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Using a Virtual Environment to Deliver Evidence-Based Interventions: The Facilitator's Experience

Using a Virtual Environment to Deliver Evidence-Based Interventions: The Facilitator's Experience Background: Evidence-based interventions (EBIs) have the potential to maximize positive impact on communities. However, despite the quantity and quality of EBIs for prevention, the need for formalized training and associated training-related expenses, such as travel costs, program materials, and input of personnel hours, pose implementation challenges for many community-based organizations. In this study, the community of inquiry (CoI) framework was used to develop the virtual learning environment to support the adaptation of the ¡Cuídate! (Take Care of Yourself!) Training of Facilitators curriculum (an EBI) to train facilitators from community-based organizations. Objective: The purpose of this study was to examine the feasibility of adapting a traditional face-to-face facilitator training program for ¡Cuídate!, a sexual risk reduction EBI for Latino youth, for use in a multi-user virtual environment (MUVE). Additionally, two aims of the study were explored: the acceptability of the facilitator training and the level of the facilitators’ knowledge and self-efficacy to implement the training. Methods: A total of 35 facilitators were trained in the virtual environment. We evaluated the facilitators' experience in the virtual training environment and determined if the learning environment was acceptable and supported the acquisition of learning outcomes. To this end, the facilitators were surveyed using a modified community of inquiry survey, with questions specific to the Second Life environment and an open-ended questionnaire. In addition, a comparison to face-to-face training was conducted using survey methods. Results: Results of the community of inquiry survey demonstrated a subscale mean of 23.11 (SD 4.12) out of a possible 30 on social presence, a subscale mean of 8.74 (SD 1.01) out of a possible 10 on teaching presence, and a subscale mean of 16.69 (SD 1.97) out of a possible 20 on cognitive presence. The comparison to face-to-face training showed no significant differences in participants' ability to respond to challenging or sensitive questions (P=.50) or their ability to help participants recognize how Latino culture supports safer sex (P=.32). There was a significant difference in their knowledge of core elements and modules (P<.001). A total of 74% (26/35) of the Second Life participants did agree/strongly agree that they had the skills to deliver the ¡Cuídate! program. Conclusions: The results showed that participants found the Second Life environment to be acceptable to the learners and supported an experience in which learners were able to acquire the knowledge and skills needed to deliver the curriculum. (JMIR Serious Games 2015;3(2):e5) doi: 10.2196/games.4293 KEYWORDS Second Life; multi-user virtual environments; evidence-based interventions; community-based organizations http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al the level of the facilitators’ knowledge and self-efficacy to Introduction implement the training. Overview Virtual Learning Environment Imagine a place where you can attend a fully interactive training The CoI [6] is one of the most common frameworks for session with people in different settings from all areas of the assessing individual acceptance and comfort with country without having to leave your home or office. You could online-learning environments. The model is comprised of three learn about topics important to your work so you could help constructs that are core elements of a collaborative constructivist others in your community. That place is a virtual environment, learning environment: (1) cognitive presence—the ability of a computer-generated three-dimensional representation of a learners to construct meaning through reflection and discourse, space in which users can interact. They can take advantage of (2) social presence—the ability of participants to feel connected current Web 2.0 technologies, which are technologies focused to each other in the absence of face-to-face contact, and (3) on user-generated content, to deliver accessible and interactive teaching presence—the design, facilitation, and direction of training for communities and organizations. Training needs of processes needed to support learning [7]. Burgess used the CoI community-based organizations (CBOs) and others can range survey to determine the extent of social, cognitive, and teaching from information sessions to more intensive training sessions presence among graduate level technology students in class to conduct evidence-based interventions (EBIs). activities held in Second Life (SL) [8]. These constructs have been positively associated with learning in an online Evidence-based interventions are programs that have undergone environment. For example, a sense of community has been rigorous outcome evaluation and have the potential to maximize shown to have a positive relationship with perceived cognitive positive impact on communities [1]. However, despite the learning [9] and all three CoI constructs were predictive of quantity and quality of EBIs for health promotion and disease perceived learning in online Master of Business Administration prevention, the need for formalized training and associated (MBA) courses [10]. In another study, Liu and colleagues found training-related expenses, such as travel costs, program social presence was a significant predictor of course retention materials, and input of personnel hours, pose implementation among students enrolled in community college [11]. challenges for CBOs [2,3]. The CoI framework and Second Life were purposely chosen to To increase access to EBI training, cost-effective training guide the adaption of the ¡Cuídate! training program because methods, such as Web-based training platforms, are needed. it requires the application of skills and reflection on the work Accordingly, advances in technology have resulted in the of self and others (cognitive presence), high interaction and development of multi-user virtual environments (MUVEs) as social connection among participants (social presence), and platforms for social interaction. The creation of a sense of real-time feedback from facilitators and peers (teaching presence among users [4] has many benefits over less dynamic presence). These elements are lacking in a traditional online forms of traditional Web-based trainings such as webinars or Web-based training environment. asynchronous podcasts. While the use of MUVEs is commonplace among gamers and the technologically savvy, Second Life the use of MUVEs among community providers is not Second Life was developed by Linden Lab and is considered widespread. Little is known about the acceptance of MUVEs one of the most mature and widely used platforms in use, in community settings and agencies whose staff vary in specifically in health care. Through the creation and use of a computer experience and in familiarity and comfort level with modifiable avatar (ie, an online, graphical representation of the virtual training environments. user), individuals in SL are able to interact with people and The purpose of this study was to examine the feasibility of objects with the ability to exhibit social cues through realistic adapting a traditional face-to-face facilitator training program gestures [12]. for ¡Cuídate! (Take Care of Yourself!), a sexual risk reduction Second Life has been used in a variety of interventions in health EBI for Latino youth [5], for use in a MUVE. Facilitators are education for both practitioners and patients. Second Life is individuals who are trained in the delivery of the EBI who then also not new to the area of sexual health; the University of deliver the intervention to youth in their communities. In this Plymouth Sexual Health Sim was developed in the United study, the community of inquiry (CoI) framework [6] was used Kingdom as a place to provide sexual health education as well to develop the virtual learning environment to support the as private one-on-one counseling [13]. Studies using SL for adaptation of the ¡Cuídate! face-to-face curriculum. The practitioner training have found positive results. For example, constructs of the CoI framework (ie, social, teaching, and one study used SL for motivational interviewing (MI) training cognitive presence) were then used as a basis to evaluate if the among physicians [14]. This training included interactive facilitator learning experience in the 2.5-day MUVE training sessions in SL using role play with standardized patients to program was acceptable to the learners and supported the practice MI skills and was found to have a high degree of user acquisition of learning outcomes. Further comparison was acceptability. Participants (n=13) rated the acceptability of the conducted with those facilitators trained in the virtual various components of the course on a range from 4.1 to 4.7 on environment and those trained in face-to-face formats. This, in a 5-point Likert scale. Proficiency scores in MI also improved, part, addressed two aims of the study: to examine the with statistically significant improvement seen in four out of acceptability of the facilitator training program and to examine five component skills. In a study with paramedic students, which http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al compared paper-based and SL case scenarios for problem-based Condom Use Skills, and (6) Building Negotiation and Refusal learning, participants reported a more authentic and collaborative Skills. The facilitators received a hard copy of the entire experience in SL [15]. In addition, 100% of participants curriculum approximately two weeks before their SL session surveyed agreed/strongly agreed that SL is a relevant resource by Select Media. Each facilitator was assigned to facilitate (ie, for field/clinical work preparation. Similarly, Schwaab and role play) several of the activities in the SL ¡Cuídate! training colleagues [16] reported that emergency medicine residents sessions. Two master trainers, or expert ¡Cuídate! trainers, (n=27) participating in mock SL, oral examination case scenarios conducted the virtual training sessions and previously conducted experienced a high degree of comfort (100%) and realism face-to-face training sessions. These master trainers facilitated (92.6%). A majority indicated that SL was easy to navigate the entire training session in SL in English, similar to the (96.3%) and easy to log in to (92.6%), and preferred the SL oral face-to-face training sessions. examinations over the traditional format (66.6%). A recently The training was designed to allow facilitators to deliver and published systematic review of the use of virtual worlds in health practice facilitating activities in the curriculum, and to receive care [17] found 11 studies published in the area of professional feedback from their peers and ¡Cuídate! master trainers similar education, including using virtual worlds for medical education to what would be experienced in a face-to-face ¡Cuídate! for diabetes [18], delivering bad news to patients [19], and training session. Specific curricular activities were selected to improving patient safety [20]. utilize the capabilities of the interactive virtual environment. Given the success of SL in training health care providers and Unlike face-to-face training sessions, not all of the activities in the capacity to create a collaborative and realistic experience every module were completed in the virtual training sessions. for learners, SL was deemed a useful environment to increase Those activities that overlapped in structure and format were dissemination of EBIs among communities. This feasibility minimized in order to demonstrate activities that might be study could provide valuable information on the viability of challenging to conduct in real life. Throughout the training using a MUVE such as SL and on creating a framework for session, facilitators were encouraged to interact with each other others to use in designing training programs. and the ¡Cuídate! master trainers by providing feedback to one another and acting as participants (ie, adolescents) during the Methods role play sessions (ie, teach backs). Facilitators were oriented to the SL environment prior to the training sessions and Overview processes; technical support in SL was provided before and during training to minimize any technical issues that might arise This was a descriptive comparative study to evaluate the during training [23]. feasibility and acceptability of the SL environment, and to compare SL training to face-to-face training. The study protocol Sample was reviewed by the Institutional Review Board at the A total of five ¡Cuídate! training sessions were conducted in University of Michigan and was deemed exempt and not the SL environment (see Figure 1) with 35 facilitators (ie, regulated. participants) representing 24 agencies across the United States. To examine feasibility and acceptability, data were obtained These facilitators were recruited via networking and social from the participants (ie, facilitators) who participated in the media from CBOs across the country. Each training session SL ¡Cuídate! Training of Facilitators. For comparison with the group met three times. The first session was a 2.5-hour overview face-to-face training process, evaluation data were obtained of the ¡Cuídate! curriculum and overview of key SL features, from the Centers for Disease Control and Prevention (CDC) followed 1 week later by two more sessions—4 hours and 3 through Danya International, Inc (personal communication, hours in length, respectively—of ¡Cuídate! content. Danya International, Inc, 2014). Facilitators ranged in age from 20 to 59 years, with the majority Training in Second Life being female (24/35, 69%) and nearly half of Hispanic/Latino ethnicity (17/35, 49%). Education levels varied widely among The ¡Cuídate! Training of Facilitators Manual [21] was used the facilitators with a large number (28/35, 80%) having earned to adapt the 2.5-day, face-to-face training program into a a bachelor’s degree or higher. combination of self-paced, prelearning podcasts and live virtual sessions in SL [22]. The ¡Cuídate! training program was Comparisons were made with data from facilitators who previously only offered as a face-to-face training program; a participated in face-to-face training sessions (4 cohorts, 55 trainer conducted the 2.5-day session to teach the facilitators facilitators) held in St Louis, Philadelphia, Atlanta, and (ie, the study participants) how to deliver the curriculum to Memphis. These training sessions were held prior to the Latino youths in their communities. The facilitators were asked implementation of the SL ¡Cuídate! training program. A total to review the ¡Cuídate! curriculum and all the associated of 55 facilitators (41/55, 75% female) were trained in the activities prior to attending the virtual training sessions. The face-to-face settings in Atlanta (19/55, 35%), St Louis (16/55, six modules of the curriculum included the following: (1) 29%), Philadelphia (12/55, 22%), and Memphis (8/55, 15%). Introduction/Overview, (2) Building Knowledge about Of the 55 trained facilitators, 44 (80%) surveys were collected Pregnancy, Sexually Transmitted Diseases (STDs), HIV, (3) from St Louis (14/16, 88%), Philadelphia (10/12, 83%), Atlanta Understanding Vulnerability to Pregnancy, STDs, HIV, (4) (13/19, 68%), and Memphis (7/8, 88%) (personal Attitudes and Beliefs about Pregnancy, STDs, HIV, (5) Building communication, Danya International, Inc, 2014). http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Figure 1. ¡Cuídate! training room in Second Life. cognitive presence (alpha=.85). Table 1 lists each of the Surveys statements from the survey. Facilitators in both the face-to-face and virtual training sessions Two questions were also asked to evaluate the overall experience were asked to complete pre- and posttraining surveys. These in SL: (1) SL experience was an effective learning activity and surveys included items measuring attitudes toward implementing (2) SL experience was a positive experience. These questions ¡Cuídate!, self-efficacy in working with Latino youth and in were rated on a 5-point Likert scale, ranging from 1 (strongly implementing ¡Cuídate!, and overall evaluation of the ¡Cuídate! disagree) to 5 (strongly agree). Qualitative data were collected training program. In addition, facilitators who participated in through a series of open-ended questions, several of which SL training were also asked to complete a modified version of focused on aspects of the training in SL, as part of a debriefing the CoI survey. These items are described below. survey. Specifically, facilitators were asked what they Evaluation of the Virtual Learning Environment liked/disliked about the SL ¡Cuídate! training program, what were the advantages/disadvantages to training in SL versus face The community of inquiry framework survey instrument is a to face, and how likely they were to participate in another or 34-item questionnaire measuring the three areas of cognitive similar training program in SL. presence, social presence, and teaching presence [10]. Original subscale alphas were found to be .94 (teaching presence), .91 To compare the face-to-face and SL training sessions, questions (social presence), and .95 (cognitive presence). Further validity posed to facilitators in SL training sessions matched questions and reliability of the original instrument has been demonstrated posed to facilitators trained in face-to-face sessions. These through other studies [7,24]. questions included evaluation of the training (eg, length and pace) and self-assessment of knowledge and skills (eg, Because the original instrument was designed for use in online knowledge of core elements and six modules, ability to respond courses, the CoI survey was adapted and reduced to 12 to sensitive questions, and ability to help facilitators recognize statements to measure the items that related to the ¡Cuídate! how Latino culture supports safe sex). Items were scored on a Training of Facilitators. The items were scored on a 5-point 5-point Likert scale ranging from 1 (not confident) to 5 (very Likert scale, ranging from 1 (strongly disagree) to 5 (strongly confident). Two additional questions were asked of SL agree). Questions were retained in each of the three subscales. facilitators to determine mastery of the curriculum and skills The first subscale—social presence—included six questions necessary to deliver the program (see Table 2 in the Results which measure the ability of facilitators to feel connected to section) each other in the absence of face-to-face contact. The teaching presence subscale was comprised of two questions that refer to All surveys for the SL facilitator training sessions (5 cohorts) ratings of the design, facilitation, and direction of processes were conducted using Qualtrics (Qualtrics, LLC). Links to each needed to support learning. Finally, four questions measured of the surveys were sent to facilitators via an email from the cognitive presence which determine a learner’s ability to research team following completion of the training. Email construct meaning through reflection. The modified CoI survey reminders were sent to ensure a high response rate (35/35, was administered only to the facilitators of the SL training. 100%) and timely completion. Original surveys completed by Cronbach alphas were high for each of the subscales: social the facilitators at the face-to-face sessions were scanned and presence (alpha=.89), teaching presence (alpha=.84), and sent via email to the research team. http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Table 1. Community of inquiry survey statements (n=35). Second Life Total training score , subscale score, Variables and statements mean (SD) mean (SD) Social presence 23.11 (4.12) I am comfortable conversing through an online medium. 3.77 (1.03) I felt comfortable participating in training discussions. 4.17 (0.66) I felt comfortable disagreeing with other facilitators while still maintaining a sense of trust. 4.06 (0.64) Getting to know other facilitators gave me a sense of belonging. 3.86 (0.81) Online or Web-based communication is an excellent medium for social interaction. 3.34 (1.08) I was able to form distinct impressions of some course participants. 3.91 (0.92) Teaching presence 8.74 (1.01) The trainer helped keep facilitators on task. 4.31 (0.58) The trainer provided feedback in a timely fashion. 4.43 (0.50) Cognitive presence 16.69 (1.97) I can describe ways to apply the knowledge I learned in training. 4.23 (0.55) I was motivated to explore content-related questions. 4.14 (0.60) Learning activities helped me construct explanations/solutions. 4.11 (0.58) Reflection helped me understand fundamental concerns in training. 4.20 (0.63) Scores are on a scale from 1 to 5, with 1 being strongly disagree and 5 being strongly agree. was 23.11 (SD 4.12) out of a possible 30. The highest ranking Analysis questions were “I felt comfortable participating in training To evaluate the facilitators' experience in the MUVE and discussions” (mean 4.17, SD 0.66), “I felt comfortable examine if a learning environment was acceptable and supported disagreeing with other facilitators while still maintaining a sense the acquisition of learning outcomes, the CoI survey responses of trust" (mean 4.06, SD 0.64), and “I was able to form distinct and qualitative responses in each of the three constructs—social impressions of some course facilitators” (mean 3.91, SD 0.92). presence, cognitive presence, and teaching presence—were Qualitative comments supported the survey findings. When analyzed together. To analyze the modified CoI survey and asked what they most liked about SL, participants/facilitators overall SL questions, descriptive statistics and frequency noted particular aspects of the training that they liked best: distributions were analyzed using SPSS version 21 (IBM Corp). “...very interactive and fun to see” and “...very interactive, very A content analysis approach was used to analyze the nine engaging.” Additionally, several comments reflected social open-ended questions with NVivo10 (QSR International) to connections—an indication of social presence—with others in code and organize the qualitative participant responses from the training session as an aspect of what they liked about SL the SL surveys. training: “...interacting with people across the country” and “...interacting with other facilitators and getting feedback.” For comparisons of face-to-face surveys and SL training sessions, responses from the four face-to-face sites (ie, St Louis, Despite the positive comments, facilitators indicated that the Philadelphia, Atlanta, and Memphis) were combined because lack of being able to see facial expressions was a disadvantage. there were no significant differences among training sites on For example, “The element of watching individual’s body any of the outcome variables (P>.05). Univariate frequencies language & facial expression is priceless...only thing MISSING” of outcome variables were run and the Mann-Whitney U test and “You can’t see everyone and their body language which is for nonparametric data was used to make bivariate comparisons important when facilitating training but it [SL training] was of the face-to-face and SL outcomes, as the data did not follow very good.” any specific parameterized distribution. Teaching Presence Results In general, facilitators reported a high perception of teaching presence. The subscale mean was 8.74 (SD 1.01) out of a Evaluation of the Virtual Learning Environment possible 10. High mean scores were reported for items related to the trainers’ skill in keeping facilitators on task and also Social Presence trainers’ ability to provide feedback in a timely fashion (mean Results indicate that most respondents experienced a moderately 4.31, SD 0.58 and mean 4.43, SD 0.50, respectively). Qualitative high level of social presence—in other words, they were able comments supported a strong teaching presence: “A good to feel connections with other participants. The subscale mean http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al balance between lecture and interactive activities was of the importance of how the cultural values are provided”—indicates design and facilitation—and “...getting threaded throughout the curriculum] feedback on our teach backs”—indicates facilitation. These I definitely learned a lot—facilitation comments indicated that the facilitator constructed activities in skills—appreciated knowledge everyone else brought a way that supported learning in the environment. [Met the objective of learning skills] The responses on the overall SL questions found that 69% of Cognitive Presence the participants (24/35) agreed/strongly agreed that SL was an Cognitive presence was also highly rated. Cognitive presence effective learning activity and 77% of the participants (27/35) supports the ability of learners to construct meaning through agreed/strongly agreed that SL was a positive experience. reflection and discourse. Overall, the subscale mean was 16.69 (SD 1.97) out of a possible 20. The majority of respondents Acceptability of Second Life Training were in agreement with statements indicating that they felt able The survey responses from the face-to-face and SL training to describe ways to apply knowledge learned in training (mean sessions are presented in Table 2; bivariate comparisons between 4.23, SD 0.55), they were motivated to explore content-related the face-to-face and SL training sessions are presented in Table questions (mean 4.14, SD 0.60), learning activities helped them construct explanations and solutions (mean 4.11, SD 0.58), and reflection helped them understand fundamental concerns in A total of 80% of the participants (28/35) responded that the training (mean 4.20, SD 0.63). Qualitative comments that length of the training in SL was “about right” and 83% (29/35) supported the survey findings were as follows: responded that the pace of the training was “about right.” When asked about their self-assessment of knowledge and skills in Good to get better understanding from what is every category—core elements, six modules, challenging expected from the curriculum, sometimes you don’t questions, and recognize how Latino culture supports safer know what the developer was thinking. [Understands sex—over 50% of the participants in the SL training program the objectives of the course] reported, at a minimum, being confident with those skills. Reinforcement of cultural values. Activities that reinforced the materials throughout [Understanding http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Table 2. Comparison between Second Life training and CDC face-to-face training. Variables and survey responses CDC survey Second Life survey (n=44), n (%) (n=35), n (%) Evaluation of training Appropriateness of training length Too long 1 (2) 1 (3) A little too long 6 (14) 2 (6) About right 29 (66) 28 (80) A little too short 8 (18) 3 (8) Much too short 0 (0) 1 (3) Pace of the training Much too slow 0 (0) 0 (0) A little slow 4 (9) 3 (8) About right 28 (65) 29 (83) A little fast 9 (21) 2 (6) Much too fast 2 (5) 1 (3) Self-assessment of knowledge and skills Knowledge of core elements Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 2 (5) 11 (32) Confident 16 (37) 19 (54) Very confident 25 (58) 5 (14) Knowledge of six modules Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 1 (2) 6 (17) Confident 21 (49) 24 (69) Very confident 21 (49) 5 (14) Respond to challenging or sensitive questions/situations Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 3 (7) 3 (8) Confident 17 (40) 16 (46) Very confident 23 (53) 16 (46) Help participants recognize how Latino culture supports safer sex Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 3 (7) 3 (9) Confident 16 (38) 17 (48) Very confident 23 (55) 15 (43) Mastery of ¡Cuídate! curriculum I have mastered content of program as written in manual Strongly disagree N/A 0 (0) http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Variables and survey responses CDC survey Second Life survey (n=44), n (%) (n=35), n (%) Disagree N/A 2 (6) In the middle N/A 14 (40) Agree N/A 18 (51) Strongly agree N/A 1 (3) I have mastered skills to deliver program as written in manual Strongly disagree N/A 0 (0) Disagree N/A 1 (3) In the middle N/A 8 (23) Agree N/A 20 (57) Strongly agree N/A 6 (17) Centers for Disease Control and Prevention (CDC). Not applicable (N/A). Table 3. Nonparametric comparisons of participant ratings between CDC face-to-face training and Second Life training. CDC Second Life Mann-Whit- training score training score ney Variable (n=44), mean (SD) (n=35), mean (SD) U test Z score P Appropriateness of training length 3.00 (0.62) 3.03 (0.65) 765.50 -0.06 .96 Pace of the training 3.21 (0.68) 3.03 (0.51) 643.00 -1.41 .16 Knowledge of core elements 4.53 (0.59) 3.83 (0.66) 353.50 -4.35 <.001 Knowledge of six modules 4.47 (0.55) 3.97 (0.57) 441.50 -3.56 <.001 Respond to challenging or sensitive questions/situations 4.47 (0.63) 4.37 (0.65) 692.50 -0.67 .50 Help participants recognize how Latino culture supports 4.48 (0.63) 4.34 (0.64) 649.00 -0.98 .33 safer sex Centers for Disease Control and Prevention (CDC). P values (significance) based on two-tailed analysis. elements and six modules significantly higher (mean 4.47, SD Comparison of Face-to-Face and Virtual Training 0.62) compared to those in the SL training sessions (mean 3.83, Experience SD 0.67). However, of the SL participants, 54% (19/35) There were no significant differences between participant ratings agreed/strongly agreed that they mastered the content of the of the length or pace of training in SL as compared to program as written in the manual, and 74% (26/35) face-to-face training (P=.96 and P=.16, respectively). Further, agreed/strongly agree that they mastered the skills to deliver results indicate no significant difference between SL and the program as written in the manual. face-to-face participant self-assessment of their ability to respond appropriately to sensitive questions and to recognize Discussion how Latino culture supports safer sex decisions (P=.50 and Principal Findings P=.32, respectively). There was a significant difference between reported knowledge of the components of the six ¡Cuídate! MUVEs hold promise for delivering training in the future modules (P<.001). Those facilitators who participated in without the training-related travel costs, thereby increasing the face-to-face training sessions had higher knowledge scores use of these crucial programs that have widespread and critical (mean 4.44, SD 0.56) as compared to those who participated in influence on population health and health outcomes. It is always SL training sessions (mean 3.97, SD 0.57). challenging to deliver training in a Web-based environment when you cannot physically see the facilitators, particularly Additionally, there was a significant difference (P<.001) when training requires active participation rather than passive between SL and face-to-face participant ratings of their ability receipt of knowledge. Part of the ¡Cuídate! Training of to describe the six core elements of the ¡Cuídate! curriculum. Facilitators curriculum [21] requires facilitators to conduct teach Facilitators who participated in the face-to-face training sessions backs, necessitating engagement with others. Consequently, the rated their level of confidence in their knowledge of the core use of a MUVE such as SL over a noninteractive format (eg, http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al webinar) is essential to support the interaction necessary to curriculum. This is essential to meeting the aim of ensuring support the role-play interaction. Results of this study indicate facilitators have the ability to deliver the curriculum effectively. that SL is an acceptable and feasible way to deliver training and The significant difference between participants' self-assessment achieve outcomes that lead to learning success. of their abilities to identify the core elements and modules was not surprising. During the face-to-face training sessions, The results of this study indicate that the three constructs of facilitators were given an overview of the six modules, whereas social, teaching, and cognitive presence were present in the SL facilitators in the virtual environment were required to review environment. The facilitators also rated the SL experience as all materials ahead of time as part of the prelearning work. Given positive and effective. Specifically, the facilitators experienced the complexities and multiple priorities of the facilitators, they a moderately high level of social presence in the SL may have not reviewed the materials or did not thoroughly environment. This connectedness to others has been shown to review them prior to the virtual training. Further work is needed be a predictor of success in online courses [11]. Although virtual to ensure facilitators complete all prelearning materials. This environments will never duplicate the social presence found in can be done by requiring interaction with the modules as they face-to-face environments, the comments demonstrated how are being presented or with a postmodule quiz. engaged and immersed in the environment the facilitators were when responding (eg, “interacting with people across the The high ratings on the mastery indicate that although country"). The facilitators only "met" or interacted in SL, yet participants did not experience all learning in SL, they did feel they felt a connection to others with whom they trained. This they had the skills to deliver the content. This finding supports is consistent with what was seen in other studies using SL the efficacy of conducting training in SL. Educators should [14-16]. consider this when trying to minimize time spent in training while ensuring mastery of the content and various learning In relation to cognitive presence—an indicator of how well our methodologies. Eliminating extra time in training will assist facilitators achieved the learning objectives—facilitators agreed with efficient use of the limited resources available to the activities were helpful and they felt capable of applying the community-based organizations or other groups pursuing knowledge gained in training. Facilitators had access to all six training. modules and all the activities in the training manual; they were asked to review all modules/activities as part of their prelearning Conclusions work prior to coming to training. Also noted in the training As it becomes more challenging to access training to deliver survey, the majority of the participants agreed they had mastered EBIs, alternative methods like training in virtual worlds need the skills to deliver the curriculum, and over half agreed they to provide access to training in a manner that is both effective had mastered the content of the program. This is consistent with and acceptable to those receiving the training. This will then the study by Schwaab [16] in which MI skills improved after open a way to increase access to even remote areas, provided training in SL. Teaching presence was also supported by the there is Internet access and a willingness to engage in a virtual SL environment. Facilitators rated the trainers high in keeping training environment. This study demonstrates that training can them on task and providing them with timely feedback, while be effectively delivered in a virtual world and the training comments supported a good balance of activities. Comparison environment in SL can be designed and delivered in a manner studies did not rate the quality of teaching presence. that is acceptable to the participants. SL was an effective training environment for the facilitators to achieve the ability to learn There were no differences between face-to-face- and SL-trained the skills needed to deliver the ¡Cuídate! curriculum, including facilitators in their confidence levels regarding their ability to demonstration of the teach backs that are essential to being able respond to challenging or sensitive questions when delivering to effectively deliver this successfully to Latino youths. the curriculum, which is important to the mastery of the Acknowledgments This research was funded by the National Institute of Mental Health (R21-MH095723; MA and AV, co-PIs). The authors would like to thank our ¡Cuídate! Second Life participants for their willingness to venture into the virtual world for training and for their dedication to working with adolescents across the country. We also want to thank ¡Cuídate! master trainer, Arman Lorez, for his ability to connect to the participants virtually and make the training experience great. Finally, we would like to thank Charles Collins from the CDC for his support throughout this study. Conflicts of Interest None declared. References 1. Evidence-Based Clinical and Public Health: Generating and Applying the Evidence. Washington, DC: US Department of Health and Human Services; 2010 Jul 26. URL: https://www.healthypeople.gov/sites/default/files/ EvidenceBasedClinicalPH2010.pdf [accessed 2015-07-11] [WebCite Cache ID 6ZwbvHPds] http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al 2. Norton WE, Amico KR, Cornman DH, Fisher WA, Fisher JD. An agenda for advancing the science of implementation of evidence-based HIV prevention interventions. AIDS Behav 2009 Jun;13(3):424-429 [FREE Full text] [doi: 10.1007/s10461-009-9556-8] [Medline: 19360464] 3. Veniegas RC, Kao UH, Rosales R, Arellanes M. HIV prevention technology transfer: challenges and strategies in the real world. Am J Public Health 2009 Apr;99 Suppl 1:S124-S130 [FREE Full text] [doi: 10.2105/AJPH.2007.124263] [Medline: 19218184] 4. Hansen MM. Versatile, immersive, creative and dynamic virtual 3-D healthcare learning environments: a review of the literature. J Med Internet Res 2008;10(3):e26 [FREE Full text] [doi: 10.2196/jmir.1051] [Medline: 18762473] 5. Villarruel AM, Jemmott LS, Jemmott JB. ¡Cuídate! Facilitator's Curriculum. New York, NY: Select Media; 2012. 6. Garrison DR, Anderson T, Archer W. Critical inquiry in a text-based environment: computer conferencing in higher education. The Internet and Higher Education 1999;2(2-3):87-105. 7. Swan K, Garrison DR, Richardson JC. A constructivist approach to online learning: the Community of Inquiry framework. In: Payne CR, editor. Information Technology and Constructivism in Higher Education: Progressive Learning Frameworks. Hershey, PA: IGI Global; 2009:43-57. 8. Burgess ML, Slate JR, Rojas-LeBouef A, LaPrairie K. Teaching and learning in Second Life: using the Community of Inquiry (CoI) model to support online instruction with graduate students in instructional technology. The Internet and Higher Education 2010;13(1-2):84-88. 9. Rovai AP. Sense of community, perceived cognitive learning, and persistence in asynchronous learning networks. The Internet and Higher Education 2002;5(4):319-332. 10. Arbaugh JB. Does the Community of Inquiry framework predict outcomes in online MBA courses? The International Review of Research in Open and Distance Learning 2008;9(2). 11. Liu SY, Gomez J, Yen C. Community college online course retention and final grade: predictability of social presence. Journal of Interactive Online Learning 2009;8(2):165-182. 12. Boulos MN, Hetherington L, Wheeler S. Second Life: an overview of the potential of 3-D virtual worlds in medical and health education. Health Info Libr J 2007 Dec;24(4):233-245. [doi: 10.1111/j.1471-1842.2007.00733.x] [Medline: 18005298] 13. Kamel Boulos MN, Toth-Cohen S. The University of Plymouth Sexual Health SIM experience in Second Life: evaluation and reflections after 1 year. Health Info Libr J 2009 Dec;26(4):279-288. [doi: 10.1111/j.1471-1842.2008.00831.x] [Medline: 19930475] 14. Mitchell S, Heyden R, Heyden N, Schroy P, Andrew S, Sadikova E, et al. A pilot study of motivational interviewing training in a virtual world. J Med Internet Res 2011;13(3):e77 [FREE Full text] [doi: 10.2196/jmir.1825] [Medline: 21946183] 15. Conradi E, Kavia S, Burden D, Rice A, Woodham L, Beaumont C, et al. Virtual patients in a virtual world: training paramedic students for practice. Med Teach 2009 Aug;31(8):713-720. [Medline: 19811207] 16. Schwaab J, Kman N, Nagel R, Bahner D, Martin DR, Khandelwal S, et al. Using second life virtual simulation environment for mock oral emergency medicine examination. Acad Emerg Med 2011 May;18(5):559-562. [doi: 10.1111/j.1553-2712.2011.01064.x] [Medline: 21521404] 17. Ghanbarzadeh R, Ghapanchi AH, Blumenstein M, Talaei-Khoei A. A decade of research on the use of three-dimensional virtual worlds in health care: a systematic literature review. J Med Internet Res 2014;16(2):e47 [FREE Full text] [doi: 10.2196/jmir.3097] [Medline: 24550130] 18. Wiecha J, Heyden R, Sternthal E, Merialdi M. Learning in a virtual world: experience with using second life for medical education. J Med Internet Res 2010;12(1):e1 [FREE Full text] [doi: 10.2196/jmir.1337] [Medline: 20097652] 19. Andrade AD, Bagri A, Zaw K, Roos BA, Ruiz JG. Avatar-mediated training in the delivery of bad news in a virtual world. J Palliat Med 2010 Dec;13(12):1415-1419. [doi: 10.1089/jpm.2010.0108] [Medline: 21091407] 20. Lee A, Berge ZL. Second life in healthcare education: virtual environment's potential to improve patient safety. Knowledge Management & E-Learning: An International Journal (KM&EL) 2011;3(1):17-23. 21. Villarruel AM, Jemmott LS, Jemmott JB. ¡Cuídate! Training of Facilitators Manual. New York, NY: Select Media; 2012. 22. Villarruel AM, Aebersold M, Valladares AF, Yeagley E, Tschannen D. Avatars travel for free: virtual access to evidence-based intervention training and capacity building. AIDS Educ Prev 2014 Oct;26(5):445-458. [doi: 10.1521/aeap.2014.26.5.445] [Medline: 25299808] 23. Valladares AF, Aebersold M, Tschannen D, Villarruel AM. Preparing facilitators from community-based organizations for evidence-based intervention training in second life. J Med Internet Res 2014;16(9):e220 [FREE Full text] [doi: 10.2196/jmir.3606] [Medline: 25270991] 24. Bangert AW. Building a validity argument for the community of inquiry survey instrument. The Internet and Higher Education 2009;12(2):104-111. Abbreviations CBO: community-based organization CDC: Centers for Disease Control and Prevention CoI: community of inquiry http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al EBI: evidence-based intervention MBA: Master of Business Administration MI: motivational interviewing MUVE: multi-user virtual environment N/A: not applicable SL: Second Life STD: sexually transmitted disease Edited by G Eysenbach; submitted 27.01.15; peer-reviewed by J Brixey; comments to author 12.04.15; revised version received 22.05.15; accepted 21.06.15; published 21.07.15 Please cite as: Aebersold M, Villarruel A, Tschannen D, Valladares A, Yaksich J, Yeagley E, Hawes A JMIR Serious Games 2015;3(2):e5 URL: http://games.jmir.org/2015/2/e5/ doi: 10.2196/games.4293 PMID: 26199045 ©Michelle Aebersold, Antonia Villarruel, Dana Tschannen, Angel Valladares, Joseph Yaksich, Emily Yeagley, Armani Hawes. Originally published in JMIR Serious Games (http://games.jmir.org), 21.07.2015. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), 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 http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | 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

Using a Virtual Environment to Deliver Evidence-Based Interventions: The Facilitator's Experience

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Background: Evidence-based interventions (EBIs) have the potential to maximize positive impact on communities. However, despite the quantity and quality of EBIs for prevention, the need for formalized training and associated training-related expenses, such as travel costs, program materials, and input of personnel hours, pose implementation challenges for many community-based organizations. In this study, the community of inquiry (CoI) framework was used to develop the virtual learning environment to support the adaptation of the ¡Cuídate! (Take Care of Yourself!) Training of Facilitators curriculum (an EBI) to train facilitators from community-based organizations. Objective: The purpose of this study was to examine the feasibility of adapting a traditional face-to-face facilitator training program for ¡Cuídate!, a sexual risk reduction EBI for Latino youth, for use in a multi-user virtual environment (MUVE). Additionally, two aims of the study were explored: the acceptability of the facilitator training and the level of the facilitators’ knowledge and self-efficacy to implement the training. Methods: A total of 35 facilitators were trained in the virtual environment. We evaluated the facilitators' experience in the virtual training environment and determined if the learning environment was acceptable and supported the acquisition of learning outcomes. To this end, the facilitators were surveyed using a modified community of inquiry survey, with questions specific to the Second Life environment and an open-ended questionnaire. In addition, a comparison to face-to-face training was conducted using survey methods. Results: Results of the community of inquiry survey demonstrated a subscale mean of 23.11 (SD 4.12) out of a possible 30 on social presence, a subscale mean of 8.74 (SD 1.01) out of a possible 10 on teaching presence, and a subscale mean of 16.69 (SD 1.97) out of a possible 20 on cognitive presence. The comparison to face-to-face training showed no significant differences in participants' ability to respond to challenging or sensitive questions (P=.50) or their ability to help participants recognize how Latino culture supports safer sex (P=.32). There was a significant difference in their knowledge of core elements and modules (P<.001). A total of 74% (26/35) of the Second Life participants did agree/strongly agree that they had the skills to deliver the ¡Cuídate! program. Conclusions: The results showed that participants found the Second Life environment to be acceptable to the learners and supported an experience in which learners were able to acquire the knowledge and skills needed to deliver the curriculum. (JMIR Serious Games 2015;3(2):e5) doi: 10.2196/games.4293 KEYWORDS Second Life; multi-user virtual environments; evidence-based interventions; community-based organizations http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al the level of the facilitators’ knowledge and self-efficacy to Introduction implement the training. Overview Virtual Learning Environment Imagine a place where you can attend a fully interactive training The CoI [6] is one of the most common frameworks for session with people in different settings from all areas of the assessing individual acceptance and comfort with country without having to leave your home or office. You could online-learning environments. The model is comprised of three learn about topics important to your work so you could help constructs that are core elements of a collaborative constructivist others in your community. That place is a virtual environment, learning environment: (1) cognitive presence—the ability of a computer-generated three-dimensional representation of a learners to construct meaning through reflection and discourse, space in which users can interact. They can take advantage of (2) social presence—the ability of participants to feel connected current Web 2.0 technologies, which are technologies focused to each other in the absence of face-to-face contact, and (3) on user-generated content, to deliver accessible and interactive teaching presence—the design, facilitation, and direction of training for communities and organizations. Training needs of processes needed to support learning [7]. Burgess used the CoI community-based organizations (CBOs) and others can range survey to determine the extent of social, cognitive, and teaching from information sessions to more intensive training sessions presence among graduate level technology students in class to conduct evidence-based interventions (EBIs). activities held in Second Life (SL) [8]. These constructs have been positively associated with learning in an online Evidence-based interventions are programs that have undergone environment. For example, a sense of community has been rigorous outcome evaluation and have the potential to maximize shown to have a positive relationship with perceived cognitive positive impact on communities [1]. However, despite the learning [9] and all three CoI constructs were predictive of quantity and quality of EBIs for health promotion and disease perceived learning in online Master of Business Administration prevention, the need for formalized training and associated (MBA) courses [10]. In another study, Liu and colleagues found training-related expenses, such as travel costs, program social presence was a significant predictor of course retention materials, and input of personnel hours, pose implementation among students enrolled in community college [11]. challenges for CBOs [2,3]. The CoI framework and Second Life were purposely chosen to To increase access to EBI training, cost-effective training guide the adaption of the ¡Cuídate! training program because methods, such as Web-based training platforms, are needed. it requires the application of skills and reflection on the work Accordingly, advances in technology have resulted in the of self and others (cognitive presence), high interaction and development of multi-user virtual environments (MUVEs) as social connection among participants (social presence), and platforms for social interaction. The creation of a sense of real-time feedback from facilitators and peers (teaching presence among users [4] has many benefits over less dynamic presence). These elements are lacking in a traditional online forms of traditional Web-based trainings such as webinars or Web-based training environment. asynchronous podcasts. While the use of MUVEs is commonplace among gamers and the technologically savvy, Second Life the use of MUVEs among community providers is not Second Life was developed by Linden Lab and is considered widespread. Little is known about the acceptance of MUVEs one of the most mature and widely used platforms in use, in community settings and agencies whose staff vary in specifically in health care. Through the creation and use of a computer experience and in familiarity and comfort level with modifiable avatar (ie, an online, graphical representation of the virtual training environments. user), individuals in SL are able to interact with people and The purpose of this study was to examine the feasibility of objects with the ability to exhibit social cues through realistic adapting a traditional face-to-face facilitator training program gestures [12]. for ¡Cuídate! (Take Care of Yourself!), a sexual risk reduction Second Life has been used in a variety of interventions in health EBI for Latino youth [5], for use in a MUVE. Facilitators are education for both practitioners and patients. Second Life is individuals who are trained in the delivery of the EBI who then also not new to the area of sexual health; the University of deliver the intervention to youth in their communities. In this Plymouth Sexual Health Sim was developed in the United study, the community of inquiry (CoI) framework [6] was used Kingdom as a place to provide sexual health education as well to develop the virtual learning environment to support the as private one-on-one counseling [13]. Studies using SL for adaptation of the ¡Cuídate! face-to-face curriculum. The practitioner training have found positive results. For example, constructs of the CoI framework (ie, social, teaching, and one study used SL for motivational interviewing (MI) training cognitive presence) were then used as a basis to evaluate if the among physicians [14]. This training included interactive facilitator learning experience in the 2.5-day MUVE training sessions in SL using role play with standardized patients to program was acceptable to the learners and supported the practice MI skills and was found to have a high degree of user acquisition of learning outcomes. Further comparison was acceptability. Participants (n=13) rated the acceptability of the conducted with those facilitators trained in the virtual various components of the course on a range from 4.1 to 4.7 on environment and those trained in face-to-face formats. This, in a 5-point Likert scale. Proficiency scores in MI also improved, part, addressed two aims of the study: to examine the with statistically significant improvement seen in four out of acceptability of the facilitator training program and to examine five component skills. In a study with paramedic students, which http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al compared paper-based and SL case scenarios for problem-based Condom Use Skills, and (6) Building Negotiation and Refusal learning, participants reported a more authentic and collaborative Skills. The facilitators received a hard copy of the entire experience in SL [15]. In addition, 100% of participants curriculum approximately two weeks before their SL session surveyed agreed/strongly agreed that SL is a relevant resource by Select Media. Each facilitator was assigned to facilitate (ie, for field/clinical work preparation. Similarly, Schwaab and role play) several of the activities in the SL ¡Cuídate! training colleagues [16] reported that emergency medicine residents sessions. Two master trainers, or expert ¡Cuídate! trainers, (n=27) participating in mock SL, oral examination case scenarios conducted the virtual training sessions and previously conducted experienced a high degree of comfort (100%) and realism face-to-face training sessions. These master trainers facilitated (92.6%). A majority indicated that SL was easy to navigate the entire training session in SL in English, similar to the (96.3%) and easy to log in to (92.6%), and preferred the SL oral face-to-face training sessions. examinations over the traditional format (66.6%). A recently The training was designed to allow facilitators to deliver and published systematic review of the use of virtual worlds in health practice facilitating activities in the curriculum, and to receive care [17] found 11 studies published in the area of professional feedback from their peers and ¡Cuídate! master trainers similar education, including using virtual worlds for medical education to what would be experienced in a face-to-face ¡Cuídate! for diabetes [18], delivering bad news to patients [19], and training session. Specific curricular activities were selected to improving patient safety [20]. utilize the capabilities of the interactive virtual environment. Given the success of SL in training health care providers and Unlike face-to-face training sessions, not all of the activities in the capacity to create a collaborative and realistic experience every module were completed in the virtual training sessions. for learners, SL was deemed a useful environment to increase Those activities that overlapped in structure and format were dissemination of EBIs among communities. This feasibility minimized in order to demonstrate activities that might be study could provide valuable information on the viability of challenging to conduct in real life. Throughout the training using a MUVE such as SL and on creating a framework for session, facilitators were encouraged to interact with each other others to use in designing training programs. and the ¡Cuídate! master trainers by providing feedback to one another and acting as participants (ie, adolescents) during the Methods role play sessions (ie, teach backs). Facilitators were oriented to the SL environment prior to the training sessions and Overview processes; technical support in SL was provided before and during training to minimize any technical issues that might arise This was a descriptive comparative study to evaluate the during training [23]. feasibility and acceptability of the SL environment, and to compare SL training to face-to-face training. The study protocol Sample was reviewed by the Institutional Review Board at the A total of five ¡Cuídate! training sessions were conducted in University of Michigan and was deemed exempt and not the SL environment (see Figure 1) with 35 facilitators (ie, regulated. participants) representing 24 agencies across the United States. To examine feasibility and acceptability, data were obtained These facilitators were recruited via networking and social from the participants (ie, facilitators) who participated in the media from CBOs across the country. Each training session SL ¡Cuídate! Training of Facilitators. For comparison with the group met three times. The first session was a 2.5-hour overview face-to-face training process, evaluation data were obtained of the ¡Cuídate! curriculum and overview of key SL features, from the Centers for Disease Control and Prevention (CDC) followed 1 week later by two more sessions—4 hours and 3 through Danya International, Inc (personal communication, hours in length, respectively—of ¡Cuídate! content. Danya International, Inc, 2014). Facilitators ranged in age from 20 to 59 years, with the majority Training in Second Life being female (24/35, 69%) and nearly half of Hispanic/Latino ethnicity (17/35, 49%). Education levels varied widely among The ¡Cuídate! Training of Facilitators Manual [21] was used the facilitators with a large number (28/35, 80%) having earned to adapt the 2.5-day, face-to-face training program into a a bachelor’s degree or higher. combination of self-paced, prelearning podcasts and live virtual sessions in SL [22]. The ¡Cuídate! training program was Comparisons were made with data from facilitators who previously only offered as a face-to-face training program; a participated in face-to-face training sessions (4 cohorts, 55 trainer conducted the 2.5-day session to teach the facilitators facilitators) held in St Louis, Philadelphia, Atlanta, and (ie, the study participants) how to deliver the curriculum to Memphis. These training sessions were held prior to the Latino youths in their communities. The facilitators were asked implementation of the SL ¡Cuídate! training program. A total to review the ¡Cuídate! curriculum and all the associated of 55 facilitators (41/55, 75% female) were trained in the activities prior to attending the virtual training sessions. The face-to-face settings in Atlanta (19/55, 35%), St Louis (16/55, six modules of the curriculum included the following: (1) 29%), Philadelphia (12/55, 22%), and Memphis (8/55, 15%). Introduction/Overview, (2) Building Knowledge about Of the 55 trained facilitators, 44 (80%) surveys were collected Pregnancy, Sexually Transmitted Diseases (STDs), HIV, (3) from St Louis (14/16, 88%), Philadelphia (10/12, 83%), Atlanta Understanding Vulnerability to Pregnancy, STDs, HIV, (4) (13/19, 68%), and Memphis (7/8, 88%) (personal Attitudes and Beliefs about Pregnancy, STDs, HIV, (5) Building communication, Danya International, Inc, 2014). http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Figure 1. ¡Cuídate! training room in Second Life. cognitive presence (alpha=.85). Table 1 lists each of the Surveys statements from the survey. Facilitators in both the face-to-face and virtual training sessions Two questions were also asked to evaluate the overall experience were asked to complete pre- and posttraining surveys. These in SL: (1) SL experience was an effective learning activity and surveys included items measuring attitudes toward implementing (2) SL experience was a positive experience. These questions ¡Cuídate!, self-efficacy in working with Latino youth and in were rated on a 5-point Likert scale, ranging from 1 (strongly implementing ¡Cuídate!, and overall evaluation of the ¡Cuídate! disagree) to 5 (strongly agree). Qualitative data were collected training program. In addition, facilitators who participated in through a series of open-ended questions, several of which SL training were also asked to complete a modified version of focused on aspects of the training in SL, as part of a debriefing the CoI survey. These items are described below. survey. Specifically, facilitators were asked what they Evaluation of the Virtual Learning Environment liked/disliked about the SL ¡Cuídate! training program, what were the advantages/disadvantages to training in SL versus face The community of inquiry framework survey instrument is a to face, and how likely they were to participate in another or 34-item questionnaire measuring the three areas of cognitive similar training program in SL. presence, social presence, and teaching presence [10]. Original subscale alphas were found to be .94 (teaching presence), .91 To compare the face-to-face and SL training sessions, questions (social presence), and .95 (cognitive presence). Further validity posed to facilitators in SL training sessions matched questions and reliability of the original instrument has been demonstrated posed to facilitators trained in face-to-face sessions. These through other studies [7,24]. questions included evaluation of the training (eg, length and pace) and self-assessment of knowledge and skills (eg, Because the original instrument was designed for use in online knowledge of core elements and six modules, ability to respond courses, the CoI survey was adapted and reduced to 12 to sensitive questions, and ability to help facilitators recognize statements to measure the items that related to the ¡Cuídate! how Latino culture supports safe sex). Items were scored on a Training of Facilitators. The items were scored on a 5-point 5-point Likert scale ranging from 1 (not confident) to 5 (very Likert scale, ranging from 1 (strongly disagree) to 5 (strongly confident). Two additional questions were asked of SL agree). Questions were retained in each of the three subscales. facilitators to determine mastery of the curriculum and skills The first subscale—social presence—included six questions necessary to deliver the program (see Table 2 in the Results which measure the ability of facilitators to feel connected to section) each other in the absence of face-to-face contact. The teaching presence subscale was comprised of two questions that refer to All surveys for the SL facilitator training sessions (5 cohorts) ratings of the design, facilitation, and direction of processes were conducted using Qualtrics (Qualtrics, LLC). Links to each needed to support learning. Finally, four questions measured of the surveys were sent to facilitators via an email from the cognitive presence which determine a learner’s ability to research team following completion of the training. Email construct meaning through reflection. The modified CoI survey reminders were sent to ensure a high response rate (35/35, was administered only to the facilitators of the SL training. 100%) and timely completion. Original surveys completed by Cronbach alphas were high for each of the subscales: social the facilitators at the face-to-face sessions were scanned and presence (alpha=.89), teaching presence (alpha=.84), and sent via email to the research team. http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Table 1. Community of inquiry survey statements (n=35). Second Life Total training score , subscale score, Variables and statements mean (SD) mean (SD) Social presence 23.11 (4.12) I am comfortable conversing through an online medium. 3.77 (1.03) I felt comfortable participating in training discussions. 4.17 (0.66) I felt comfortable disagreeing with other facilitators while still maintaining a sense of trust. 4.06 (0.64) Getting to know other facilitators gave me a sense of belonging. 3.86 (0.81) Online or Web-based communication is an excellent medium for social interaction. 3.34 (1.08) I was able to form distinct impressions of some course participants. 3.91 (0.92) Teaching presence 8.74 (1.01) The trainer helped keep facilitators on task. 4.31 (0.58) The trainer provided feedback in a timely fashion. 4.43 (0.50) Cognitive presence 16.69 (1.97) I can describe ways to apply the knowledge I learned in training. 4.23 (0.55) I was motivated to explore content-related questions. 4.14 (0.60) Learning activities helped me construct explanations/solutions. 4.11 (0.58) Reflection helped me understand fundamental concerns in training. 4.20 (0.63) Scores are on a scale from 1 to 5, with 1 being strongly disagree and 5 being strongly agree. was 23.11 (SD 4.12) out of a possible 30. The highest ranking Analysis questions were “I felt comfortable participating in training To evaluate the facilitators' experience in the MUVE and discussions” (mean 4.17, SD 0.66), “I felt comfortable examine if a learning environment was acceptable and supported disagreeing with other facilitators while still maintaining a sense the acquisition of learning outcomes, the CoI survey responses of trust" (mean 4.06, SD 0.64), and “I was able to form distinct and qualitative responses in each of the three constructs—social impressions of some course facilitators” (mean 3.91, SD 0.92). presence, cognitive presence, and teaching presence—were Qualitative comments supported the survey findings. When analyzed together. To analyze the modified CoI survey and asked what they most liked about SL, participants/facilitators overall SL questions, descriptive statistics and frequency noted particular aspects of the training that they liked best: distributions were analyzed using SPSS version 21 (IBM Corp). “...very interactive and fun to see” and “...very interactive, very A content analysis approach was used to analyze the nine engaging.” Additionally, several comments reflected social open-ended questions with NVivo10 (QSR International) to connections—an indication of social presence—with others in code and organize the qualitative participant responses from the training session as an aspect of what they liked about SL the SL surveys. training: “...interacting with people across the country” and “...interacting with other facilitators and getting feedback.” For comparisons of face-to-face surveys and SL training sessions, responses from the four face-to-face sites (ie, St Louis, Despite the positive comments, facilitators indicated that the Philadelphia, Atlanta, and Memphis) were combined because lack of being able to see facial expressions was a disadvantage. there were no significant differences among training sites on For example, “The element of watching individual’s body any of the outcome variables (P>.05). Univariate frequencies language & facial expression is priceless...only thing MISSING” of outcome variables were run and the Mann-Whitney U test and “You can’t see everyone and their body language which is for nonparametric data was used to make bivariate comparisons important when facilitating training but it [SL training] was of the face-to-face and SL outcomes, as the data did not follow very good.” any specific parameterized distribution. Teaching Presence Results In general, facilitators reported a high perception of teaching presence. The subscale mean was 8.74 (SD 1.01) out of a Evaluation of the Virtual Learning Environment possible 10. High mean scores were reported for items related to the trainers’ skill in keeping facilitators on task and also Social Presence trainers’ ability to provide feedback in a timely fashion (mean Results indicate that most respondents experienced a moderately 4.31, SD 0.58 and mean 4.43, SD 0.50, respectively). Qualitative high level of social presence—in other words, they were able comments supported a strong teaching presence: “A good to feel connections with other participants. The subscale mean http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al balance between lecture and interactive activities was of the importance of how the cultural values are provided”—indicates design and facilitation—and “...getting threaded throughout the curriculum] feedback on our teach backs”—indicates facilitation. These I definitely learned a lot—facilitation comments indicated that the facilitator constructed activities in skills—appreciated knowledge everyone else brought a way that supported learning in the environment. [Met the objective of learning skills] The responses on the overall SL questions found that 69% of Cognitive Presence the participants (24/35) agreed/strongly agreed that SL was an Cognitive presence was also highly rated. Cognitive presence effective learning activity and 77% of the participants (27/35) supports the ability of learners to construct meaning through agreed/strongly agreed that SL was a positive experience. reflection and discourse. Overall, the subscale mean was 16.69 (SD 1.97) out of a possible 20. The majority of respondents Acceptability of Second Life Training were in agreement with statements indicating that they felt able The survey responses from the face-to-face and SL training to describe ways to apply knowledge learned in training (mean sessions are presented in Table 2; bivariate comparisons between 4.23, SD 0.55), they were motivated to explore content-related the face-to-face and SL training sessions are presented in Table questions (mean 4.14, SD 0.60), learning activities helped them construct explanations and solutions (mean 4.11, SD 0.58), and reflection helped them understand fundamental concerns in A total of 80% of the participants (28/35) responded that the training (mean 4.20, SD 0.63). Qualitative comments that length of the training in SL was “about right” and 83% (29/35) supported the survey findings were as follows: responded that the pace of the training was “about right.” When asked about their self-assessment of knowledge and skills in Good to get better understanding from what is every category—core elements, six modules, challenging expected from the curriculum, sometimes you don’t questions, and recognize how Latino culture supports safer know what the developer was thinking. [Understands sex—over 50% of the participants in the SL training program the objectives of the course] reported, at a minimum, being confident with those skills. Reinforcement of cultural values. Activities that reinforced the materials throughout [Understanding http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Table 2. Comparison between Second Life training and CDC face-to-face training. Variables and survey responses CDC survey Second Life survey (n=44), n (%) (n=35), n (%) Evaluation of training Appropriateness of training length Too long 1 (2) 1 (3) A little too long 6 (14) 2 (6) About right 29 (66) 28 (80) A little too short 8 (18) 3 (8) Much too short 0 (0) 1 (3) Pace of the training Much too slow 0 (0) 0 (0) A little slow 4 (9) 3 (8) About right 28 (65) 29 (83) A little fast 9 (21) 2 (6) Much too fast 2 (5) 1 (3) Self-assessment of knowledge and skills Knowledge of core elements Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 2 (5) 11 (32) Confident 16 (37) 19 (54) Very confident 25 (58) 5 (14) Knowledge of six modules Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 1 (2) 6 (17) Confident 21 (49) 24 (69) Very confident 21 (49) 5 (14) Respond to challenging or sensitive questions/situations Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 3 (7) 3 (8) Confident 17 (40) 16 (46) Very confident 23 (53) 16 (46) Help participants recognize how Latino culture supports safer sex Not confident 0 (0) 0 (0) Little confident 0 (0) 0 (0) Somewhat confident 3 (7) 3 (9) Confident 16 (38) 17 (48) Very confident 23 (55) 15 (43) Mastery of ¡Cuídate! curriculum I have mastered content of program as written in manual Strongly disagree N/A 0 (0) http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al Variables and survey responses CDC survey Second Life survey (n=44), n (%) (n=35), n (%) Disagree N/A 2 (6) In the middle N/A 14 (40) Agree N/A 18 (51) Strongly agree N/A 1 (3) I have mastered skills to deliver program as written in manual Strongly disagree N/A 0 (0) Disagree N/A 1 (3) In the middle N/A 8 (23) Agree N/A 20 (57) Strongly agree N/A 6 (17) Centers for Disease Control and Prevention (CDC). Not applicable (N/A). Table 3. Nonparametric comparisons of participant ratings between CDC face-to-face training and Second Life training. CDC Second Life Mann-Whit- training score training score ney Variable (n=44), mean (SD) (n=35), mean (SD) U test Z score P Appropriateness of training length 3.00 (0.62) 3.03 (0.65) 765.50 -0.06 .96 Pace of the training 3.21 (0.68) 3.03 (0.51) 643.00 -1.41 .16 Knowledge of core elements 4.53 (0.59) 3.83 (0.66) 353.50 -4.35 <.001 Knowledge of six modules 4.47 (0.55) 3.97 (0.57) 441.50 -3.56 <.001 Respond to challenging or sensitive questions/situations 4.47 (0.63) 4.37 (0.65) 692.50 -0.67 .50 Help participants recognize how Latino culture supports 4.48 (0.63) 4.34 (0.64) 649.00 -0.98 .33 safer sex Centers for Disease Control and Prevention (CDC). P values (significance) based on two-tailed analysis. elements and six modules significantly higher (mean 4.47, SD Comparison of Face-to-Face and Virtual Training 0.62) compared to those in the SL training sessions (mean 3.83, Experience SD 0.67). However, of the SL participants, 54% (19/35) There were no significant differences between participant ratings agreed/strongly agreed that they mastered the content of the of the length or pace of training in SL as compared to program as written in the manual, and 74% (26/35) face-to-face training (P=.96 and P=.16, respectively). Further, agreed/strongly agree that they mastered the skills to deliver results indicate no significant difference between SL and the program as written in the manual. face-to-face participant self-assessment of their ability to respond appropriately to sensitive questions and to recognize Discussion how Latino culture supports safer sex decisions (P=.50 and Principal Findings P=.32, respectively). There was a significant difference between reported knowledge of the components of the six ¡Cuídate! MUVEs hold promise for delivering training in the future modules (P<.001). Those facilitators who participated in without the training-related travel costs, thereby increasing the face-to-face training sessions had higher knowledge scores use of these crucial programs that have widespread and critical (mean 4.44, SD 0.56) as compared to those who participated in influence on population health and health outcomes. It is always SL training sessions (mean 3.97, SD 0.57). challenging to deliver training in a Web-based environment when you cannot physically see the facilitators, particularly Additionally, there was a significant difference (P<.001) when training requires active participation rather than passive between SL and face-to-face participant ratings of their ability receipt of knowledge. Part of the ¡Cuídate! Training of to describe the six core elements of the ¡Cuídate! curriculum. Facilitators curriculum [21] requires facilitators to conduct teach Facilitators who participated in the face-to-face training sessions backs, necessitating engagement with others. Consequently, the rated their level of confidence in their knowledge of the core use of a MUVE such as SL over a noninteractive format (eg, http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al webinar) is essential to support the interaction necessary to curriculum. This is essential to meeting the aim of ensuring support the role-play interaction. Results of this study indicate facilitators have the ability to deliver the curriculum effectively. that SL is an acceptable and feasible way to deliver training and The significant difference between participants' self-assessment achieve outcomes that lead to learning success. of their abilities to identify the core elements and modules was not surprising. During the face-to-face training sessions, The results of this study indicate that the three constructs of facilitators were given an overview of the six modules, whereas social, teaching, and cognitive presence were present in the SL facilitators in the virtual environment were required to review environment. The facilitators also rated the SL experience as all materials ahead of time as part of the prelearning work. Given positive and effective. Specifically, the facilitators experienced the complexities and multiple priorities of the facilitators, they a moderately high level of social presence in the SL may have not reviewed the materials or did not thoroughly environment. This connectedness to others has been shown to review them prior to the virtual training. Further work is needed be a predictor of success in online courses [11]. Although virtual to ensure facilitators complete all prelearning materials. This environments will never duplicate the social presence found in can be done by requiring interaction with the modules as they face-to-face environments, the comments demonstrated how are being presented or with a postmodule quiz. engaged and immersed in the environment the facilitators were when responding (eg, “interacting with people across the The high ratings on the mastery indicate that although country"). The facilitators only "met" or interacted in SL, yet participants did not experience all learning in SL, they did feel they felt a connection to others with whom they trained. This they had the skills to deliver the content. This finding supports is consistent with what was seen in other studies using SL the efficacy of conducting training in SL. Educators should [14-16]. consider this when trying to minimize time spent in training while ensuring mastery of the content and various learning In relation to cognitive presence—an indicator of how well our methodologies. Eliminating extra time in training will assist facilitators achieved the learning objectives—facilitators agreed with efficient use of the limited resources available to the activities were helpful and they felt capable of applying the community-based organizations or other groups pursuing knowledge gained in training. Facilitators had access to all six training. modules and all the activities in the training manual; they were asked to review all modules/activities as part of their prelearning Conclusions work prior to coming to training. Also noted in the training As it becomes more challenging to access training to deliver survey, the majority of the participants agreed they had mastered EBIs, alternative methods like training in virtual worlds need the skills to deliver the curriculum, and over half agreed they to provide access to training in a manner that is both effective had mastered the content of the program. This is consistent with and acceptable to those receiving the training. This will then the study by Schwaab [16] in which MI skills improved after open a way to increase access to even remote areas, provided training in SL. Teaching presence was also supported by the there is Internet access and a willingness to engage in a virtual SL environment. Facilitators rated the trainers high in keeping training environment. This study demonstrates that training can them on task and providing them with timely feedback, while be effectively delivered in a virtual world and the training comments supported a good balance of activities. Comparison environment in SL can be designed and delivered in a manner studies did not rate the quality of teaching presence. that is acceptable to the participants. SL was an effective training environment for the facilitators to achieve the ability to learn There were no differences between face-to-face- and SL-trained the skills needed to deliver the ¡Cuídate! curriculum, including facilitators in their confidence levels regarding their ability to demonstration of the teach backs that are essential to being able respond to challenging or sensitive questions when delivering to effectively deliver this successfully to Latino youths. the curriculum, which is important to the mastery of the Acknowledgments This research was funded by the National Institute of Mental Health (R21-MH095723; MA and AV, co-PIs). The authors would like to thank our ¡Cuídate! Second Life participants for their willingness to venture into the virtual world for training and for their dedication to working with adolescents across the country. We also want to thank ¡Cuídate! master trainer, Arman Lorez, for his ability to connect to the participants virtually and make the training experience great. Finally, we would like to thank Charles Collins from the CDC for his support throughout this study. Conflicts of Interest None declared. References 1. Evidence-Based Clinical and Public Health: Generating and Applying the Evidence. Washington, DC: US Department of Health and Human Services; 2010 Jul 26. URL: https://www.healthypeople.gov/sites/default/files/ EvidenceBasedClinicalPH2010.pdf [accessed 2015-07-11] [WebCite Cache ID 6ZwbvHPds] http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al 2. Norton WE, Amico KR, Cornman DH, Fisher WA, Fisher JD. An agenda for advancing the science of implementation of evidence-based HIV prevention interventions. 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Abbreviations CBO: community-based organization CDC: Centers for Disease Control and Prevention CoI: community of inquiry http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Aebersold et al EBI: evidence-based intervention MBA: Master of Business Administration MI: motivational interviewing MUVE: multi-user virtual environment N/A: not applicable SL: Second Life STD: sexually transmitted disease Edited by G Eysenbach; submitted 27.01.15; peer-reviewed by J Brixey; comments to author 12.04.15; revised version received 22.05.15; accepted 21.06.15; published 21.07.15 Please cite as: Aebersold M, Villarruel A, Tschannen D, Valladares A, Yaksich J, Yeagley E, Hawes A JMIR Serious Games 2015;3(2):e5 URL: http://games.jmir.org/2015/2/e5/ doi: 10.2196/games.4293 PMID: 26199045 ©Michelle Aebersold, Antonia Villarruel, Dana Tschannen, Angel Valladares, Joseph Yaksich, Emily Yeagley, Armani Hawes. Originally published in JMIR Serious Games (http://games.jmir.org), 21.07.2015. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), 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 http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2015/2/e5/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e5 | p. 11 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Jul 21, 2015

Keywords: Second Life; multi-user virtual environments; evidence-based interventions; community-based organizations

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