A Serious Game (ACE of Hearts) to Support Mental Health among Young People with Adverse Childhood Experiences: A Mixed Methods Feasibility and Acceptability Evaluation

Background: Adverse childhood experiences (ACEs) have life-long detrimental effects on physical and mental health. ACE impacted young people are under-represented in research and cautious about seeking help. Practitioners fear re-traumatisation during assessment and treatment. Innovative approaches to care are needed. To respond, we co-designed a serious game called ACE of Hearts (AoH) focusing on promoting awareness of ACEs and providing guidance and support. This paper reports on a feasibility and acceptability study and a process evaluation of mechanisms. Method: A diverse cohort of young people aged between 12-24 years, reporting three or more ACEs, and living in different geographical areas of England were recruited through trusted partner organisations. Following informed consent, they were provided access to AoH for three months. Feasibility (rates of recruitment, uptake, engagement, retention, and follow-up), acceptability (affective attitude, burden, ethicality, intervention coherence, perceived effectiveness, self-efficacy), demographic and mental health outcome data were collected at baseline, 1- and 3-month follow-up. Process evaluation interviews at 3 months assessed mechanisms, acceptability and feasibility. Results: Of 40 eligible subjects, 36 completed the baseline assessment and 22 downloaded AoH. Twenty participants completed the questionnaires at 1 and 3 months (91% follow-up of those accessing AoH); 19 participants completed all assessments (86%). Many participants valued the central cosy den space and its customisation options. Engagement rates for 4 mini-games ranged from 32% to 73%. Most participants enjoyed playing AoH, found it easy to use, and felt it helped them reflect on their experiences. The process evaluation found positive views of the game design, style, and content along with perceived benefits through education, awareness, emotional connection, and considering help-seeking. Several improvements for access, relevance, acceptability, engagement and retention were recommended. No adverse events were reported. Conclusions: AoH was found to be feasible to use and acceptable and recommendations were given for improvements.