease in the levels of stigma toward Both the escape room of the control group and the escape room people with schizophrenia [6]. of the experimental group were used during class time in Playful strategies, such as video games, have the potential to subjects that had some content related to mental health. Students be widely motivating for students, making them pivotal to the enrolled in the first semester of their nursing degree could acquisition of social skills among young people with mental participate in the research if they gave their written consent. disorders [7] and to the reduction of stigma [8]. The escape room did not score on the average of the course, and no financial reward or any other type of incentive was In recent years, new forms of games have emerged and offered (Figure 1; Multimedia Appendix 1). established themselves as a leisure alternative, including escape rooms [9]. Escape rooms consist of being locked in a room, A total of 306 nursing students participated in the study, with solving a series of puzzles, unlocking locks, and finding hidden a mean age of 23.34 (SD 8.37) years, comprising 57 (18.6%) clues to escape from that room. Using a variety of settings and men and 249 (81.4%) women. They were selected through challenges, escape rooms create an experience that manages to cluster sampling, where a particular batch of students were be both motivating and educational for participants [10]. selected as participants, dividing them by participating classrooms. They were randomly allocated between the control The results of recent studies [11] show that games and the use group and the experimental group. The experimental group of escape rooms have been effective in engaging students in the consisted of 197 students with a mean age of 22.93 (SD 7.93) learning process and helping them retain information. In higher years, comprising 37 (18.8%) men and 160 (81.2%) women; education, specifically in the health care field, games have been the control group consisted of 109 students with a mean age of used to evaluate the theoretical and practical knowledge of nursing students and study their motivation, where it can be https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al 24.1 (SD 9.10) years, comprising 20 (18.3%) men and 89 questions were asked of the students before beginning the (81.7%) women. intervention about whether they had relatives who had SMI. The data showed that 67 students had relatives with SMI, with To fulfill the third objective of this study—to determine whether a mean age of 22.78 (SD 4.27) years. Of these 67 students, 23 the degree of stigmatizing attitudes is different between students (34.3%) belonged to the control group, 19 (82.6%) women and with family members with severe mental disorders and students 4 (17.4%) men, with a mean age of 23 (SD 4.62) years, and 44 without family members with SMI and to analyze whether the (65.7%) belonged to the experimental group, 38 (86.4%) women program has the same effects on these people—demographic and 6 (13.6%) men, with a mean age of 22.7 (SD 4.07) years. Figure 1. Flowchart followed for the selection of participants. from 1 to 9. It has a Cronbach α of .87. A higher score on this Ethics Approval questionnaire indicates a greater number of stigmatizing attitudes This study was conducted in accordance with the Declaration toward people with SMI. It measures the following four factors: of Helsinki. All participants provided written informed consent. Dangerousness—measures whether people with SMI pose Ethics approval was obtained from the Research Ethics a threat or create feelings of fear. An example question is, Committee of the University of Almería (Ref. UALBIO “Do you feel that people with SMI are dangerous?” 2021/01). Solidarity—measures the willingness to help a person with Instrument SMI; for example, “If I owned an apartment, I would rent it to people with SMI.” Attributional Questionnaire Coercion—people with SMI are required to participate in The 14-item abbreviated version of public stigma in mental treatment. An example of an item for this factor is “I think health (Spanish) was used, adapted from the Attributional it is in the best interest of the community where a person Questionnaire (AQ) 27 [16], with 14-point Likert-type questions with SMI lives to be placed in a psychiatric facility.” https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al Avoidance—indicates the willingness to live or work near were designed and evaluated according to the intervention group someone with SMI. For example, “I will share my car every (Table 1). day with a person with SMI.” Owing to sanitary measures arising from the COVID-19 situation, both escape rooms were designed on the web. The Motivation Questionnaire for Cooperative Playful escape rooms were prepared using the Genially digital platform, Learning Strategies allowing the creation of Click and Point spaces, which is why The Motivation Questionnaire for Cooperative Playful Learning it favors creating an interactive experience that can favor student Strategies [17] was used to evaluate the learning process, degree immersion. To create the scenarios proposed in the escape room, of immersion, and motivation toward gamified activities. It is images and illustrations from the FreePik resource bank were a Likert scale, ranging from 1 to 7, with 1 being totally disagree used, owing to a premium license for free use (Figures 2 and and 7 being totally agree. The flow factor has been used in this 3). questionnaire, with a Cronbach α of .83. An example of the items contained in the factor is, “While playing, I was not aware The main advantage of placing the escape room on the web is of what was going on around me.” the ease of implementation in different universities through a link. The steps to carry out both escape rooms were as follows: For this study, an escape room has been designed based on SMI, namely, the Without Memories escape room. The narrative is 1. On the official platform of the university (Blackboard that the main character must remember his or her identity and web-based learning platform), the class began, and the game leave the apartment where he or she is to be on time for an master explained in a general way what an escape room appointment. In the escape room, the player wakes up with no was, how the Genially platform was used, and that this memory of who or where he or she is and, through solving tests escape room was cooperative. Once any questions among and exploration, discovers that he or she is a young man with the students had been resolved, the escape rooms were a mental disorder. Through different elements, such as distributed to the students in teams of 4 people. newspapers, mobile phones, social networks, and computers, a 2. Each team was housed in a web-based workroom so that normalized life is gradually presented together with the different they could share ideas and opinions about solving the escape barriers that people with SMI face because of the stigma and room. They had 2 options: either one of them shared a discrimination they face; for example, difficulties in health screen and they solved it together through that screen or services or difficulty finding work. each person solved the escape room simultaneously on their computer, maintaining the relationship between their The escape room features linear mechanics: one test allows the partners in both options. next to be solved and so on until the final task, which requires The game master was in the general room of the Blackboard the resolution of 2 tasks to obtain the code that ultimately allows platform during the entire escape room implementation the player to exit. The escape room is web-based and is designed time, in case a team contacted to request clues. There was within the Genialy digital platform, designed as a graphic no limit to the number of clues, as it was important that adventure (Click and Point). The difficulty of the escape room they felt they could receive feedback and were able to get is low because it is designed for a nonexpert audience in these out of the escape room even if they had never played before. activities, and its duration is approximately 1 hour. Once the team passed the last test and managed to leave Procedure the escape room, they completed the posttest questionnaire individually. To investigate whether web-based escape rooms could modify stigmatizing attitudes toward SMI, 2 web-based escape rooms Table 1. Investigation procedure. Pretest Intervention Posttest Control group Attributional Questionnaire [14] and Motivation Escape room Attributional Questionnaire [14] and Motivation Questionnaire for Cooperative Playful Learning Locked In Questionnaire for Cooperative Playful Learning Strategies [16] Strategies [16] Experimental Attributional Questionnaire [14] and Motivation Escape room Attributional Questionnaire [14] and Motivation group Questionnaire for Cooperative Playful Learning Without Memo- Questionnaire for Cooperative Playful Learning Strategies [16] ries Strategies [16] https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al Figure 2. Example of elements where you must search for clues. Figure 3. Example of awareness elements mixed with clues for other puzzles. To design the escape room Without Memories, interviews were must be solved in a particular order. The experiment was conducted with people with SMI and 2 professionals from a conducted on the web and synchronously. The average duration local mental health association with the aim of understanding of the escape room was 60 minutes. the difficulties people with SMI deal with daily and the reality The escape room narrative involves waking up in a room without they face as told from their own experiences. The game design any memories of who or where you are. You must overcome for an escape room has a linear structure. Solving one clue will different challenges until you know that your name is Enrique, provide the object necessary to solve the next clue, and so on you have an SMI, and you have a normal life. and so forth until the students escape. Tasks in a linear room https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al The different tasks of the escape room are presented in the 277 students. Therefore, the sample size for this study was following formats inside the game: considered sufficient. • Computer: in this game, there are elements hidden around Before starting the analyses to answer the research questions, the room (click and point) that allow the student to know the direct scores of the administered tests were calculated using the password of a computer. On the computer, Enrique’s the corresponding descriptive statistics. browsing history can then be accessed, where there are 2 To answer the first research question, an ANOVA (2×2) with videos of awareness campaigns on mental health and mental repeated measures was performed for each factor of the AQ14, disorders, and Enrique’s social networks can be accessed, as well as another test for the total result of the battery. The where 2 conversations with friends and a conversation with Bonferroni correction was used as the adjustment method for his family physician are observed, in which he mentions the comparison of post hoc tests. difficulties related to medication, such as the fear of not being able to have erections and to relate intimately with To determine the relationship between flow and the change in the woman he likes. Between these conversations, the key stigmatizing attitudes, a linear regression was performed, in for the next test is observed. which the differential scores were calculated. In other words, • Diary and mobile phone: more conversations with Enrique’s pretest scores were subtracted from posttest measurements. family and friends are reflected on the mobile phone. These With the differential scores and the score obtained in the flow, conversations reflect Enrique’s concerns and limited the linear regression was performed with the score of the flow relationships. Some responses to his messages can be as an independent variable. interpreted as condescension, childishness, and other To address the last research objective, a 3-way ANOVA was behaviors that people with SMI reported in previous carried out for each of the factors and the total score of the interviews. It is also narrated how these people may have AQ14. a perception of the world that is different from the norm and may display different concerns and hobbies. The analyses were carried out using the R programing language • Safe and door: the safe is opened by means of a phrase that with the R Studio development environment. The libraries used is encoded in the computer. To achieve this, it is necessary were ggplot2, tidyverse, emmeans, and rstatix. to find the decoding key located in one of the rooms. This coded information allows the safe to be opened using Results information contained in the mobile phone and in the The means and SDs are presented in Table 2. To better bedroom and allows you to remember that you are Enrique, understand these results, it should be clarified that higher scores you are an adult, you have an SMI, and you have met the on the questionnaire indicate a greater stigma expressed by girl you like for a coffee. The box finally gives you the key participants. to open the door. When you click on the door again, there is a concluding message. This message provides statistical Regarding the first research question, ANOVAs (2×2) were information about SMI and the possibility that the player performed with repeated measurements. The results of the tests may have an SMI or meet someone close with an SMI in between the groups are reported in Table 3, which shows the the future. results of the ANOVAs along with the effect size using generalized eta squared. Post hoc tests are reported in this table, For the control group, an escape room called Locked In was indicating the group in which there are statistically significant prepared. This escape room is a copy of the previous one in differences together with significance. This table shows that all which all the elements that had been prepared to raise awareness, statistical differences were found in favor of the experimental such as narrative texts and correspondence on social networks, group in the posttest measurements. Table 4 indicates that the were removed, replacing them with others without any burden starting groups had equivalent scores, and statistically significant of awareness, as they are logical tests, puzzles, and numerical differences were found after applying the program. Regarding locks. The narrative of this escape room assumes that you wake the effect sizes found in the variables, it can be indicated that up in bed with no memories and must leave the apartment you are in. The steps for resolution are the same as those carried out in all the variables there is a large effect size (η >0.14), except by the experimental group; that is, they follow a linear logic in in coercion, where the size is medium, and avoidance, where which one test leads to another until the final resolution is the size is small (η >0.01). reached. As for the second research question, as already mentioned, a Data Analysis linear regression was carried out between the flow variables Initially, a sample size calculation was performed using the (mean 18.4, SD 3.16), such as the independent variable, and G*Power 3.1 program [18]. The parameters used for the the differential scores (mean −16.7, SD 18.4), such as the calculation were α=.05 and statistical power (1−β)=0.80. For dependent variable. The results obtained in the analysis indicated the effect size reference, the scientific literature was reviewed that the predictor variables explained 84.5% of the total variance [6,14,19]. The effect size was moderate (d>0.20). Using these (r =−0.845) and a moderate slope of the curve (β=−0.145; data, the minimum sample size needed for ANOVA testing was t =−22.15; P<.001); that is, the higher the score obtained for flow, the more the stigma displayed was reduced. https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al Table 2. Mean and SD (pre- and posttreatment) of the control and experimental groups. Control, mean (SD) Experimental, mean (SD) Pretest Posttest Pretest Posttest Dangerousness 17.93 (6.78) 17.91 (6.76) 18.03 (7.57) 11.01 (6.17) Solidarity 11.14 (5.5) 10.99 (5.39) 10.2 (5.48) 6.04 (3.58) Coercion 8.63 (4.51) 8.87 (4.5) 8.18 (4.72) 5.65 (3.82) Avoidance 11.86 (4.51) 11.78 (4.69) 11.16 (4.99) 8.13 (5.05) Total 49.56 (16.03) 49.55 (16.02) 47.57 (16.7) 30.83 (14.79) Table 3. ANOVA tests comparing between groups with the variables AQ14. Pretest Posttest Post hoc 2 2 η η F test (df) P value (adjusted) F test (df) P value (adjusted) g g b c,d Dangerousness 0.01 (1,304) .91 0 81.81 (1,304) <.001 0.212 Exp -Cont Solidarity 2.04 (1,304) .16 0.007 92.61 (1,304) <.001 0.234 Exp-Cont Coercion 0.67 (1,304) .41 0.002 43.81 (1,304) <.001 0.126 Exp-Cont Avoidance 1.52 (1,304) .22 0 38.60 (1,304) <.001 0.011 Exp-Cont Total battery 1.03 (1,304) .62 0.003 106.16 (1,304) <.001 0.258 Exp-Cont Bonferroni adjusted. Exp: experimental. Cont: control. P<.001. Table 4. ANOVA tests comparing within groups with the variables AQ14. Control Experimental Post hoc 2 2 η η F test (df) P value (adjusted) F test (df) P value (adjusted) g g Dangerous- 0.01 (1,108) .90 0 196.13 (1,196) <.001 0.206 Pre-post ness Solidarity 2.12 (1,108) .15 0 104.81 (1,196) <.001 0.169 Pre-post Coercion 3.68 (1,108) .58 0 55.42 (1,196) <.001 0.08 Pre-post Avoidance 0.47 (1,108) .49 0 64.61 (1,196) <.001 0.084 Pre-post Total battery 0.01 (1,108) .98 0 163.19 (1,196) <.001 0.221 Pre-post Bonferroni adjusted. P<.001. The means and SDs before and after the intervention are a close relative. In other words, people with a close relative with displayed in Table 5, differentiating those who reported having SMI display a lower level of stigma than those without a close a close relative and those who did not, both for the control group relative with SMI. and the experimental group. With the intention of knowing how the program affects the fact The results of the ANOVA indicated that having a close relative of having or not having family members with SMI, the 3-way influences the level of stigma of the participants in all study ANOVA was continued, and the results of this are reported for the posttest measures. The ANOVA results are presented in variables (dangerousness: F =6.33, P=.01, η =0.01; 1.604 g Table 6. In addition, the post hoc tests are reported, indicating solidarity: F =30.8, P<.001, η =0.04; coercion: F =25, 1.604 g 1.604 only the statistically significant results. 2 2 P<.001, η =0.04; avoidance: F =49.5, P<.001, η =0.08; g 1.604 g As can be seen, statistically significant differences were found and total battery: F =42.2, P<.001, η =0.06), with 1.604 g between the control and experimental groups, especially in the statistically significant differences in favor of people who have https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al case of not having a family member affected by SMI. In this for the variables dangerousness and total battery, there were case, statistically significant differences were observed in all statistically significant changes between the people in the control study variables. However, when someone had a family member and experimental groups who had family members affected by affected by SMI, no statistically significant changes were found SMI. for the variables solidarity, coercion, and avoidance, whereas Table 5. Means and SDs of participants with and without relatives with severe mental illness in the control and experimental group. Control-pre, mean (SD) Experimental-pre, mean (SD) Control-post, mean (SD) Experimental-post, mean (SD) Family No family Family No family Family No family Family No family Dangerousness 15.43 (5.68) 18.59 (6.92) 16.48 (7.59) 18.46 (7.53) 15.95 (6.03) 18.43 (9.92) 11.48 (5.95) 10.87 (6.24) Solidarity 7.91 (4.36) 12 (5.47) 7.48 (4.52) 10.96 (5.49) 7.82 (4.03) 11.83 (5.40) 5.58 (3.43) 6.16 (3.62) Coercion 6.39 (4.08) 9.23 (4.45) 5.81 (3.58) 8.83 (4.79) 6.69 (3.94) 9.45 (4.48) 4.60 (2.87) 5.94 (3.99) Avoidance 8.30 (4.34) 12.81 (4.08) 7.6 (4.65) 12.14 (4.62) 8.34 (4.93) 12.69 (4.19) 6.90 (4.85) 8.46 (5.06) Total 38.04 52.63 (14.86) 37.39 (16.70) 50.40 (15.61) 38.82 (15.90) 52.41 (14.86) 28.58 31.45 (15.33) (15.23) (12.56) Table 6. Three-way ANOVA with the interaction between the control and experimental group and whether they have declared a close relative or not in posttest measures. Family No family Post hoc 2 2 η η F test (df) P value (adjusted) F test (df) P value (adjusted) g g b c d Dangerousness 6.41 (1,65) <.001 0.011 67.512 (1,238) <.001 0.101 Exp -cont (no family) /exp- cont (family) Solidarity 3.317 (1,65) .280 0.005 77.812 (1,238) <.001 0.114 Exp-cont (no family) Coercion 3.61 (1,65) .232 0.006 37.40 (1,238) <.001 0.058 Exp-cont (no family) Avoidance 1.45 (1,65) .916 0 46.028 (1,238) <.001 0.071 Exp-cont (no family) Total battery 6.79 (1,65) .036 0.011 105.88 (1,238) <.001 0.148 Exp-cont (no family) /exp-cont (family) Bonferroni adjusted. Exp: experimental. Cont: control. P<.001. Persons without family members affected by severe mental illness. Persons with family members affected by severe mental illness. However, as stated earlier, escape rooms are an increasingly Discussion used tool in the educational field [23,24] because of their playful contribution and proximity to the current language of young Principal Findings people. This study sought to provide new methodologies to raise In this study, we investigated the effectiveness of an escape awareness among the young adult population, especially room as an awareness tool based on empathizing or putting university students who in their professional future could work oneself in the role of a leading character with an SMI. The with people with severe mental disorders. There are very few intervention significantly reduced the stigmatizing attitudes of studies that have used a web-based methodology [20], and at university students in the experimental group compared with present, we do not know about any other study that has been the control group. It is worth highlighting the size of the large based on an escape room, despite being a methodology that is effect observed in the factors of danger, perceived fear, and in being used more and more in the educational field. A recent solidarity, variables in which the greatest reduction was systematic review on this topic did not identify any studies that obtained. applied this tool [21]. Applying them in a web-based format is also novel and, of course, was brought on by the effects of the Dangerousness is the most common stigma dimension in the pandemic, which resulted in a rapid adaptation to these methods general population [25], and it scored the highest in the [22]. pretreatment evaluation in this study. In contrast, because of https://games.jmir.org/2022/2/e34222 JMIR Serious Games 2022 | vol. 10 | iss. 2 | e34222 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Rodriguez-Ferrer et al the characteristics of the sample, the intervention also had a interpretation of the effect size. Second, the specific great effect on solidarity. More specifically, providing characteristics of the participants and the possible confounding information about mental health problems in a participatory factors that may influence the results, such as their sociocultural way, such as in the escape room, favored the strengthening of origin, their level of knowledge, and their desire to work with this variable. patients with SMI, were not evaluated; the only exception was whether they had family members with SMI, in which case they The implementation of the escape room was carried out with were evaluated. Finally, another limitation was not conducting university students from the health sector, which is important a reevaluation months after the intervention to determine considering that some of these professionals will work directly whether the changes achieved in the experimental group could with people affected by SMI, and their expectations and beliefs be perpetuated over time. will affect the recovery of their patients [26]. Another aspect that should be highlighted is that professionals who work in the Conclusions field of mental health continue to have negative beliefs, Mental health awareness is a very important subject for the paternalistic attitudes, and even restrictive and directive attitudes proper professional development of health care students. It is on occasions [27]. These can have repercussions not only on the responsibility of university teachers to prepare students to recovery but also on the patients’ own perception of themselves, learn, understand, and know how to work with their patients. causing them to label themselves in a stigmatizing way, which The lack of theoretical knowledge and stigma toward people is known as self-stigma [28]. with SMI can contribute to discrimination toward this group, which, in turn, can influence their self-esteem and quality of In contrast, it has been proven how the narrative of the story life. Therefore, it is necessary to implement new strategies in and immersion in the activity encourage the re-elaboration of university education to improve the knowledge and awareness value judgments that alter the beliefs and attitudes of people of mental disorders. The integration of playful strategies such with SMI. Escape rooms have already been tested as active as escape rooms can be of great interest because of their methodological tools that promote motivation and student immersive and motivating capacity. commitment toward learning [10,29], obtaining good results when they have been applied. Similar studies [30-32] have found Without Memories, a web-based escape room where the narrative that it is possible to reduce stigma through other methodologies, is about a character with SMI, is an effective tool to promote and the interesting aspect of this study is that it is able to raise awareness around mental health because it favors learning by awareness through a playful activity that is easy to implement discovery and playful challenges through attractive dynamics and replicate. and mechanics, which can encourage students to learn about SMI and be more empathetic toward these people. As for other findings, a variable found to influence the results is whether the person has a family member with mental health Future studies could use this escape room not only in nursing problems. When a person has a family member with this type degree studies but also in other degrees related to health and of difficulty, we can observe that the stigma is lower and community education to promote awareness among other possibly owes to the greater knowledge and direct contact that professionals who also have direct contact with people with an individual has around these problems, which is fundamental SMI. Furthermore, future research could assess whether the in the reduction of stigma [33]. results on the impact of playful strategies for mental health awareness vary because of other sociodemographic factors. Limitations Finally, the duration of the escape room Without Memories is This study has several limitations. First, the sample is relatively very limited, and although this may have benefits for its small, it comes from 2 universities, and it is not representative replication, there is a need to plan future awareness programs of the general population. Furthermore, the sample of university through playful strategies of longer duration to evaluate whether students included only individuals from nursing schools. This they can achieve a greater impact on motivation, acquisition of may undermine the generalizability of the results and limit the knowledge, and awareness. Conflicts of Interest None declared. Editorial Notice This randomized study was not registered, explained by authors on the basis that the subjects were nursing students. The editor granted an exception from ICMJE rules mandating prospective registration of randomized trials, given that the subjects were undergraduate students. However, readers are advised to carefully assess the validity of any potential explicit or implicit claims related to primary outcomes or effectiveness, as retrospective registration does not prevent authors from changing their outcome measures retrospectively. Multimedia Appendix 1 CONSORT-EHEALTH checklist (V 1.6.1). 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[doi: 10.1016/j.cpr.2019.02.001] [Medline: 30908990] Abbreviations AQ: Attributional Questionnaire SMI: severe mental illness Edited by N Zary; submitted 12.10.21; peer-reviewed by N Gronewold, A Teles, X Wang; comments to author 23.12.21; revised version received 09.02.22; accepted 17.02.22; published 05.05.22 Please cite as: Rodriguez-Ferrer JM, Manzano-León A, Cangas AJ, Aguilar-Parra JM A Web-Based Escape Room to Raise Awareness About Severe Mental Illness Among University Students: Randomized Controlled Trial JMIR Serious Games 2022;10(2):e34222 URL: https://games.jmir.org/2022/2/e34222 doi: 10.2196/34222 PMID: ©Jose M Rodriguez-Ferrer, Ana Manzano-León, Adolfo J Cangas, Jose M Aguilar-Parra. Originally published in JMIR Serious Games (https://games.jmir.org), 05.05.2022. 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Published: May 5, 2022

Keywords: escape room; severe mental disorder; higher education; nursing education; mental health; mental disorder; serious games

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