United Nations Public Service Awards Case Studies

- Game addiction: a worldwide problem

Game addiction is considered a major behavioral and psychological problem that, generally, requires mental health services including counseling, behavioral management, or even hospitalization. The prevalence of game addiction is skyrocketing in many countries around the world such as the United States (8.5%), England (12%), and China (10.3%). In Thailand, an epidemiological study on game addiction revealed that 14.4% of Thai youths were game addicts. Another concerning issue is that children start becoming addicted to computer games at a younger age.

- Negative impacts: not only to individuals but also to their family and society

The consequences of game addiction involve physical, psychological, behavioral, relationship and social problems. In Thailand, there have been many tragic events related to game addiction. Suicide and homicide are not uncommon outcomes in these severe cases. One alarming incident occurred in 2004 when a 16-year-old boy who admitted that he imitated and practiced his violent act from a violent computer game slaughtered a taxi driver. The most recent study confirmed that the more children play violent computer games, the more violent they become when they grow up. What would happen to our society when game addicted individuals become adults?

- Major obstacles: lack of awareness, poor insight, fear of stigmatization, and difficulty getting access to mental health services

The vast majority of game addicted youths have not yet received proper treatment. There are many reasons accounting for this problem. First, the game addiction among youths is underreported due to lack of awareness. Some parents are naïve and still believe that games have caused their children no harm. It may be true that some games may contribute to some benefit. Many games have the opposite effect, especially when combined with poor parenting and lack of parental supervision. Second, most people with game addiction simply deny that they have a problem. If they do, they tend to minimize it similar to substance dependence problems. Third, when the problem becomes more serious and requires mental healthcare, many parents hesitate to bring their children to the psychiatric clinic due to the fear of stigmatization. Fourth, even if the parents finally decide to get help, they have difficulty getting access to mental health services. In Thailand, there are currently only 150 child psychiatrists taking care of approximately 15 million youths. Thus, the ratio of child psychiatrists for youths is 1 per 100,000 in Thailand, as compared to 8.7 per 100,000 in the United States. Such a serious shortage makes it almost impossible for children with game addiction to be evaluated by a child psychiatrist in a timely manner. They are usually categorized as having a “non-urgent” problem and placed onto a six-month long waiting list. Providing an “old-style” psychiatric service is definitely insufficient.

Increasing the number of violent acts related to game addiction has urged us to find a better solution. The idea of creating a website that includes all kinds of possible psychiatric services required for ameliorating the game addiction problem was then initiated.

What is the initiative about? (the solution)
- Proactive healthcare on game addiction: (1) Increase awareness and understanding of the public and offer a universal access for everyone The nature of game addiction is complicated and involves biological, psychological as well as social factors. Apparently, the speed of invasiveness of game addition surpasses the capacity of conventional mental health services. The solution offers a comprehensive, proactive and innovative approach to reduce this gap. We have attempted to find a means to deliver mental health services to gamers and their parents who are often ignored or have difficulty getting access to traditional services in time. Department of Psychiatry, the Faculty of Medicine Siriraj Hospital, Mahidol University, has initiated innovative healthcare services which entirely take care, treat, and prevent youths from game addiction via the Internet (HealthyGamer.net) that is easily accessible for everyone. Parents, teachers, and those who seek for appropriate gamer care would find this online platform valuable as a one-stop service for game addiction which contains various information. Moreover, its education and edutainment styles help people to easily understand game addiction care and become closer to the network of mental health services, resulting in better understanding and healthy and warm social support. (2) Pervade “Balanced gaming … Balanced life” Research indicates that minimization of the chance of playing games, maximization of the responsibility and self-control of the child, setting up time limitations for playing games, spending quality time having family activities with children, and encouraging them to have alternative activities, are all important and effective strategies to reduce the game addiction problem. Our creative and positive concept of “Balanced Gaming…Balanced Life” can be distributed to the society as fast as possible, through all channels including the Internet. The website is a platform that brings all stakeholders together, including parents, youths, care seekers, educators, and service providers. (3) Offer screening tests online and increase efficiency of mental health service delivery The research-based Game Addiction Screening Test (GAME-S) is the first-time available online self-evaluated questionnaire for the public free of charge. This new online platform is very comfortable for users to be able to access from anywhere and at anytime. Since HealthyGamer.net started its operation, many more users have accessed the website and completed the screening tests than those who have come to the Child Psychiatry Clinic. 7,156 users accessed the website and had a screening service within one year (4 May 2010 – 4 May 2011), while only 70 people came to the Clinic during the same period of time. The figure demonstrates that “customers” are more interested in this new service delivery which is consistent with the parents’ attitude and their inclination not to take children to see a psychiatrist. Our psychiatrists are able to treat more than one patient at a time since a lot of users can now find existing answers through the designated online forum, i.e. knowledge sharing. Furthermore, users are not required to identify themselves, which makes them anonymous and helps them keep their confidentiality. These are unique characteristics of this new online service.

Who proposed the solution, who implemented it and who were the stakeholders?
- Faculty of Medicine Siriraj Hospital, Mahidol University proposed the initiative Beginning with the research granted by the Office of National Research Council of Thailand to study the problem, Associate Professor Chanvit Pornnoppadol, a child psychiatrist, and his colleagues have discovered useful information that can be utilized in real life practice. Afterwards, the Department of Psychiatry, together with the Division of Education, the Faculty of Medicine Siriraj Hospital, Mahidol University pushed forward and came up with an online service foreseeing that this channel is a much more effective strategy in dealing with the fast growing game addiction problem. The service was established, planned, and developed with the cooperation of a multidisciplinary team working in the Faculty of Medicine Siriraj Hospital. The innovative HealthyGamer.net website has been created with the cooperation of both public and private sectors. This is parallel to the policy; to create new knowledge to improve efficiencies of human resources, the primary factor to enhance Thai society and to catch up with the change of globalization. - Working together for the brighter future in Thailand The Center for Game Addiction Prevention and Treatment operated by the Child and Adolescent Mental Health Rajanakarindra Institute (CAMRI), the Department of Mental Health, the Ministry of Public Health has been a longstanding ally of this innovation. CAMRI has become a part of our network and receive referral for severe cases who need an intensive, face-to-face psychiatric treatment. Besides the medical institute, other public and private organizations have also been involved. The Thai Health Promotion Foundation provided the financial support to develop the first version of the website. The Ministry of Culture allocated the budget to revise, maintain and advertise the website over the past two years. The Ministry of Education has granted the permission for HealthyGamer.net staff to run the campaign on how to be a healthy gamer among the middle and high school students in Bangkok area. The HealthyGamer.net has exchanged the banner with other websites dealing with children and families to promote the web. - The most important stakeholder: the website’s visitors The most important stakeholder of the HealthyGamer.net website is our visitors including youths, parents, educators, researchers and health care professionals. Every comment was listened to and taken into account. The channels of two-way communication are widely open through phone calls, e-mail, online forums, web blogs and the Facebook. Feedbacks have also been received during the seminars, meetings, and road-show events. Our visitors have played important roles of being clients, evaluators and supporters all at the same time during the process of website development and its major revisions.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The goal of this initiative was to build a practical platform for promoting responsible gaming as well as offering a one-stop online service for game addiction. The followings are the main strategic objectives to be achieved: - Develop the standardized Game Addiction Screening Test (GAME-S) and the Game Addiction Protection Scale (GAME-P) The first objective was to develop reliable and valid self-rated instruments through two years of collaborative research. GAME-S was developed to measure the level of game addiction while GAME-P, to measure the level of immunity against game addiction. Both tests were methodologically validated and criticized by parents and their children across Thailand. The Game Addiction Quality of Life Scale (GAME-Q) is being developed and expected to be available by mid-2012. - Develop a website as a means to overcome limited resources and difficulty getting access to service The second objective, HealthyGamer.Net was strategically developed as a means to overcome these challenges of the “traditional” psychiatric services. It offers a universal access for anyone from anywhere at anytime. It resembles a “24-hour clinic” in which clients can get the services from their home. They can choose what kind of services they would like to receive ranging from testing their level of game addiction, checking their immunity against game addiction, seeking knowledge regarding how to prevent or overcome game addiction, to forming a self-help group or getting advice through the designated online forums. This unique online service provides easy accessibility and requires much less personnel and other resources. - Embrace participation of all possible stakeholders The third objective is to embrace participation of stakeholders as comprehensive as possible. Gamers, families, schools, teachers, local and national government must participate in order to bring success to this initiative. Agencies were invited and agreed to become allies. Our team has been diligently working on this strategy with some success. The Thai Health Promotion Foundation and the Ministry of Culture financially support this project. The Ministry of Public Health agrees to be a part of our network regarding promotion and treatment aspect. We have promoted our website to middle and high school students with the cooperation of the Ministry of Education. We have also planned to collaborate with NGOs working with children and their families, i.e. the Family Network Foundation and the Internet Foundation for the Development of Thailand in the near future. - Build a user-friendly platform Last but not least, in order to build a user-friendly, content-rich, and healthcare-focused network, feedback is the key success factor. Participation was promoted through continuous public relations and advertisements. Both negative and positive feedback was received from visitors, and revolution of the website seriously took such suggestions into account. We reorganized the information and changed the looks, designs and styles to make it more attractive and easier to use. The most important message, promoting healthy gaming and not against gaming at all, was conveyed to the users using the explicit motto of “Balanced Gaming…Balanced Life”. These changes have made the platform become more acceptable by visitors.

b. What were the key development and implementation steps and the chronology? No more than 500 words
- Start with the research (2006-2008) In 2006, the Faculty of Medicine Siriraj Hospital, Mahidol University received research funding granted by the National Research Council of Thailand to conduct a study to discover the protective factors for (Internet) game addiction among Thai youths. A large-scale data collection was carried out across Thailand, where 4,000 subjects participated. The Game Addiction Screening Test (GAME-S) and the Game Addiction Protection Scale (GAME-P) were developed as part of this research project. To obtain a highly reliable and valid self-rated instrument, child psychiatrists and psychologists, who are specialized in game addiction, generated the items in the GAME-S and the GAME-P. More importantly, many protective factors of game addiction in the context of Thai society were identified. - New service platform initiative (2009) The Thai Health Promotion Foundation as a service platform for game addiction initially granted the development of the HealthyGamer.net. The Game-S and the Game-P were converted into intelligent online questionnaires in which visitors can conduct self-evaluation at their own privacy from anywhere at anytime. The key components of the website, both online contents and structures of community-based e-health portal, including the information about protective factors of game addiction (research findings), positive parenting, i.e. “How to raise a healthy gamer, How to effectively discipline your child” etc., and an online self-evaluation game addiction test, were created. This initial platform was a proof of concept of technology utilization and realization of the new service model. The primary target groups were parents and schoolteachers. Feedback channels were created to receive comments for improving the website. - “HealthyGamer.Net” in action (2010) The HealthyGamer.Net officially began to offer its services to the public as the first online resource for game addiction in Thailand on May 4th 2010. Promoting how to be healthy gamers and creating recognition of the website started through campaigns, advertisements and road-show events. Six months after the opening of the website, we evaluated the statistics obtained from Google Analytics and feedback from users. We discovered that youths visited our website much more than adults. The website was then slightly redesigned to make it more youth-oriented. The new contents that would be more useful and interesting for youths were added. - Revolutionize the website to make it more user-oriented and sustainable platform (2011) The more positive feedbacks we have received from the users, the more confident we are that the website is beneficial to many families. In 2011, resources and endless effort were allocated to the website making it a truly user-oriented service platform for everyone, conveying gamer-friendly attitudes. The contents of the website were also reorganized and revised to get more attention from a variety of new audiences and to serve their needs, particularly combining edutainment flavors such as cartoons, documentaries and short films. The objective is to ensure right understanding and guiding gamers to find a balanced life. The community activities were conducted to gain more user awareness and participation from the public for the sustainability of the services.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
Challenges: difficulty getting involvement from the responsible agencies, limited resources, resistance from the gamers, low rates of web traffic Throughout the six years of development, the team has encountered several challenges. Since the HealhyGamer.net is a project established by a non-profit organization, the financial support relies only on funding from outside agencies which initially had no interest and recognition of the game addiction problem. At the beginning of this project, some gamers had opposed the idea of labeling people as being addicted to games and misunderstood that the HealhyGamer.net absolutely banned the gaming. Moreover, web traffic had been quite low during the first six months due to the lack of effective mass communication, unattractive web design and serious content presentation. Solution 1: Raising awareness based on research data To overcome the lack of involvement from the responsible agencies, we conducted an epidemiological study confirming that the size and seriousness of game addiction problem can no longer be ignored. Several meetings with the “key persons” of each responsible agency were arranged and the alarming statistics were revealed. As a result, many agencies have achieved more understanding and are now willing to support this project. The sense of partnership was instilled to those agencies through acknowledgments and incorporation of their strength. Solution 2: Fund raising After the initial meeting with responsible agencies, the objectives, procedures and financial plan of this project were proposed. Each agency has provided support and resources that were not a burden to their budget. The benefits the children and their families would receive if the website was successfully established were emphasized. The “win-win situation” was a strategy employed during the fund raising process. Acknowledgment has been clearly made to every agency participated in this innovation. The pressure working under limited resources was then dissipated. Solution 3: Putting ourselves in gamers’ shoes At the beginning, the resistance of misunderstanding gamers was obvious. The negative feedback from those gamers helped the team look back and review the strategies to receive more acceptances from the users. We discovered that gamers naturally did not prefer to be called “a game addict” and opposed any person telling that gaming was “bad”. The motto “Balanced Gaming…Balanced Life” was then initiated to convey the good intention that we merely attempted to promote healthy gaming and did not totally prohibit gaming. This goal was eventually achieved and the resistance was gradually lessened. Solution 4: Self-analyses and revolutionize the website The HealthyGamer.net operating team regularly analyzes web traffic using Google Analytics. The low rate of web visitation during the first six months urged the team to find the causes and solutions. The feedbacks from users through focus group interview were obtained. The unattractive design, poor organization of the information and lack of an effective marketing were the major reasons of this obstacle. The team has revolutionized the website to improve its design and better organize the information. Also, the plan for an effective mass communication is being revised and will be launched in the near future.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The core team members consist of personnel from the Faculty of Medicine Siriraj Hospital, Mahidol University, all working part-time on the project. There have been three members since the project started six years ago, including a child psychiatrist (the Principal Investigator), a clinical psychologist and a research assistant. A medical informatician from the Faculty has joined the team since the project aimed to develop an innovative online platform (e-health) for mental health services, i.e. the HealthyGamer.net. This project has been funded mainly by government agencies for research as the Principal Investigator proposed annually. Once the budget was granted, the project task lists were carried out by additional resources required for the task completion in the project plan. However, limited budget was always allocated due to the lack of ample funding in the area of mental healthcare plus this kind of innovative concept had not yet been proven. Thus, the support from the Faculty of Medicine on these personnel is crucial for the execution of this project, including the support for the project office and availability of multidisciplinary human resources at the Hospital. The Office of National Research Council of Thailand sponsored the project to study prevalence of game addiction in Thai youths and to develop an effective screening test for game addiction, resulting as the GAME-S and GAME-P questionnaires. This study was carried out with collaboration from the Ministry of Public Health through the Department of Mental Health on country-wide data collection and validation of the screening tests developed. Development of the HealthyGamer.Net platform was initially supported by the Thai Health Promotion Foundation as direct funding and website development effort through subsidized IT agencies that worked on multiple projects. The core team was focused on design concepts and contents while the IT team developed the actual website and its programming components. In addition, voluntary helps were received from the network of clinical psychologists in which graphic designers, story writers, cartoonists, youths and parents gathered. Consequently, a proof of concept for this new service was realized. Similar support was provided on the following years until last year which a significant amount of budget from the Ministry of Culture was allocated on a major website redesign to leverage the level of user experience, to complete the database engine of the online tests and to relocate web hosting. These resources were allocated according to best practices of software development life-cycle that take user feedbacks and system testing as the key requirements for improvement. The clinical psychologist asked youths from online and real life communities to test our system. There were a web master and a user-experience specialist hired during the last year to help the team on look-and-feel design, content creation, information update, campaign and network building. These activities are critical for the success of the e-health platform. Promoting “Balanced Gaming…Balanced Life” not only requires innovative also conventional means. The core team and our allies conducted workshops, road-show events, and counseling to increase awareness and understanding about proper game addiction care.

Is the initiative sustainable and transferable?
- “HealthyGamer.net”: an inexpensive, easy to access service Although information service via the Internet is not considered new, the HealthyGamer.net website is an innovative online mental health service. To the best of our knowledge, HealthyGamer.net is the first website operated by mental health professionals to provide care for people with gaming addiction free of charge. The cost of this project is incredibly inexpensive. The accumulated expense of creating this website over the past six years is approximately $40,000 US dollars. Since the official opening of the website in May 2010, there have been more than 80,000 persons visiting the website and presumably receiving some form of service. Therefore, it costs only 50 cents for each service the website has delivered which makes HealhyGamer.net one of the most cost-effective mental health services available. It is quite easy to obtain the service from the website for any persons who have Internet access. The technology required for establishment of the website is rather simple and available in every country in the world. - A universal model of online game addiction care Through research-based activities and multiple-year development effort, this innovative mental health service has gone through the complete development life-cycle in the actual environments from requirement gathering, design, deployment, testing to revision of the solution. This ensures the proposed platform to achieve a high level of being a universal model of online game addiction care. We have a long-term plan to publicize our website by translating its contents into foreign languages. By so doing, gamers and their families around the world will benefit from the HealthyGamer.net. Given its cost-effectiveness, easy accessibility, simple technology and translatability, we are certain that the HealthyGamer.net platform is transferable to other countries. - Raising “awareness”: a work in progress at both individual and policy levels In order to make the HealthyGamer.net project sustainable, our team realizes that active participation from the people, the government and the private organizations is extremely important. At present, many people believe that game addiction is not a real problem. They have no insight regarding the magnitude and the seriousness of the problem as well as the negative impacts which game addiction has caused to the young generation and the Thai society. An awareness of game addiction in youths will urge both public and private sectors to pay more attention to social development, particularly in youth welfare. The collaboration between the government and the NGOs will play an important role to drive the HealhyGamer.net to success. Therefore, the promotion of an awareness of the problems related to game addiction at both individual and policy levels is our top priority. The sense of ownership to the HealthyGamer.net perceived by all responsible sectors is also an essential factor. This will be beneficial in terms of getting supports and social network cooperation, making this service platform sustainable. Our team is paying a close attention to this factor and it is seen as a work in progress.

What are the impact of your initiative and the lessons learned?
- Six years of hard working finally pays off: online service for game addiction The HealthyGamer.net was eventually established and started providing a proactive online service to promote responsible gaming. The website offers an online game addiction screening test which instantaneously gives the users an interpretation and advice. We attempt to encourage cyber-community of gamers, parents, teachers and professionals to share their ideas on how to prevent or solve game addiction. We strongly believe that our website can be a solution for many game addicted individuals and an answer for concerned parents. - Promoting more awareness of this problem and extending service delivery to the society. Because of the nature of being an online service and anonymity on the part of users, it is practically impossible to measure the direct impact of the website. We were unable to demonstrate whether the website could reduce the prevalence of game addiction. The growing number of visitors accessing the website each month, nevertheless, can imply increasing attention and awareness of game addiction. Many educators and researchers have requested the permission to use GAME-S to screen their students or conduct research regarding game addiction. Moreover, we have received encouraging feedbacks posted on the online forum and the Facebook from many users reflecting the usefulness of the website, e.g. “I should have found this website sooner…Thanks for the information, it helps me deal with my son better…”. This initiative aims strategically to build a platform for providing mental healthcare and professional supports to those in need who are living with the limited access to mental health services in remote area, hence promoting equity. In addition, anxious and doubtful parents may feel relief when they learn that their child is not a game addict. This may help to avoid undesirable labeling and pressure put on children who may not have been “game addicts”. If parents remain concerned and need psychological supports, they are able to get instant access to those services. - Key success factors: incessant learning, embracing feedback and networking Learning is required for developing an e-health platform for psychiatry health care. Team members have to improve themselves through regular meetings, trainings and creative feedback. They are encouraged to seek, learn and share all kinds of knowledge such as psychological aspects of game addiction, online advertisement, data management. Collaboration with public and private agencies must be enhanced, including an effective network for game addiction management. The aforementioned characteristics are essential for perfecting and sustaining the website. - All of this is to promote the motto ‘Balanced Gaming…Balanced Life’ for everyone. In conclusion, it is clear that social cooperation, effective resource management, creativity, positive approach, and reflective learning from past experiences both successes and failures altogether have brought about a new innovation that helps reduce the possibilities of stigmatization and increase accessibility to mental health services. The HealthyGamer.net is an excellent example of innovation, focusing on the game addiction problem in the youths, to make the Motto pervasive and acceptable for gamers around the world.


Institution Name:		Faculty of Medicine Siriraj Hospital
Institution Type:		Government Agency
Contact Person:		Chanvit Pornnoppadol
Title:		Dr.
Telephone/ Fax:		+(66)24194275/+(66)24113843
Institution's / Project's Website:		www.si.mahidol.ac.th, www.healthygamer.net
E-mail:		cp3008@gmail.com
Address:		Faculty of Medicine Siriraj Hospital
Postal Code:		10700
City:		Bangkok
State/Province:		Krung Thep
Country:		Thailand

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information