Evaluation of a Digital Game-Based Learning Program for Enhancing Youth Mental Health: A Structural Equation Modeling of the Program Effectiveness.

BACKGROUND: Digital game-based learning (DGBL) makes use of the entertaining power of digital games for educational purposes. Effectiveness assessment of DGBL programs has been underexplored and no attempt has been made to simultaneously model both important components of DGBL: learning attainment (ie, educational purposes of DGBL) and engagement of users (ie, entertaining power of DGBL) in evaluating program effectiveness. OBJECTIVE: This study aimed to describe and evaluate an Internet-based DGBL program, Professor Gooley and the Flame of Mind, which promotes mental health to adolescents in a positive youth development approach. In particular, we investigated whether user engagement in the DGBL program could enhance their attainment on each of the learning constructs per DGBL module and subsequently enhance their mental health as measured by psychological well-being. METHODS: Users were assessed on their attainment on each learning construct, psychological well-being, and engagement in each of the modules. One structural equation model was constructed for each DGBL module to model the effect of users' engagement and attainment on the learning construct on their psychological well-being. RESULTS: Of the 498 secondary school students that registered and participated from the first module of the DGBL program, 192 completed all 8 modules of the program. Results from structural equation modeling suggested that a higher extent of engagement in the program activities facilitated users' attainment on the learning constructs on most of the modules and in turn enhanced their psychological well-being after controlling for users' initial psychological well-being and initial attainment on the constructs. CONCLUSIONS: This study provided evidence that Internet intervention for mental health, implemented with the technologies and digital innovations of DGBL, could enhance youth mental health. Structural equation modeling is a promising approach in evaluating the effectiveness of DGBL programs.

The prevalence and correlates of severe social withdrawal (hikikomori) in Hong Kong: A cross-sectional telephone-based survey study.

BACKGROUND: Severe social withdrawal behaviors among young people have been a subject of public and clinical concerns. AIMS: This study aimed to explore the prevalence of social withdrawal behaviors among young people aged 12-29 years in Hong Kong. METHODS: A cross-sectional telephone-based survey was conducted with 1,010 young individuals. Social withdrawal behaviors were measured with the proposed research diagnostic criteria for hikikomori and were categorized according to the (a) international proposed duration criterion (more than 6 months), (b) local proposed criterion (less than 6 months) and (c) with withdrawal behaviors but self-perceived as non-problematic. The correlates of social withdrawal among the three groups were examined using multinomial and ordinal logistic regression analyses. RESULTS: The prevalence rates of more than 6 months, less than 6 months and self-perceived non-problematic social withdrawal were 1.9%, 2.5% and 2.6%, respectively. In terms of the correlates, the internationally and locally defined socially withdrawn youths are similar, while the self-perceived non-problematic group is comparable to the comparison group. CONCLUSIONS: The study finds that the prevalence of severe social withdrawal in Hong Kong is comparable to that in Japan. Both groups with withdrawal behaviors for more or less than 6 months share similar characteristics and are related to other contemporary youth issues, for example, compensated dating and self-injury behavior. The self-perceived non-problematic group appears to be a distinct group and the withdrawal behaviors of its members may be discretionary.

The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong.

BACKGROUND: Previous studies revealed that there was a significant increase in suicide deaths among those aged 65 and over in 2003. The peak coincided with the majority of SARS cases being reported in April 2003. AIMS: In this paper we examine the mechanism of how the SARS outbreak resulted in a higher completed suicide rate especially among older adults in Hong Kong. METHODS: We used Qualitative data analysis to uncover the association between the occurrence of SARS and older adult suicide. Furthermore, we used a qualitative study based on the Coroner Court reports to provide empirical evidence about the relationship between SARS and the excessive number of suicide deaths among the elderly. RESULTS: SARS-related older adult suicide victims were more likely to be afraid of contracting the disease and had fears of disconnection. The suicide motives among SARS-related suicide deaths were more closely associated with stress over fears of being a burden to their families during the negative impact of the epidemic. Social disengagement, mental stress, and anxiety at the time of the SARS epidemic among a certain group of older adults resulted in an exceptionally high rate of suicide deaths. CONCLUSIONS: We recommend that the mental and psychological well-being of the community, in particular older adults, be taken into careful account when developing epidemic control measures to combat the future outbreak of diseases in the community. In addition, it is important to alert family members to vulnerable individuals who are at potential risk because of their illnesses or anxieties.

Restricting the means of suicide by charcoal burning.

We conducted an exploratory controlled trial to examine the efficacy of restricting access to charcoal in preventing suicides from carbon monoxide poisoning by charcoal burning in Hong Kong. All charcoal packs were removed from the open shelves of major retail outlets in the intervention region for 12 months; in the control region, charcoal packs were displayed as usual. The suicide rate from charcoal burning was reduced by a statistically significant margin in the intervention region (P<0.05) but not in the control region. We observed no significant change in the suicide rate using other methods in either location.

Population-attributable risk of suicide conferred by axis I psychiatric diagnoses in a Hong Kong Chinese population.

OBJECTIVE: This study was conducted to determine the population-attributable risk (PAR) of completed suicide among Hong Kong Chinese with axis I psychiatric diagnoses. METHODS: With a case-control psychological autopsy method, 150 suicide decedents aged 15-59 were compared for axis I psychiatric diagnoses and psychosocial variables with 150 randomly selected age- and gender-matched persons living in the community. RESULTS: In the presence of other, non-disease-related social risk factors (unemployment and unmanageable debt), past suicide attempt independently accounted for 44% of the PAR of suicide, followed by current major depressive disorder (27%), schizophrenia spectrum disorders (22%), and substance use disorder or pathological gambling (16%). Other diagnoses (such as anxiety and phobic disorders, dysthymia, adjustment disorders, and past major depressive episode) accounted for 24% of PAR. CONCLUSIONS: Psychiatric morbidity remains the major risk factor for suicide in Hong Kong despite well-developed psychiatric services. Mental health policy should be refined to target clinical groups at high risk of suicide.

An integrative suicide prevention program for visitor charcoal burning suicide and suicide pact.

An integrative suicide prevention program was implemented to tackle an outbreak of visitor charcoal burning suicides in Cheung Chau, an island in Hong Kong, in 2002. This study evaluated the effectiveness of the program. The numbers of visitor suicides reduced from 37 deaths in the 51 months prior to program implementation to 6 deaths in the 42 months post-implementation period. The number of visitor suicide pacts decreased from 7 pacts (15 individuals) to 1 pact (2 individuals). No statistically significant differences in the numbers of visitor suicide attempts and resident suicides were observed in the two time periods. No statistically significant changes in visitor suicides during the study period were observed on the comparison islands. The consistency and timing of reduction in visitor suicides correlated with the development and delivery of the integrative program on the intervention island, suggesting a causal association between program delivery and reduction of visitor suicides. The possibility of displacement seems small because there was no increase in visitor suicides on the comparison islands during the study period. This integrative approach in preventing target-specific suicides may serve as an example for other communities to develop suicide prevention programs that make use of the existing local resources.

What does psychological autopsy study tell us about charcoal burning suicide--a new and contagious method in Asia?

Charcoal burning suicides in Hong Kong between 2002-2004 in the 15 to 59-year-old age group were investigated using the psychological autopsy method. The psychopathological profiles of charcoal burning suicides (N = 53) were compared against "other suicides" (N = 97). The two groups did not differ significantly in the prevalence of DSM-IV axis I diagnoses with the exception of schizophrenic spectrum disorder which was less frequently associated with charcoal burning suicides. Score on "neuroticism" in the NEO-five Factor Inventory (NEO-FFI) was significantly higher in victims of charcoal burning suicide. There was also a trend toward higher score on "conscientiousness" in the NEO-FFI among charcoal burners than victims of other suicide.

Evaluating the effectiveness of barrier installation for preventing railway suicides in Hong Kong.

BACKGROUND: Railway suicide is a serious mortality issue. Most attempters are unmarried psychotic young men under psychiatric care having a high level of lethal intent. Installation of platform screen doors (PSDs) to limit access to the track has been suggested as an effective way for prevention. This study aims to examine the effectiveness of installing PSDs for preventing railway suicides; any sign of substitution of suicide location; and changes in psychiatric profile of suicide deceased after the PSD installation in the subway system of Hong Kong. METHODS: Cases of railway suicide and related information from 1997 to 2007 were provided by the railway operators and the Coroner's Court. The effectiveness of installing PSDs was assessed through a quasi-experimental setting. Poisson regression and chi-squared test were used. RESULTS: Over the 11-year study period, a total of 76 railway suicide cases (0.71% of all suicides) were reported. A significant reduction of 59.9% (p=0.0003) in railway suicides was found after the PSD installation. Analyses confirmed that there was no significant sign of substitution by displacing potential attempters to unsealed platforms (p=0.9051). Those having psychosis would be better protected as no suicide cases with such psychiatric background were reported after the installation of PSDs. LIMITATIONS: It has not considered the potential economic benefits of PSD. It is difficult if not possible to examine whether the potential attempters would substitute to an alternative method of suicide. CONCLUSIONS: This study shows that PSDs can effectively prevent suicides with no substitution by "delethalizing" the image and altering people's perception about the desirability of railway suicide. Railway operators should extend the coverage of PSD to all railway stations in Hong Kong without any delay.

Suicide among adults aged 30-49: a psychological autopsy study in Hong Kong.

BACKGROUND: A surge in suicide rates in middle age people in Hong Kong and many Asian countries was recently observed. However, there is a paucity of suicide research on this subgroup of people in Asia. METHODS: The next-of-kin of 85 suicide cases and 85 community subjects aged 30-49 years were interviewed by a psychological autopsy approach. Information was triangulated by interview notes, coroner's court files, and police investigation reports. RESULTS: A multiple logistic regression analysis identified the following risk factors for suicide among the middle age people in Hong Kong: the presence of at least one psychiatric disorder (OR = 37.5, 95% CI 11.5-121.9, p < 0.001), indebtedness (OR = 9.4, 95% CI 2.2-40.8, p < 0.01), unemployment (OR = 4.8, 95% CI 1.3-17.5, p < 0.05), never married (OR = 4.2, 95% CI 1.1-16.3, p < 0.05), and lived alone (OR = 3.9, 95% CI 1.2-13.4, p < 0.05). CONCLUSION: The data show that socio-economical factors had a strong impact on suicide in the target group. Further research is needed to explore any positive qualities that protect the middle-aged from suicide. The prevention of suicide in the middle-aged requires multiple strategies.

A cluster analysis of the circumstances of death in suicides in Hong Kong.

Classification of suicides is essential for clinicians to better identify self-harm patients with future suicidal risks. This study examined potential subtypes of suicide in a psychological autopsy sample (N = 148) in Hong Kong. Hierarchical cluster analysis extracted two subgroups of subjects in terms of expressed deliberation assessed by the Beck Suicide Intent Scale (SIS). The first group was associated with charcoal burning suicide, no psychiatric illness, indebtedness, better problem-solving ability, chronic stress, and higher overall SIS scores. The second group was associated with jumping from a height, psychotic disorders, psychiatric treatment, acute stress, and lower overall SIS score. The existence of a substantial cluster of subjects with lower expressed intent and preparation has important implications for the performance of the SIS as a predictive tool. Suicide prevention strategy may have to target potential subgroups with specific approaches.

Socio-economic and psychological correlates of suicidality among Hong Kong working-age adults: results from a population-based survey.

BACKGROUND: The global toll of suicide is estimated to be one million lives per year, which exceeded the number of deaths by homicide and war combined. A key step to suicide prevention is to prevent less serious suicidal behaviour to preclude more lethal outcomes. Although 61% of the world's suicides take place in Asia and the suicide rates among middle age groups have been increasing since the economic crisis in many Asian countries, population-based studies of suicidal behaviour among working-age adults in non-western communities are scarce. METHOD: Data from a population-based survey with 2015 participants were used to estimate the prevalence of suicidal ideation and behaviour among the working-age population in Hong Kong, and to study the associated socio-economic and psychological correlates. We focused particularly on potential modulating factors between life-event-related factors and suicidal ideation. RESULTS: Six per cent of the Hong Kong population aged 20-59 years considered suicide in the past year, while 1.4% attempted suicide. Hopelessness, reasons for living, and reluctance to seek help from family and friends had direct association with past-year suicidal ideation. Reasons for living were found to moderate the effect of perceived stress on suicidal ideation. CONCLUSIONS: Suicidality is a multi-faceted problem that calls for a multi-sectored, multi-layered approach to prevention. Prevention programmes can work on modulating factors such as reasons for living to reduce suicidal risk in working-age adults.

Suicide in Hong Kong: a case-control psychological autopsy study.

BACKGROUND: The relative contribution of psychosocial and clinical risk factors to suicide among Chinese populations is an important issue. In Hong Kong, this issue requires vigorous examination in light of a 50% increase in suicide rate between 1997 and 2003. METHOD: Using a case-control psychological autopsy method, 150 suicide deceased were compared with 150 living controls matched by age and gender. Semi-structured interviews were conducted with the next-of-kin of the subjects. Data were collected on a wide range of potential risk and protective factors, including demographic, life event, clinical and psychological variables. The relative contribution of these factors towards suicide was examined in a multiple logistic regression model. RESULTS: Six factors were found to significantly and independently contribute to suicide: unemployment, indebtedness, being single, social support, psychiatric illness, and history of past attempts. CONCLUSIONS: Both psychosocial and clinical factors are important in suicides in Hong Kong. They seem to have mediated suicide risk independently. In addition, socio-economic adversities seem to have played a relatively important role in the increasing suicide rate in Hong Kong.

Social and economic burden of suicides in Hong Kong SAR: a year of life lost perspective.

The paper proposes to use the years-of-life-lost method (YLL) in assessing the social and economic burden of suicides in Hong Kong SAR. The YLL from suicide by age group in 1981-2002 is calculated based on the standard set by World Health Organization (WHO). It shows that the middle age group (25-39) contributed most to the burden of disease in Hong Kong. The proportion of older adults' suicides is about 25% of the total number of suicides but its disease burden is less than 6% in terms of the YLL. Though the group aged 25-39 contributed disproportionately to the total YLL from suicide, the prevention effort for this particular group has been very much neglected and needs to be strengthened. It illustrates that use of YLL could provide a new viewpoint for setting up public health policies.

Newspaper reporting of suicide cases in Hong Kong.

This study addresses the concerns over newspapers' reporting of suicide cases in Hong Kong, SAR (Special Administrative Region), using the WHO guidelines on the reporting of suicide news as a reference for comparison. We compared the official suicide information extracted from the Coroner's Court for the year 2000 with newspaper reports on suicides taken from five major Chinese local newspapers, which accounted for about 80% of the total circulation in Hong Kong. The type of newspaper reporting on suicides was also examined. Newspapers tended to report on those suicide victims who suffered relationship problems, whereas those who had family problems were significantly underreported. Among the suicides reported in the newspapers, 6.2% were found on the front page and the majority of the reports were presented pictorially. The reporting of suicides was selective and the coverage was incomplete, with student suicides reported excessively. The method of reporting for Hong Kong newspapers was not in line with the recommendations of the WHO or international best practices on presenting suicide news. For this reason we recommend a partnership approach with active participation from the media on suicide prevention so that communication professionals can proactively participate in suicide prevention work more effectively.

Suicide in Hong Kong: epidemiological profile and burden analysis, 1981 to 2001.

OBJECTIVE: To describe changes of the epidemiological profile of suicides in Hong Kong, and the burden of suicides in terms of years of life lost between 1981 and 2001. DESIGN: Retrospective study. SETTING: Hong Kong. PARTICIPANTS: Data on registered deaths of the Hong Kong population from 1981 to 2001 were retrieved from records of the Census and Statistics Department of the Government of the Hong Kong Special Administrative Region. MAIN OUTCOME MEASURES: Crude, standardised, age- and sex-standardised suicide rates; years of life lost; suicide method used; and rank among leading causes of death. RESULTS: Suicide ranked sixth in the leading cause of deaths and represented about 3% of all deaths each year. The suicide rate has increased from 9.6 per 100000 to 15 per 100000 between 1981 and 2001. The total years of life lost due to suicide increased by 96.0%, from about 9900 years in 1981 to 19 400 years in 2001, whereas the figure for all causes of death decreased by 14.0%, from 274600 years to 236700 years. The total share of years of life lost attributable to suicide deaths has increased from 3.6% to 8.1% and is still increasing, especially among the middle age-groups (30-59 years). The use of charcoal burning as a suicide method has increased from 6.0% before 1998 to more than 28.0% in 2001. CONCLUSION: The burden on the years of life lost due to suicide is underestimated and overlooked. The increase of suicides in recent years has had a significant impact on the years of life lost and can be used as a useful indicator of performance in Hong Kong.

Characteristics of workers attending the pneumoconiosis clinic for silicosis assessment in Hong Kong: retrospective study.

OBJECTIVE: To describe and analyse the baseline characteristics of workers attending the pneumoconiosis clinic for assessment of silicosis. DESIGN: Retrospective cross-sectional study. SETTING: Outpatient clinic. PATIENTS: One thousand and fifty-six patients with silica dust exposure attending the pneumoconiosis clinic for compensation assessment. MAIN OUTCOME MEASURES: Baseline demographic characteristics, lung function parameters, and radiographic findings. RESULTS: Six hundred and forty-eight patients were diagnosed with silicosis, of which 10 were female. Excluding the data on female patients, the mean duration of dust exposure was 24.2 years. The majority of patients were involved in caisson work and stone splitting. Most newly diagnosed patients had simple silicosis. Less than a quarter (24.8%) had progressive massive fibrosis. Lung function parameters at diagnosis were within the normal range. Pulmonary tuberculosis remained an important co-existing disease. CONCLUSION: The major cause of silicosis in Hong Kong is chronic silica dust exposure in the construction industry. Simple silicosis predominated at diagnosis, with normal lung function parameters seen in the majority of patients.