Enjoyment: A Conceptual Exploration and Overview of Experimental Evidence in the Context of Games for Health

Digital Educational Game "O Jardim do Ferro": A Tool for the Prevention of Iron Deficiency Anemia in Childhood

Objective: To create and evaluate a digital educational game (DEG) for preschool children for the prevention of iron deficiency and iron deficiency anemia. Methodology: The DEG software was developed by a multidisciplinary team, according to Chandler's methodology, in Engine Unity. The game is a 2D platformer, for Android, with three different phases. A quiz was developed for parents/caregivers about iron absorption and anemia. The quiz content was evaluated by experts. The evaluation of the game was carried out through a questionnaire applied in the school for children from 4 to 6 years of age. Results: For the construction of the game, programming, team planning, art, and soundtrack were necessary. The game was registered at the National Institute of Industrial Property. The quiz was evaluated by 14 experts and all questions had more than 80% agreement. The questionnaire was answered by 32 children with a mean age of 5.0 ± 0.7 years, and ∼70% evaluated the game positively. Thus, the acceptability of the software was favored by most players. Conclusion: The "O Jardim do Ferro" software, from its conception to evaluation, proved to be a promising tool to contribute to food and nutrition education actions, providing opportunities for the construction of knowledge about iron-rich foods for the prevention of iron deficiency and iron deficiency anemia in childhood.

Beyond Intrinsic Motivation: Why Researchers Should Consider the Full Motivation Continuum in Games for Health Research

Research within the domain of games for health has predominantly focused on individuals' intrinsic motivation characterized by an inherent enjoyment of the activity. Despite the apparent benefits of intrinsic motivation, we argue that it is imperative to adopt a more nuanced and refined perspective on motivation. Relying on the motivation continuum as outlined within Self-Determination Theory, research within this domain needs to distinguish between both intrinsic and extrinsic (i.e., external, introjected, identified, and integrated regulation) types of motivation. Researchers should, therefore, embrace instruments that assess a broader continuum of motivation rather than just intrinsic motivation alone. By doing so, future research can yield more insight into what fosters autonomous forms of motivation in the field of health-related games, including intrinsic and identified and integrated regulation.

User experience testing of the mobile pulmonary rehabilitation (m-PR™) app in people with chronic obstructive pulmonary disease

Objective

Mobile health (mHealth) technologies are emerging to support the delivery of pulmonary rehabilitation (PR). This study aimed to explore the ease of use, satisfaction and acceptability of an Australian mobile pulmonary rehabilitation app (m-PR™) in people with chronic obstructive pulmonary disease (COPD).

Methods

In this mixed methods observational study, participants with COPD were recruited following PR assessment. Participants were educated on m-PR™ which contained symptom monitoring, individualised exercise training with exercise videos, education videos, goal setting, health notifications and medication action plan. Participants used m-PR™ for 4-8 weeks. At baseline, participants were surveyed to assess level of technology engagement. At follow-up, participants completed the system usability survey (SUS), a satisfaction survey and a semi-structured interview.

Results

Fifteen participants (mean age 70 [SD 10] years, 53% female) completed the study. Technology usage was high with 73% (n = 11) self-rating their technology competence as good or very good. The SUS score of 71 (SD 16) demonstrated above average perceived usability of m-PR™. The satisfaction survey indicated that 67% (n = 10) enjoyed m-PR™ and 33% (n = 5) were neutral. Most participants found the different m-PR™ components somewhat easy or very easy to use (range 69-100%) and somewhat helpful or very helpful (range 76-100%). Interview responses revealed that m-PR™ elicited divergent feelings among participants, who reported both positive and negative feelings towards the app's features, the effort required to use it and data security.

Conclusion

The majority of participants found m-PR™ enjoyable, easy to use and helpful in managing their COPD. Further research is warranted to understand the effectiveness of mHealth to deliver PR.

Design Features Associated With Engagement in Mobile Health Physical Activity Interventions Among Youth: Systematic Review of Qualitative and Quantitative Studies

BACKGROUND

Globally, 81% of youth do not meet the physical activity (PA) guidelines. Youth of families with a low socioeconomic position are less likely to meet the recommended PA guidelines. Mobile health (mHealth) interventions are preferred by youth over traditional in-person approaches and are in line with their media preferences. Despite the promise of mHealth interventions in promoting PA, a common challenge is to engage users in the long term or effectively. Earlier reviews highlighted the association of different design features (eg, notifications and rewards) with engagement among adults. However, little is known about which design features are important for increasing engagement among youth.

OBJECTIVE

To inform the design process of future mHealth tools, it is important to investigate the design features that can yield effective user engagement. This systematic review aimed to identify which design features are associated with engagement in mHealth PA interventions among youth who were aged between 4 and 18 years.

METHODS

A systematic search was conducted in EBSCOhost (MEDLINE, APA PsycINFO, and Psychology & Behavioral Sciences Collection) and Scopus. Qualitative and quantitative studies were included if they documented design features associated with engagement. Design features and related behavior change techniques and engagement measures were extracted. Study quality was assessed according to the Mixed Method Assessment Tool, and one-third of all screening and data extraction were double coded by a second reviewer.

RESULTS

Studies (n=21) showed that various features were associated with engagement, such as a clear interface, rewards, multiplayer game mode, social interaction, variety of challenges with personalized difficulty level, self-monitoring, and variety of customization options among others, including self-set goals, personalized feedback, progress, and a narrative. In contrast, various features need to be carefully considered while designing mHealth PA interventions, such as sounds, competition, instructions, notifications, virtual maps, or self-monitoring, facilitated by manual input. In addition, technical functionality can be considered as a prerequisite for engagement. Research addressing youth from low socioeconomic position families is very limited with regard to engagement in mHealth apps.

CONCLUSIONS

Mismatches between different design features in terms of target group, study design, and content translation from behavior change techniques to design features are highlighted and set up in a design guideline and future research agenda.

TRIAL REGISTRATION

PROSPERO CRD42021254989; https://tinyurl.com/5n6ppz24.

The role of motivation factors in exergame interventions for fall prevention in older adults: A systematic review and meta-analysis

Balance disorders and falls are common in the elderly population. Regular balance exercises are an evidence-based physical intervention to prevent falls in older adults, while patient motivation and adherence are important factors for intervention outcome. Exergames are a relatively new, alternative intervention for physical rehabilitation as they improve balance and strength in older adults. The aims of this systematic review and meta-analysis were to assess the (1) effect of motivation factors as per the Capability, Opportunity and Motivation model of Behavior change (COM-B) on the effectiveness of exergame interventions in healthy older adults, (2) effectiveness of exergames to improve balance in older healthy adults and, (3) impact of exergames on cognitive outcomes. Results show that motivation and capability components influence the general outcome of the exergame training. Motivational factors should thus be considered when setting-up an exergame intervention. Furthermore, exergame intervention appears to be a promising training method in comparison to traditional exercise training. However, exergame training in itself might not be sufficient to improve fall risk and cognitive performance.

Does Dynamic Tailoring of A Narrative-Driven Exergame Result in Higher User Engagement among Adolescents? Results from A Cluster-Randomized Controlled Trial

Physical activity interventions for youth are direly needed given low adherence to physical activity guidelines, but many interventions suffer from low user engagement. Exergames that require bodily movement while played may provide an engaging form of physical activity intervention but are not perceived as engaging to all. This study aimed to evaluate whether dynamic tailoring in a narrative-driven mobile exergame for adolescents played in leisure settings, can create higher user engagement compared to a non-tailored exergame. A cluster-randomized controlled trial assessed differences in user engagement between a dynamically tailored (based on an accelerometer sensor integrated in a T-shirt) and non-tailored condition. In total, 94 participants (M age = 14.61 ± 1.93; 35% female) participated and were assigned to one of the two conditions. User engagement was measured via a survey and game metric data. User engagement was low in both conditions. Narrative sensation was higher in the dynamically tailored condition, but the non-tailored condition showed longer play-time. User suggestions to create a more appealing game included simple and more colorful graphics, avoiding technical problems, more variety and shorter missions and multiplayer options. Less cumbersome or more attractive sensing options than the smart T-shirt may offer a more engaging solution, to be tested in future research.

Satisfied or Frustrated? A Qualitative Analysis of Need Satisfying and Need Frustrating Experiences of Engaging With Digital Health Technology in Chronic Care

Introduction: Digital health technologies such as self-monitoring devices and apps are becoming increasingly important as tools to promote healthy habits and support individuals in their self-care. There is still a scarcity of research that builds on motivational theory to better understand the functioning of digital health technologies. The self-determination theory (SDT) is a macro theory of motivation that delineates three basic psychological needs that are linked to different types of motivation and lead to well-being when satisfied and illbeing when frustrated.

Objective: To explore how the use of a digital tool for self-monitoring and communication with healthcare satisfies or frustrates basic psychological needs across four spheres of user experience: interface, task, behavior, and life.

Methods: The study was conducted in a Swedish primary care setting with individuals who participated in a pilot study of a digital health intervention for self-monitoring in chronic care management. Data from a follow-up survey with participants 7 months after recruitment were analyzed using a thematic approach mixing inductive and deductive analysis. The unit of analysis is based on a total of 642 individual answers to seven open-ended questions, from 121 respondents.

Results: The analysis identified positive and negative influences of self-monitoring and digital communication with healthcare on all three psychological needs. Three main findings are that: (1) data covered all four spheres of user experiences, but most user experiences concerned the behavior and task spheres; (2) satisfaction and frustration of competence needs was more prominent than influences on other needs; (3) the same experience may be perceived as both need frustrating and need satisfying, which suggests a tension that reflects individual differences.

Conclusion: Designers of digital health technologies need to take into account basic psychological needs within all spheres of user experience, from interface to life in general. Because some features may be simultaneously experienced as satisfying and frustrating by different users, these types of tools need to be flexible to accommodate for variation of user experiences. Careful design considerations that take motivational theory into account would contribute to the transformation of care for individuals with chronic conditions.

Psychometric Evaluation of the TWente Engagement with Ehealth Technologies Scale (TWEETS): Evaluation Study

Background

Engagement emerges as a predictor for the effectiveness of digital health interventions. However, a shared understanding of engagement is missing. Therefore, a new scale has been developed that proposes a clear definition and creates a tool to measure it. The TWente Engagement with Ehealth Technologies Scale (TWEETS) is based on a systematic review and interviews with engaged health app users. It defines engagement as a combination of behavior, cognition, and affect.

Objective

This paper aims to evaluate the psychometric properties of the TWEETS. In addition, a comparison is made with the experiential part of the Digital Behavior Change Intervention Engagement Scale (DBCI-ES-Ex), a scale that showed some issues in previous psychometric analyses.

Methods

In this study, 288 participants were asked to use any step counter app on their smartphones for 2 weeks. They completed online questionnaires at 4 time points: T0=baseline, T1=after 1 day, T2=1 week, and T3=2 weeks. At T0, demographics and personality (conscientiousness and intellect/imagination) were assessed; at T1-T3, engagement, involvement, enjoyment, subjective usage, and perceived behavior change were included as measures that are theoretically related to our definition of engagement. Analyses focused on internal consistency, reliability, and the convergent, divergent, and predictive validity of both engagement scales. Convergent validity was assessed by correlating the engagement scales with involvement, enjoyment, and subjective usage; divergent validity was assessed by correlating the engagement scales with personality; and predictive validity was assessed by regression analyses using engagement to predict perceived behavior change at later time points.

Results

The Cronbach alpha values of the TWEETS were .86, .86, and .87 on T1, T2, and T3, respectively. Exploratory factor analyses indicated that a 1-factor structure best fits the data. The TWEETS is moderately to strongly correlated with involvement and enjoyment (theoretically related to cognitive and affective engagement, respectively; P<.001). Correlations between the TWEETS and frequency of use were nonsignificant or small, and differences between adherers and nonadherers on the TWEETS were significant (P<.001). Correlations between personality and the TWEETS were nonsignificant. The TWEETS at T1 was predictive of perceived behavior change at T3, with an explained variance of 16%. The psychometric properties of the TWEETS and the DBCI-ES-Ex seemed comparable in some aspects (eg, internal consistency), and in other aspects, the TWEETS seemed somewhat superior (divergent and predictive validity).

Conclusions

The TWEETS performs quite well as an engagement measure with high internal consistency, reasonable test-retest reliability and convergent validity, good divergent validity, and reasonable predictive validity. As the psychometric quality of a scale is a reflection of how closely a scale matches the conceptualization of a concept, this paper is also an attempt to conceptualize and define engagement as a unique concept, providing a first step toward an acceptable standard of defining and measuring engagement.

Relationship Between Children's Enjoyment, User Experience Satisfaction, and Learning in a Serious Video Game for Nutrition Education: Empirical Pilot Study

Background

The design and use of serious video games for children have increased in recent years. To maximize the effects of these games, it is essential to understand the children’s experiences through playing. Previous studies identified that enjoyment and user experience satisfaction of the players are principal factors that can influence the success of serious video games and the learning of their players. However, research about the relationship between enjoyment and user experience satisfaction with learning in children 8 to 10 years old is sparse.

Objective

We examined the relationship of enjoyment and user experience satisfaction with the learning of children aged 8 to 10 years while playing a serious video game for health, FoodRateMaster. This serious video game teaches children about the characteristics of healthy and unhealthy foods and how to identify them in their environment.

Methods

Children aged 8 to 10 years were recruited from a primary school in Mexico. Participants completed 12 individual gaming sessions with FoodRateMaster in 6 weeks. A food knowledge questionnaire was administered before and after game play to assess the players’ food knowledge. In addition, after the gaming sessions, the children’s enjoyment and user experience satisfaction were evaluated using the EGameFlow questionnaire and the Game User Experience Satisfaction Scale (GUESS) questionnaire.

Results

We found significant positive associations for children’s (n=60) posttest knowledge with enjoyment (r₅₈=0.36, P=.005) and user experience satisfaction (r₅₈=0.27, P=.04). The children’s posttest knowledge scores were also positively correlated with challenge (r₅₈=0.38, P=.003), knowledge improvement (r₅₈=0.38, P=.003), and goal clarity (r₅₈=0.29, P=.02) EGameFlow subscales and with narrative (r₅₈=0.35, P=.006), creative freedom (r₅₈=0.26, P=.04), and visual esthetics (r₅₈=0.32, P=.01) GUESS subscales. Regression analysis indicated that the EGameFlow (F_7,52=2.74, P=.02, R²=0.27) and the GUESS (F_8,51=2.20, P=.04, R²=0.26) ratings significantly predicted the children’s posttest knowledge scores. EGameFlow challenge (β=0.40, t₅₂=2.17, P=.04) and knowledge improvement (β=0.29, t₅₂=2.06, P=.04) subscales significantly contributed to predicting children’s learning. None of the GUESS subscales significantly contributed to predicting children’s learning.

Conclusions

The findings of this study suggest that both enjoyment and user experience satisfaction for children aged 8 to 10 years were positively correlated with their learning and that were significant predictors of it. Challenge, knowledge improvement, narrative, creative freedom, and visual esthetics subscales correlated positively with children’s learning. In addition, challenge and knowledge improvement contributed to predicting their learning. These results are relevant to consider during the design stages of serious games developed for young children’s learning purposes.

Design Features Associated with User Engagement in Digital Games for Healthy Lifestyle Promotion in Youth: A Systematic Review of Qualitative and Quantitative Studies

User engagement in digital (serious) games may be important to increase their effectiveness. Insights into how to create engaging games for healthy lifestyle promotion are needed, as despite their potential, not all digital (serious) games are highly engaging. This study systematically reviewed game features that were associated with higher user engagement among youth. A systematic search was conducted in PubMed, Web of Science, CINAHL, and PsycARTICLES databases. Qualitative and quantitative studies were included, if they documented game features associated with youth engagement. Coding of game features was performed using the mechanics-dynamics-aesthetics (MDA) framework. A total of 60 studies met the inclusion criteria and were included in the registered systematic review (No. CRD42018099487). Results showed that various game features were associated with user engagement in digital (serious) games: an attractive storyline, adaptable to gender and age, including diverse (antagonist) characters the user may identify with, high-end realistic graphics, well-defined instructions, which can be skipped, in combination with clear feedback and a balance of educational and fun content. This review underpinned the relevance of investigating engaging game features specifically for youth, as deviations were found with characteristics that are engaging for other populations.

Mediators of physical activity between standard exercise and exercise video games

OBJECTIVE

Exercise video games (EVGs) may offer an attractive, sustainable alternative or supplement to traditional modes of exercise. Understanding the psychosocial factors that influence the appeal of EVGs is important for improving the efficacy of video games as a method of promoting the uptake and long-term maintenance of physical activity.

METHODS

This study examined changes in psychosocial constructs from self-determination theory and self-efficacy theory as mediators of intervention efficacy among 189 healthy, sedentary adults randomized to 12-week programs of either EVGs or standard exercise (e.g., treadmill walking, stationary cycling) followed by 6 months of follow-up. The EVG group engaged in significantly more weekly minutes of moderate to vigorous physical activity (MVPA) at the end of treatment compared with the standard exercise group. Univariate and multivariate mediational models were used to examine theoretically derived psychosocial constructs as potential mediators of differential intervention effects.

RESULTS

Univariate mediational models suggest a significant indirect effect of treatment on MVPA outcomes through enjoyment, self-efficacy, stress management, depressive symptoms, and positive engagement (p < .05). Multiple mediational analyses confirm all the univariate results (p < .05), with the exception of enjoyment.

CONCLUSIONS

Differences in the efficacy of EVG versus standard exercise interventions were mediated by several psychosocial constructs, suggesting that qualities specific to game play may enhance adherence to physical activity both in and outside of the laboratory environment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Motivational strategies and approaches for single and multi-player exergames: a social perspective

BACKGROUND

Exergames have attracted the interest of academics, practitioners, and designers, in domains as diverse as health, human-computer interaction, psychology, and information technology. This is primarily because exergames can make the exercise experience more enjoyable and entertaining, and in turn, can increase exercise levels. Despite the many benefits of exergames, they suffer from retention problems. Thus, the objective of this article was to review theories and game elements that have been empirically examined or employed in an attempt to make exergames more motivating so people engage in sustained physical activity (duration of physical activity) in a repeating pattern over time (frequency of physical activity).

METHODOLOGY

A literature search and narrative review were conducted.

RESULTS

Five major theories and elements were prevalent in the exergaming literature: (1) self-determination theory, (2) gamification, (3) competition and cooperation, (4) situational interest, and (5) social interaction. These theories and elements are important for encouraging long-term play and show promise for designing exergames to promote sustained engagement and motivate physical activity. We discuss their strengths and weaknesses throughout the paper.

CONCLUSIONS

The long-term effectiveness of exergame interventions is unclear mainly because of the limited amount of long-term studies. Better metrics are also needed to evaluate this effectiveness. We also identified particular attention to social factors and group dynamics, such as multi-player exergames and more effective player matchmaking strategies for increasing social connectedness, as a key area of future research.

A Smartphone Game to Prevent HIV among Young Kenyans: Household Dynamics of Gameplay in a Feasibility Study

OBJECTIVE

mHealth interventions often favour individual-level effects. This is particularly problematic in contexts where social support and shifts in social norms are critical to sustained behaviour change. Mobile digital games represent a promising health education strategy for youth, including in low-resource settings. We sought to better understand the interpersonal and social interactions that can be elicited by digital games for health.

DESIGN

We piloted Tumaini, a smartphone game rooted in interactive narrative designed to prevent HIV among young Africans (aged 11-14), in a randomised controlled feasibility study and analysed reports of the household dynamics surrounding gameplay. Following a 16-day intervention period, phone gameplay log files were downloaded and intervention arm participants (n=30) completed a gameplay experience survey; eight focus group discussions were held, four with intervention arm participants (n=27), four with their parents (n=22).

SETTING

This study took place in Kisumu, Kenya, in Spring 2017.

METHOD

Descriptive statistics were computed from survey responses and log files. Focus group transcripts were labelled, analysed thematically, and compared demographically using MaxQDA software.

RESULTS

Data from log files, survey and focus groups indicate that the game generated considerable interaction and dialogue with parents, siblings, and friends, and served as a catalyst for children to act as advocates for healthful decisions about sex, both within the family and beyond. The game showed a high level of acceptability with parents.

CONCLUSION

Serious digital games using a smartphone platform can generate considerable household interaction. Games can model and facilitate these exchanges, maximising multi-level effects. An additional app for parents could reinforce these effects.

Nutrition Education and Dietary Behavior Change Games: A Scoping Review

Games provide an attractive venue for engaging participants and increasing nutrition-related knowledge and dietary behavior change, but no review has appeared devoted to this literature. A scoping review of nutrition education and dietary behavior change videogames or interactive games was conducted. A systematic search was made of PubMed, Agricola, and Google Scholar. Information was abstracted from 22 publications. To be included, the publication had to include a videogame or interactive experience involving games (a videogame alone, minigames inserted into a larger multimedia experience, or game as part of a human-delivered intervention); game's design objective was to influence dietary behavior, a psychosocial determinant of a dietary behavior, or nutrition knowledge (hereinafter referred to as diet-related); must have been reported in English and must have appeared in a professional publication, including some report of outcomes or results (thereby passing some peer review). This review was restricted to the diet-related information in the selected games. Diversity in targeted dietary knowledge and intake behaviors, targeted populations/audiences, game mechanics, behavioral theories, research designs, and findings was revealed. The diversity and quality of the research in general was poor, precluding a meta-analysis or systematic review. All but one of the studies reported some positive outcome from playing the game(s). One reported that a web-based education program resulted in more change than the game-based intervention. Studies of games may have been missed; a number of dietary/nutrition games are known for which no evaluation is known; and the data presented on the games and research were limited and inconsistent. Conclusions and Implications: A firmer research base is needed to establish the efficacy and effectiveness of nutrition education and dietary behavior change games.

Improvements in health-related quality of life and function in middle-aged women with chronic diseases of lifestyle after participating in a non-pharmacological intervention programme: A pragmatic randomised controlled trial

Background

Musculoskeletal diseases consume a large amount of health and social resources and are a major cause of disability in both low- and high-income countries. In addition, patients frequently present with co-morbid chronic diseases of lifestyle. The area of musculoskeletal disease is restricted by a lack of epidemiological knowledge, particularly in low- and middle-income countries.

Objectives

This pragmatic randomised controlled trial assessed the benefits of a 6-week physiotherapy intervention for middle-aged women with musculoskeletal conditions compared to usual care.

Method

A weekly 2-h educational programme utilising a workbook, discussion group and exercise class was presented for the intervention group, while the control group received usual care. The primary outcome was health-related quality of life. Parametric and non-parametric data were used to determine the equivalence between the groups.

Results

Twenty-two participants were randomised to the intervention and 20 to the control group. The control group demonstrated no within-group improvement in health-related quality of life items, compared to significant improvements in two items in the intervention group. The change in median utility score within the intervention group was twice as large as the change in the control group. With regard to self-efficacy, the intervention group demonstrated significant within-group changes in perceived management of fatigue and discomfort.

Conclusion

The positive impact of the intervention on the participants suggests that the programme should continue at the clinic in question, but should be presented at a more convenient time for participants who work, as recruitment to the study was less than anticipated. Primary health care systems in South Africa urgently need to put structures in place for effective management of the functional impact of chronic diseases of lifestyle and musculoskeletal conditions. It is time for physiotherapists and possibly other health care professionals to participate in the development of appropriate community level interventions to address the functioning and quality of life of individuals living with the diseases.

Education on tick bite and Lyme borreliosis prevention, aimed at schoolchildren in the Netherlands: comparing the effects of an online educational video game versus a leaflet or no intervention

Background

Lyme disease or Lyme borreliosis (LB) is the most common tick-borne disease both in the United States and Europe. Children, in particular, are at high risk of contracting LB. Since child-specific educational tools on ticks, tick bites and LB are lacking, we developed an online educational video game. In this study, we compared the effectiveness of an online educational video game versus a newly developed leaflet aimed to improve prevention of tick bites and LB among Dutch schoolchildren.

Methods

A total of 887 children, aged 9–13 years and attending the two final years of primary schooling, were recruited from 25 primary schools in June and July 2012. They were assigned through cluster randomization to one of three intervention groups: ‘game’ (22.4%), ‘leaflet’ (35.6%) or ‘control’ (41.9%). Prior to and directly following intervention, the children were asked to complete a short questionnaire. The main outcome measures were knowledge, perception (perceived susceptibility and importance) and preventive behavior in relation to tick bites and LB. Generalized linear mixed models were used to analyze the data.

Results

In the game group, the leaflet group and the control group, knowledge about ticks and tick bites improved significantly. The game was also an effective tool for improving preventive behavior; the frequency of checking for ticks increased significantly. However, there were no significant differences in knowledge improvement between the interventions. The game outperformed the leaflet in terms of improving preventive behavior, whereas the frequency of tick checks increased significantly. But this frequency didn’t increase more than in the control group.

Conclusions

The positive knowledge effects observed in the control group suggests the presence of a mere measurement effect related to completion of the questionnaire. The game did not outperform the leaflet or control group on all outcome measures. Therefore, the game may be of value as a complementary role, in addition to other media, in child-specific public health education programs on ticks and LB.

This trial was retrospectively registered on October 21, 2016 (trial registration number: ISRCTN15142369).

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3811-5) contains supplementary material, which is available to authorized users.