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Internet-based learning programs provide people with massive health care information and self-help guidelines on improving their health. The advent of Web 2.0 and social networks renders significant flexibility to embedding highly interactive components, such as games, to foster learning processes. The effectiveness of game-based learning on social networks has not yet been fully evaluated.
The aim of this study was to assess the effectiveness of a fully automated, Web-based, social network electronic game on enhancing mental health knowledge and problem-solving skills of young people. We investigated potential motivational constructs directly affecting the learning outcome. Gender differences in learning outcome and motivation were also examined.
A pre/posttest design was used to evaluate the fully automated Web-based intervention. Participants, recruited from a closed online user group, self-assessed their mental health literacy and motivational constructs before and after completing the game within a 3-week period. The electronic game was designed according to cognitive-behavioral approaches. Completers and intent-to-treat analyses, using multiple imputation for missing data, were performed. Regression analysis with backward selection was employed when examining the relationship between knowledge enhancement and motivational constructs.
The sample included 73 undergraduates (42 females) for completers analysis. The gaming approach was effective in enhancing young people’s mental health literacy (
Electronic games implemented through social networking sites appear to effectively enhance users’ mental health literacy.
The Internet plays an increasingly important role in our daily lives. With the shift of the World Wide Web from Web 1.0 to Web 2.0, the Web becomes an essential platform for information sharing, user-centered design, and collaboration. The Web 2.0 concept has led to the development and evolution of Web-based communities and applications, such as social networking sites (SNS), video-sharing sites, blogs, forums, wikis, and interactive games.
Apart from leisure use, some studies have indicated that the Internet has become an instrumental information-searching tool for people with health concerns [
Different kinds of multimedia techniques and interaction methods based on advanced technologies have been evaluated for their learning efficacy through preliminary evidence [
In Hong Kong, mental health education is not a regular school subject in the school curriculum. Rather, some concepts and skills may be taught in subjects like Life Education or Liberal Studies. Therefore, some school-based mental health promotion programs were developed. For instance, “The Little Prince is Depressed” project was a 12-week, school-based, universal program aimed at reducing depressive symptoms and enhancing protective factors of depression among secondary school students [
In the past few years, online social networks, an important aspect of Web 2.0 applications, have emerged as a mainstream communication and interaction modality, especially among young people. SNS, such as Facebook, can be an excellent platform to reach a large spectrum of the population. People make use of these platforms to have fun and socialize with each other through games, chats, and status updates. Games on social networks are called “social games” and attract large numbers of players every day. For example, many people, especially adolescents, spend a lot of time growing crops on “Happy Farm” and feeding pets in “Pet Society” on Facebook. This new form of communication modality, however, has created both concerns and opportunities for health professionals and researchers. For instance, some reported that SNS might be related to problematic use of the Internet [
Previous studies revealed gender differences in the use of Internet. For example, males have been shown to spend more time playing games and on other forms of entertainment, whereas females use the Internet more for communication and SNS [
The current study attempted to evaluate a novel approach of using DGBL through an SNS for mental health education. We designed a learner-centered, self-paced, electronic game, meaning that people could play and learn whenever they wanted to and could achieve as much as they preferred in terms of domain knowledge enhancement. The game developed for this study was placed on Facebook, and no facilitator was required. We hypothesized that mental health literacy would be enhanced through Web-based DGBL and three motivational constructs (ie, expectancy, value, and affect), would influence learning outcomes. Mental health literacy was first defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (page 182, [
explore the effectiveness of using DGBL to enhance mental health literacy through an SNS;
explore learning motivation in DGBL;
examine whether gender plays a role in intervention effectiveness and learning motivation; and
explore the impact of motivational constructs on mental health literacy.
Participants were recruited at a major university in Asia. An invitation email was sent to all undergraduate and postgraduate students’ (N=22,260) university email accounts inviting them to participate in the current study. Students who were between 17-25 years old, had adequate Internet literacy and a Facebook account, and were reachable via the local network were eligible to participate. The invitation email explained to participants that they would not only be required to complete a 3-week game on Facebook, but would also be asked to complete a set of Web-based, self-assessed questionnaires both before and after finishing the game. They were allowed to play the game anytime and anywhere with a computer connected to the Internet within the study period. Those who completed the game and the online questionnaires received cash compensation and were entered in a drawing for a tablet computer, supermarket coupons, and theme park tickets. Interested students replied to the invitation email and provided their Facebook ID for verification. The research team then confirmed their eligibility through email.
The electronic game “Ching Ching Story” and its content were developed by the authors of the paper. The development process involved contextual and technical aspects. For the contextual aspect, the learning content was adopted and modified from a school-based, mental health enhancement program for adolescents by members of the research team. The school-based program effectively reduced depressive symptoms within those with highly depressed moods [
“Ching Ching Story” consisted of 10 topics: (1) identifying stressors and how to handle stress, (2) understanding the relationship between stress and coping, and the consequence of depression, (3) understanding what goal-directed thinking is, (4) affirming existing strengths and acknowledging the concept of “self”, (5) cognitive restructuring, (6) advanced cognitive restructuring, (7) understanding others’ feelings, (8) communication skills, (9) conflict resolution based on a problem-solving approach, and (10) anger management [
Adobe Flash was used to produce interactive gaming elements and animated graphics on the client side of the system. Flash ActionScript 3.0 handled the logic of the game and sent requests to the backend in response to user actions. Moreover, we used Facebook API, where both Facebook iFrame and Javascript SDK facilitated the retrieval of a user’s profile and social network data from the Facebook application. Javascript was used for backend programming. Questionnaire and game progress data were stored in a MySQL database. The system was hosted on a computer server on the authors’ host institution network. The game was accessible by the public on Facebook [
“Ching Ching Story” is a role-playing game. It is thought that proper instructional design is capable of facilitating both mental health learning and intervention [
Despite the limitations on playtime, players still had great flexibility within the game, selecting the mission they preferred. In an effort to encourage active and self-paced learning, there was no predefined order of completion. Once players completed the ten missions, no advanced plots and/or tools were provided. Also, a level system was installed to record the level and skills learned for each player. The record was shared among friends who also joined the game to establish a leader board and create an atmosphere of competition to enhance the game’s appeal. Moreover, the game facilitated social support by encouraging interaction between players. Examples included sending gifts and greetings among friends, shown in
Missions for players to choose.
Psychological gym room.
Visiting friends and sending gifts.
Two sets of Web-based, self-assessed questionnaires were developed for measuring participants’ mental health literacy (primary outcome) and their learning motivation (secondary outcome). Facebook ID was used as a user identifier for verification and avoided duplicate entries. Pre- and posttests automatically popped up once the game started and ended, respectively. The pretest consisted of demographic information and self-developed questions on mental health literacy, whereas the posttest consisted of the same questions for mental health literacy plus modified questions for learning motivation from the Motivated Strategies for Learning Questionnaire (MSLQ) [
Mental health literacy was measured through 31 questions, which were constructed by the researchers to address the 10 topics of the game. They included true-or-false, sequencing, multiple-choice, and matching questions. The questions, designed to evaluate a broader understanding of learning through online DGBL, covered topics like understanding of mental health concepts and application of skills. Sample questions may be found in
Participants’ learning motivation was measured in terms of (1)
Descriptive statistics were used to illustrate the general picture of the data for each measurement. Any participants with missing data or who dropped out were not included in the completers analysis. In addition to completers analysis, data were analyzed through an intent-to-treat (ITT) analysis, using multiple imputation (MI) to address loss of follow-up data. Dropout participants who completed questionnaires only at the pretest were handled by applying the technique of MI with 5 imputations for missing data [
Linear regression was used to examine the relation between knowledge enhancement and motivational constructs. By fitting knowledge enhancement with motivational constructs, the coefficient and 95% confidence interval could be presented. The regression was further adjusted by adding pretest score, gender, and age as control variables. Backward selection was employed in the regression analysis. All data analyses were conducted using SPSS software.
Ethics approval, from the Human Research Ethics Committee for Non-Clinical Faculties at the authors’ institution, was obtained before data collection. Participants provided informed online consent before they started the game. The informed consent form detailed information about the procedures of the study.
Participants were recruited from November to December 2011 at the authors’ institution. A total of 221 undergraduates agreed to participate in the study. Out of those who started the game (n=136), a majority completed the pretest (n=127). The other 9 participants did not fully complete the pretest due to technical problems, such as early termination of the questionnaire. Out of these 127 participants, 73 completed both the pre- and posttest. All 127 participants were included in the ITT analysis, whereas only data from the 73 participants who completed both assessments were used for the completers and regression analyses.
Nonsignificant motivational subscales were eliminated in the regression analysis with backward selection. Nonsignificance of the three subscales within the value construct indicated that reasons for participating in the game did not affect knowledge enhancement. The influence of control of learning beliefs in the expectancy construct was also not statistically significant. Control variables, namely pretest score, gender, and age, were retained in the model regardless of their level of statistical significance. As expected, gender and age did not affect learning outcomes, whereas pretest score did significantly affect knowledge enhancement (see
Participant flowchart.
Descriptive statistics of pretest, posttest, and evidenced improvement on the knowledge test.
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Male | Female | All |
Pretest score, mean (SD) | 19.61 (3.30) | 18.55 (3.63) | 19.00 (3.51) |
Posttest score, mean (SD) | 21.85 (3.53) | 20.74 (3.12) | 21.21 (3.33) |
Improvement, mean (SD) | 2.23 (4.39) | 2.19 (3.07) | 2.21 (3.66) |
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.008 | <.001 | <.001 |
Descriptive statistics of the six motivational subscales and gender comparisons.
Motivational subscales | Male, |
Female, |
All, |
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Intrinsic goal orientation | 5.02 (0.78) | 4.93 (1.01) | 4.97 (0.91) | .68 |
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Extrinsic goal orientation | 4.18 (1.22) | 3.71 (1.34) | 3.91 (1.30) | .13 |
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Task value | 4.74 (0.73) | 4.66 (1.17) | 4.70 (1.00) | .72 |
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Control of learning beliefs | 4.82 (0.83) | 4.70 (0.93) | 4.75 (0.88) | .56 |
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Self-efficacy for learning and performance | 4.92 (0.70) | 4.71 (0.92) | 4.80 (0.83) | .29 |
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Test anxiety | 3.59 (1.19) | 3.16 (1.23) | 3.34 (1.23) | .14 |
Regression of knowledge enhancement on motivational constructs adjusted by pretest score, gender, and age after backward selection.
Variables | Coefficients | 95% CI Lower | 95% CI Upper |
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Self-efficacy for learning and performance | .21 | 0.09 | 0.32 | <.001 |
Test anxiety | -.19 | -0.31 | -0.06 | .005 |
Gender | .81 | -0.55 | 2.18 | .24 |
Age | .18 | -0.20 | 0.56 | .34 |
Pretest score | -.63 | -0.83 | -0.44 | <.001 |
The fully automated Web-based intervention was effective in enhancing young people’s mental health literacy. Intrinsic goal orientation was the primary factor in learning motivation, whereas test anxiety was successfully alleviated in the game setting. No gender differences were found on any outcome measures. Moreover, self-efficacy for learning and performance positively influenced learning outcomes, whereas test anxiety negatively affected them.
To our knowledge, this is one of the first studies to explore the use of DGBL through an SNS to enhance mental health literacy. Despite the limitations of this exploratory study, participants attained mental health knowledge in a continual and self-paced manner. With moderate improvements among participants, it seems players may be able to acquire knowledge in the game at their own learning pace and apply the skills to solve real-life problems. This finding provides supporting evidence that Web-based DGBL can effectively enhance mental health knowledge. The combination of gaming concepts and online education may also facilitate self-paced learning processes in higher-order thinking. It seems that this new type of learning initiative for mental health information is efficient for both male and female learners.
Thus, the current study reinforces Lieberman’s suggestion [
Participants’ learning motivation was generally positive. They believed in their own abilities to learn in the game and tailored their learning processes in the absence of a facilitator. Although participants who were outstanding in the knowledge test were rewarded with an extra prize, intrinsic goal orientation was still stronger when compared to extrinsic orientation. High intrinsic motivation indicates that participants primarily perceived that they took part in the game for its challenges, out of curiosity, and in an effort to attain mastery. Therefore, participants enjoyed playing the game and learning about mental health knowledge throughout the intervention, instead of simply pursuing rewards. With high expectancy, participants also believed that their efforts to learn throughout the self-paced game would result in positive learning outcomes. Self-directed learning was possible in the game. The positive influence of self-efficacy for learning and performance on learning outcomes implies participants’ expectations about their own performance and judgment generally reflected their learning outcomes. Participants were capable of enhancing their mental health knowledge and manage the learning process in the game. Moreover, the game-based environment provided an enjoyable learning environment for participants, evidenced by substantially reductions in their stress over the knowledge test. However, participants’ worries and concerns about the test could have still resulted in performance decrements. Although the knowledge test was conducted in a casual way, relationships between test anxiety and test results still existed.
In addition, the feedback collected from participants on learning motivation and game design provided additional information about the high intrinsic goal orientation. The feedback from participants was generally positive and encouraging. Participants appreciated the combination of gaming concepts and mental health knowledge. The transformation of mental health knowledge into a game made mental health knowledge easy to understand and attractive (eg, “The game helped me understand more about stress management”; “Overall the game was quite interesting as it used animations to show what stress and emotional distress are and solutions to manage them”). They also found that the game was good to raise their awareness in mental health (eg, “Informative about mental disorder”; “A good way to promote awareness in mental health”), and the game itself was interesting and interactive (eg, “Interactive and easy to play”). This may explain why intrinsic goal orientation remained high in the learning process. Some participants, however, pointed out the game sometimes had too many words, which may decrease the enjoyment of the game (eg, “More informative than interesting”; “Sometimes want to skip information and conversations to advance plots”). We therefore may need to think of balancing information and entertainment to achieve better learning motivation in our future intervention development.
There are some limitations of this exploratory study: lack of a control group, small sample size, high dropout rate, and a biased sample. Moreover, the social functions in the game might not have been fully utilized, as the total number of players was not large. Time limitations prevented the number of players in the game to grow to an adequate size. Since the number of players influences the interactivity of a social game, the game in this study might not have been as interactive as other social games for pure entertainment on the market. In addition, our DGBL study was domain-specific, a common issue in most previous studies.
In sum, DGBL in combination with an online social communication platform in health education should be advocated as a way to promote mental health awareness and equip people with domain-specific knowledge education, and warrants further examination. Future studies should involve a larger sample, incorporate a control group, and recruit different age groups in order to have a more comprehensive understanding of the effects of this Web-based electronic game on mental health education. In addition to augmenting the sample size, another future research direction includes investigating the effectiveness of social game education based on this study. Social games on SNS facilitate social interaction and communication, making them different from traditional online games. SNS could provide tools to embed communication platforms (eg, blogs, forums) into games, which may, in turn, substantially enhance levels of sharing and knowledge exchange among players [
Questionnaire items.
CONSORT-EHEALTH checklist V1.6.2 [
digital game-based learning
intent-to-treat
missing completely at random
multiple imputation
Motivated Strategies for Learning Questionnaire
social networking sites
This research has been supported in part by the following grants: Health Care and Promotion Fund (#23090514) , Food and Health Bureau, Hong Kong Government; General Research Fund (#742012), Research Grants Council, Hong Kong Government; Azalea (1972) Endowment Fund, The University of Hong Kong; and Quality Education Fund, Education Bureau, Hong Kong Government. The authors thank Chris Wong, Broderick Koo, Alice Lee, and Wai-ki Sung of the University of Hong Kong for their assistance in the project.
None declared.