It’s a breezy afternoon at Miami Lakes Middle School, and Mighty Girls program facilitator Dina Ferranti greets 15 Latina seventh-graders who are entering the classroom. The girls talk excitedly as they line their backpacks against the wall, cell phones safely tucked inside. They take their seats and look expectantly at Ferranti. “It’s time for our NO thanks, NO way Mighty Moment,” she announces.

During the next 45 minutes, the 11- to 13-year-olds learn about three different styles of communication—aggressive, passive and assertive—and how they can refuse their friends’ requests to engage in risky behaviors by using their words, their voice, and their body language.

“Communication is more than the words you say,” Ferranti tells them. “You’re also ‘talking’ with your body and the sound of your voice.”

The girls learn that when their words, voice, and body language match, others will see them as being confident and convincing. “Voice and Body-language Always Match,” emphasizes Ferranti, who is a School of Nursing and Health Studies (SONHS) Ph.D. student. “That’s V-BAM power!”

The girls break into pairs and take turns practicing the “strategies for refusal” they are learning in the group. One girl tries to talk the other into engaging in the kind of risky behaviors that many early adolescent girls face every day, such as skipping class, shoplifting, hanging out with older teens, or sneaking beer from the refrigerator at home. The other girl uses her “V-BAM power,” together with “POW,” the Power of Words, to refuse the request in a way that’s convincing, considerate, and confident. She practices putting her shoulders back, looking her partner in the eye, and saying no without talking in a “squeaky” voice or sounding like she’s asking a question. And she learns how to choose words that will protect her friendship while getting her safely out of the risky proposition.

A week later, the girls are back. This time their eyes are on Christina Lopez, a SONHS alumna, who is sending them to the game room to play DRAMA-RAMA, the Mighty Girls skill-building video game. After 15 minutes, they return with big smiles on their faces and giggle while comparing stories, especially stories about “Javier.” Girls need to use a lot of POW and V-BAM with Javier—he likes to flirt and invite them to do things like come over to his house when his parents are not there.

The girls are participants in Mighty Girls, an early intervention pregnancy prevention program for Hispanic and Brazilian girls and the brainchild of University of Miami School of Nursing and Health Studies Professor Anne Norris. Mighty Girls is currently being implemented in Miami-Dade County middle schools as part of the JUEGA! study The program combines highly interactive classroom sessions with DRAMA-RAMA, a cutting-edge video game that uses avatar-based, mixed-reality technology to empower early adolescent girls with skills to resist everyday peer pressure and remove themselves from risky situations. SONHS undergraduate and graduate students team together with School of Education and Human Development graduate students to help Norris deliver and evaluate the program.

Resisting Risk without Losing Face

“Early adolescents are at risk for engaging in behaviors linked to early initiation of intercourse, such as hanging out with older teens who are engaging in sexual behavior,” explains Norris. “Girls who initiate intercourse early are at risk for teen pregnancy, especially pregnancies that end up with a baby in the NICU [Neonatal Intensive Care Unit]. The costs to the adolescent, family, health care system, and society are high—but preventable.”

National statistics show an increased risk for teen pregnancy among Hispanics living in low socioeconomic neighborhoods, such as the ones targeted by Norris’s study. Data from a Mighty Girls feasibility trial indicates that the program has a more powerful impact on reducing risky sexual behavior than other early intervention prevention programs. These promising early results led the National Institute of Nursing Research of the National Institutes of Health to award Norris a $3.3 million, five-year grant in 2014 to further test the efficacy of Mighty Girls.

“Early adolescents need information presented in a concrete, rule-based manner that at the same time enables them to think about the effects of their choice and to resist social influences without losing face with their friends,” says Norris. “Mighty Girls was designed to do all of these things.” Through activities such as rating the riskiness of various behavior choices or critiquing the messages embedded in media images and television programs, the girls also develop critical thinking skills.

“The classroom sessions teach decision-making by scaffolding formal operations thinking through fun, game-like activities that link goals, choices and results of choices,” says Norris. Through Mighty Moments and other fun, interactive activities Norris developed in collaboration with Roxana Delcampo Thalasinos (research support coordinator for JUEGA!), “the girls develop a kinesthetic or whole-body awareness of assertive communication,” Norris explains.

“You can see them grow from one session to another,” notes Ferranti. “They begin to think of their own new ways to say no or to avoid giving an answer altogether.”

The project is an interdisciplinary, collaborative effort that brings together experts in communication, psychology, theatre and technology. “When you bring people from different fields together, you get multiple areas of expertise and different perspectives on a problem that enriches the solution-finding process,” explains Norris.

Jeff Temple, an associate professor and psychologist at the University of Texas, is bringing his expertise on dating violence to the project. He explains that problem-solving, conflict resolution and decision-making in real time are some of the foundational skills participants learn in this program. “Greater self-confidence and increased self-efficacy are the results,” he says.

Michael Hecht, distinguished professor of communication arts and sciences at The Pennsylvania State University, is a communications scientist and nationally recognized drug abuse prevention researcher who serves as the study co-investigator. He says that DRAMA-RAMA enables girls to “practice putting themselves in the risky situation. They learn what they can do and develop the self-efficacy to do it when they are in the real situation.” Together with colleague Michelle Miller-Day, a professor of communication studies at Chapman University, Hecht developed Keepin’ it REAL, a prevention modality that provides teens with effective communication skills to help them negotiate risky situations that might lead to drug use. REAL stands for four important skills: refuse, explain, avoid and leave. Because the skills that kids use to refuse drug offers are similar to the skills they use to refuse other risky behaviors, the REAL resistance skills component is an important part of the Mighty Girls program.

JUEGA! (“PLAY!”) is a randomized group trial that tests the efficacy of Mighty Girls, a teen pregnancy prevention program that empowers early adolescent girls with the peer-resistance skills they need to avoid risky social situations. The study focuses on low-income Hispanic adolescent girls in response to national concerns about the increased risk for teen pregnancy within this U.S. subpopulation. It is an interdisciplinary, collaborative effort involving the UM School of Nursing and Health Studies, REAL Prevention, E2i Creative Studios at the University of Central Florida’s Institute for Simulation and Training, Interactor Simulation Systems, and experts in teen dating violence and economics.

The JUEGA! study is being conducted in 20 Miami-Dade County public middle schools that have a predominantly Hispanic student body as well as a high proportion of students who qualify for free or reduced lunch. Study participants are seventh-grade, English-speaking girls of Hispanic or Brazilian background, and 85 percent qualify for free or reduced lunch. Girls are followed into fall of their ninth-grade year. All study activities are held after regular school hours, and girls are provided healthy snacks and free transportation home.

Participating schools are randomly assigned to either the Mighty Girls intervention or a control condition called Game Girls, but regardless of study condition, all girls in JUEGA! have access to fun computer games and the opportunity to build skills for success in life. This year, the study was implemented in nine schools—five Mighty Girls schools and four Game Girls schools.

The Mighty Girls condition has six classroom sessions in which girls learn to link choices and consequences, identify risky behaviors and situations, match their words with their tone of voice and body language, use avoidance and refusal techniques to respond to peers, and critique sexualized messages in the media.

After completing the classroom sessions, girls play DRAMA-RAMA, a computer game that allows them to practice their newly acquired skills verbally and non-verbally with several “early adolescent” avatars. The girls’ words, voices and body language are the “inputs” to which the avatars respond. They earn game points for socially competent and effective responses to simulated interpersonal encounters that are drawn from the kinds of situations that middle school girls typically encounter in their schools and neighborhoods.

The Game Girls condition features Science Valley, an interactive, virtual reality computer game designed by UCF’s E2i Creative Studio to help increase girls’ interest in science and create an opportunity for them to practice using the scientific method as they interact with male and female scientist avatars and a friendly robot dog in a virtual world. Girls are able to experiment with building a wind turbine or a robot, or with determining the environmental conditions needed to grow a crop. The Game Girls condition helps the study team ensure that changes in the Mighty Girls participants are due to the intervention and not to girls maturing or changing their behavior over the short term simply by virtue of being part of a research study (i.e., “the Hawthorne Effect”).

“I think we’re going to see some really groundbreaking and innovative results,” said Anne Norris, principal investigator of this study and a professor in the University of Miami School of Nursing and Health Studies. “The Mighty Girls intervention, the DRAMA-RAMA game, and the way we’re going to analyze the data are all cutting edge,” Norris said.

Engaging the Digital Generation

The Mighty Girls classroom sessions take place after school over six consecutive school days. In the days following the last session, the girls play DRAMA- RAMA two times. Developed by Norris and her colleagues, this innovative computer game presents the player with four distinct stories and engaging, recognizable characters: the best friend who doesn’t always make good choices, the popular girl who is involved with a high school boyfriend, the cute boy all the girls want attention from, and the party boy who is always offering alcohol or other drugs. These characters challenge the girls to use their new communication and refusal skills to make wise choices. One of the most innovative aspects of the gaming technology is the use of digital puppetry which allows the girls to talk directly to the avatars as if they were real people, fully immersing them in a virtual world that simulates their everyday experiences. Each story unfolds differently as the characters respond to each girl’s own words, tone of voice, and body language. The players earn points by using their Mighty Girl “powers”—V-BAM and POW—to respond to the risky scenarios.

“This is the model of the future,” says Temple. “Technology isn’t going away, and we can use it to our advantage to promote healthy behaviors in teens.”

Eileen Smith, director of the E2i Creative Studio at the University of Central Florida Institute for Simulation and Training, collaborated with Norris in the production of DRAMA-RAMA. Together with project manager and designer Alexia Mandeville, they helped create the look of the fun, cartoonlike characters and the virtual world in which they live. Actors with expertise in interactive performance helped Norris create the game stories and provided the physical poses and facial expressions for each of the characters.

“Emerging media research is about creative innovation, transcending the limitations of current technology, and getting to the next level,” says Smith. “We’re finding new ways to use creative technology for learner engagement.”

Another innovation is the use of the players’ voices and body language—instead of a mouse, joystick or keyboard—as the “input” for the game. “They need to learn how to respond the way they would in a real-life situation—by using their voices and body language,” explains Smith.

Using gaming technology to advance prevention science is an approach that greatly interests the NIH. “The technology behind DRAMA-RAMA helps us capture the girls’ decisions so we can learn more about female empowerment,” says Smith. “The technology guides the experience, but the girls drive the experience.”

Taking New Skills into the Real World

There is great enthusiasm for the project among the girls as well as their parents. “The girls are super positive about the game. They say, ‘This is so fun, I wish I could take it home with me,’” says Ferranti. “And the parents say their daughters have changed in a positive way after being in the program,” adds study assistant Jennifer Donoso, who helps coordinate the DRAMA-RAMA sessions.

The schools are just as enthused. Marly Hernandez is a specialist and school counselor at Miami Lakes Middle School, one of the schools participating in the Mighty Girls program. “The girls who are engaged seem more empowered, and the parents are happy with the program,” she says. “I’ve noticed girls using their skills in my individual and family meetings. It’s exciting. We want to start offering this program to all the girls in our school every year.”

Clearly, Norris’ vision and leadership are at the heart of the program’s success. “Projects like this come down to someone like her making it happen,” says Hecht. “She’s a gifted researcher who has the ability to move effectively within interdisciplinary groups and to connect to the schools and teachers and parents and computer programmers.”

In the end, the girls are taking their new awareness and skills into the very real, everyday world of middle school. After a Mighty Girls session last fall, Natacha Janac, one of Norris’ program facilitators and a master’s student in the UM School of Education and Human Development, was outside the school with one of her students when both noticed a girl trying to tell a boy to stop bothering her. The young “mighty girl” sized up the situation right away. “She’s saying no, but her body language doesn’t match,” she observed. “That girl really needs to learn how to V-BAM!”