A serious game is a video game that uses computer-based entertainment technology to teach, train, or change behaviour.10 The development, implementation and evaluation of gaming technologies applied to health-related conditions was discussed at the inaugural Games for Health Conference in 2004. Resulting recommendations for game design included the need for enhanced self-concepts, improved self-efficacy, increased knowledge and skills, increased communication and social support, empowering individuals to take action in regards to their own health, a multidisciplinary approach, and a regard for ethical issues.23 Other serious games such as Food Force and Re-Mission show great promise (Box 1).

A comprehensive model of learning for behaviour change in video games is based on social cognitive theory and the elaboration likelihood model. Social cognitive theory proposes that behaviour change is a function of enhanced skill and confidence (self-efficacy) in doing the new behaviour, while modelling and feedback are keystones for learning skills. The elaboration likelihood model proposes that gaining and maintaining a person’s attention is the first step in getting the person to process the information in a message to promote behaviour change.10

In addition to behaviour change principles, the storylines and modules of ROC were developed by drawing on the principles of cognitive behaviour theory (CBT) and were based on a schools-based intervention with demonstrated effectiveness, “Adolescents Coping with Emotions”.26 The adaptation and use of CBT in schools-based interventions delivered via classroom curricula show promising results.27,28 Theoretically, it seemed logical to combine the principles of social cognitive theory, the elaboration likelihood model and CBT in a translational research delivery model that appealed to young men.

Although ROC is part of Reach Out, it is located on a separate website (http://www.reachoutcentral.com.au) with a distinct navigation style designed to appeal to young men. ROC is not a structured treatment; rather, the objectives of the game are to teach life skills, such as communication, problem solving and optimistic thinking, in a virtual setting using real-life scenarios.

ROC is a single-player game, and when a player logs in, he or she is asked to complete a short survey that measures positive affect, allowing the player to track his or her mood over time. The player’s in-game mood is affected by activities and how he or she responds to other characters and situations. The aim is to encourage young people to recognise that there are simple and effective strategies for improving their mood (eg, sleep increases energy and relaxation, while studying increases confidence and decreases energy). Players also get tips sent to their mobile phones by text message and links to fact sheets on the Reach Out website.

When the game begins, the player is presented with a scenario of having just moved to a new town. He or she interacts with a set of non-playing characters (Box 2) through different plots and progresses through the game by choosing responses from a series of options. Plots are discrete storylines that usually involve up to five characters (Box 3). The plots may have outcomes that affect the player’s moods or the friendship ratings of various characters, or may allow the player to gain items or money, which are all dependent on the player’s choices during interactions with other characters. The player can significantly affect the events during a particular plot but the ultimate outcome is predetermined. The purpose of the plots is to present real-life scenarios that allow young people to make choices, see the consequences of their choice, and learn from them. Several key themes are explored, including mental health difficulties such as depression and drug and alcohol use, while underlying themes are also explored, such as relationship problems, bullying and victimisation, grief and loss, family relations and managing money.

The ROC marketing campaign was specifically designed to appeal to young men, and marketing materials were created to appeal to “gamers”. Advertorials were posted on six gaming, entertainment, social and community youth websites. Specific male youth-oriented magazines were targeted, including Zoo Weekly, Alpha, Waves, Rolling Stone, XBox and FHM. The campaign was advertised in print and the popular press, including 1500 bus and tram interior advertisements nationally, and was picked up nationally by metropolitan, suburban and specialty newspapers, radio stations and television networks. Music was included in the game plan, and Australian artists contributed tracks.

In the first month after its launch in September 2007, ROC had 76 045 website visits, with 10 542 new members joining Reach Out. Fifty-two per cent of new members were male, suggesting that advertising campaigns had reached the target audience. When filling out the Reach Out member sign-up page, new members are asked to indicate where they heard about ROC. New members reported having heard about ROC via a link on another website (23%), a magazine, bus or tram advertisement (11%), through their school, university or youth centre (7%), through an internet search engine (4%) or by word of mouth (4%). Smaller proportions of new members heard about ROC from their counsellor or family doctor, a postcard or poster, on the radio or at a youth event. Forty-one per cent did not respond to the question.

Online advertising delivered 49% of website visits to the ROC game landing page and 19% of all visits to the Reach Out member sign-up page. The best performing sites were Miniclip, Bored of Studies, Bebo, Piczo and Ad2One Youth and Entertainment. The overall “click-through” rate from online advertising was 1%, which is five times the industry average for a comparable online campaign.

An external evaluation of ROC involving 266 young people aged 18–25 years was conducted between August 2007 and February 2008 by Swinburne University of Technology.29,30 The study was a single-group, quasi-experimental design with repeated measures of psychological wellbeing, stigma and help seeking (pre-game play, post-game play, and at 2-month follow-up). Overall results were consistent with the interpretation that ROC was a successful way of educating, attracting and engaging young people.30 Psychological distress scores for young women significantly reduced over time, and they reported improved satisfaction with life, problem solving and help seeking.29 No significant changes were observed for young men; however, the recruitment of young men in the study was low and subsequent loss to follow-up was substantial. Of the 266 participants at baseline, only 88 (33%) were male and, at follow-up, 22 had dropped out. The study authors concluded:

While ROC is a single-player game, it is possible to use it to provide direct links to online and offline mental health resources and services and to create online communities within the Reach Out website for discussing game play. These could have a focus on promoting community participation and building social connectedness, both protective factors with a positive impact on mental health. Resources promoted through the game could include: an online diary where players keep track of scenarios to try or stories of their success in applying learned skills in their day-to-day life; direct links to fact sheets about professional services (eg, letting young people know that Medicare covers 12 free counselling sessions) to promote help seeking offline; online health records to promote consumer-driven wellbeing management; and virtual tours of youth mental health services. In their online communications, young people could share stories about their experiences with ROC (eg, how they have used the game or how it has helped them with real-life experiences), and share game tips and provide encouragement to the community of players. Evaluation should focus on measuring accurate user numbers and interactivity across resources, longitudinal tracking to measure online and offline interactions, and qualitative content analysis of young people’s stories to determine the capacity of the game to build online communities.

Minimal research has been done that explores how young people interact with existing and evolving technology, and how it can be used in a clinical setting to promote engagement and facilitate illness management. Reach Out Pro (http://www.reachoutpro.com.au) was launched in March 2009, with the aim of providing health care professionals with insight into young people’s use of technology and its relevance in clinical practice. This service was developed in collaboration with researchers and clinicians, who provided advice and input into content development. A particular focus of the project is to trial the use of ROC in a variety of clinical settings. For example, clinicians working with young people who have difficulty opening up in talk therapy could use ROC with their clients. Working through the storylines could provide the opportunity for discussion about the issues that arise or the skills learned from them. Clinicians could also assign ROC as homework between sessions — clients can play the game, read fact sheets on particular issues (eg, anxiety or relationships), or choose worst- and best-case scenarios to see how they impact on the in-game mood. In group therapy, clinicians can split the group into pairs or use ROC with the entire group to work through storylines. This approach removes the first-person focus and can promote conversation around the issues raised in the storylines. Clients do not need to be engaged directly in the game to have conversations about the issues it raises, the unintended consequences of their actions, developing other strategies for managing problems effectively, or exploring the relationship between their thoughts, feelings and behaviour.

Adolescence and young adulthood present a unique opportunity to promote optimal mental health, and the rapid uptake of technology by young people provides considerable scope to trial new approaches designed to prevent mental health difficulties and intervene early in the management of mental health problems. The internet has great potential to be more than simply an information portal, but rather a community or setting in which relationships, both positive and negative, are formed.