Digital advances in health education with fun health games for children

doi:10.21203/rs.3.rs-2494374/v1

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Digital advances in health education with fun health games for children

https://doi.org/10.21203/rs.3.rs-2494374/v1

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Health education is a life-long process for every individual and improves the health and quality of life of the society and it is important to benefit from interactive digital learning environments in providing health education for the digital children of the new age. The aim of the study is to develop educational digital health games and to investigate the role of primary school students in health awareness. Accordingly, in this study, various educational digital health games were designed, developed and evaluated in many health areas, healthy daily life, dental health, hygiene/cleaning, diseases and coronavirus disease. The study is a design-based research and the ASSURE model, one of the design-based research types, was used in the study. The sample of the study consists of 12 primary school 4th grade students. In the study, semi-structured interview was used as data collection tool and content analysis was applied in the analysis. As a result of the study, it was found that educational digital health games improved the health awareness of primary school students and the students gave more and various correct answers after the implementation than before the implementation. Accordingly, educational digital health games can be used in health education for children.

Health education

advance

digital

health games

children

Health education is a life-long process for every individual in society. It has an important role in increasing the welfare level and quality of life of societies. Therefore, it is at a critical point for the future of humanity and should be given from an early age. In this direction, health education is included in the general education given in schools and given is mostly in theory and its practicality is very low. Therefore, interactive learning environments are needed in health education (Azadbakht, 2004).

This study is important in terms of presenting an applied practical health education against the existing theoretical health education understanding. Educational digital games, which are accepted as current educational tools, are used in the study. With the educational digital game-based health education, an education approach that appeals to today's children is offered, and children are provided with health learning while having fun. Thus, a new perspective is offered to health education (Molnar & Kostkova, 2018).

When the literature is examined, it is reached that there are various learning approaches for health education in studies. In the studies, problem-based learning approach in health education (Polyzois et al., 2010), project-based learning approach (Allison et al., 2015), innovative learning approaches (Hew & Lo, 2018), game-based learning approach (von Kotzebue et al., 2022) use has been achieved. In the studies reached, it has been stated that it provides significant improvements in students' learning, motivation and academic achievement. On the other hand, in studies in which digital game-based learning approach is used (Turner et al., 2022), it has been found that digital games offer a fun learning environment and increase students' interest in learning, in addition to what has been achieved in other studies (van Gaalen et al., 2021).

In the study of MacDonald et al. (2022), the opinions of adolescents and their parents about a possible health education for testicular disorders were taken. The qualitative findings obtained show that participants support school-based health education. Participants suggested mixed-gender learning environment and video use in trainings. It was also pointed out that social media could be used as a primary dissemination tool, but possible reservations were expressed.

In the study by Schwarz et al. (2020) used a systematic approach to utilize educational digital games to support healthy lifestyles in young people. The study supports the usability of educational digital games in health education, as they contain interesting stories and characters, are adaptable to gender and age, and provide an enjoyable learning environment.

Health education covers basic concepts and fields related to health. It is a life-long education that contains content suitable for all ages (Nutbeam, 2019). Effective health education, health knowledge and healthy living habits can make changes or affect the acquisition of lifestyle and health skills (Burke & Snyder, 2008).

The study of Tsakpounidou et al. (2020) drew attention to public stroke (stroke) education and awareness programs. In the study, a school-based education intervention was designed for children and family members. In the participatory action study, 66 preschool children were given school-based health education, which included many interesting activities, to their families for 5 weeks. As a result of the study, it has been reached that the school-based health education provided encourages the students and enables them to recognize the symptoms of stroke.

When used in the context of education, digital games turn into educational tools that provide learning along with entertainment (Tlili et al., 2016). In health education, which is considered the most important education for human life, interest in educational digital games has increased (Asuero et al., 2014).

Dankbaar et al. (2016) examined the effects of simulation games on students' cognitive skills and motivation in open patient cases. The study was continued for 4 weeks with the experimental and control groups and questionnaires were applied. The e-module developed as a result of the study is very effective; on the other hand, it has been found that the module may seem complicated for students.

The multidimensional nature of health education and rapid changes in the field of health lead to interesting tools that can be used in health education (Hawks et al., 2008). At this point, digital games come to the fore in health education with their effective and interesting features offered by today's age. Today, thanks to the widespread use of digital devices and online platforms, digital games have the potential to reach many students regardless of time and place (Fadda et al., 2022). Thus, effective and widespread health education can be provided (Smith et al., 2005).

The aim of the study is to examine the effects of educational digital health games on participants' health awareness.In the studies reviewed in the literature, the health theme(s) and health games used in general are limited (Anusha et al., 2021; Hamdanieh et al., 2021; Wang et al., 2022). Differently, in this study, many educational digital health games have been developed, in many health areas such as healthy daily life, dental health, hygiene/cleaning, diseases and coronavirus disease for in school health education.With this aspect of the study, it is aimed to contribute to the literature. The research problem of the study is as follows: “What are the effects of educational digital health games on health awareness of primary school students (9-10 age)?

Model of the study

The model of this study is design-based research that is defined as a methodological approach that tends to develop and produce theory by developing new tools, environments and game-based education types (Plomp, 2010). The cyclical nature of design-based research is illustrated in Figure 1.

Design

In this study, the ASSURE model, which is one of the design-based research models, was applied (Okoroma,2018). The application of the model in the study is shown in Figure 2.

Study group

The study was carried out in a public primary school in Istanbul, Turkey. Working with few people in qualitative studies provides deeper information gathering (Yan & Horwitz, 2008). Therefore, 12 students were selected and 12 students (9-10 years age) participated. Of the participating students, 10 students (83.33%) are boy (S1,S2,S4,S6,S7,S8,S9,S10,S11,S12) and 2 students (16.66%) are girl (S3,S5). Criterion sampling model, one of the purposeful sampling methods, was used in the selection of students to participate in the research. In the criterion sampling method, predetermined criteria are taken as basis in the selection of the sample (Sandelowski, 2000). In this study, the criteria for determining the study group were determined to be a 4th grade student, to have an interest in digital games, to have a tendency and inclination to technology, and also to be a volunteer. In addition, any learning performance or academic achievement has not been taken into consideration. The students participating in the study represent the average student population. The fact that the working group is small (9-10 years) is important that health education should be given at a young age (WHO, 2020).

Data collection tools

Interviews are very important qualitative data collection tools, as they provide researchers with the opportunity to describe the participants' experiences and perspectives on any phenomenon, event or situation. Semi-structured interviews include a series of open-ended questions that were pre-planned by the researcher and developed during the interview (Ryan et al., 2009).

Ethics committee approval was obtained from the university before data collection. A semi-structured interview form was used in the research. It was applied to the students before and after the implementation. Interview questions were developed by the researchers. Interviews were conducted one-on-one between researchers and students on the zoom video conference system and for each student lasted approximately 20-25 minutes. In the interviews, the answers given by the students were noted by the researchers and analyzed.

Data analysis

Various types of analysis such as content and thematic analysis are applied in qualitative studies. thematic analysis; It aims to compare and interpret qualitative research on a specific field in terms of similarities and differences. In this type of analysis, qualitative facts are transformed into quantitative data (Smith, 2015). In content analysis, which is used in the analysis of qualitative data, codes are derived from the data and categories are obtained and themes are created. These codes, themes and categories are interpreted (Damschroder et al., 2005). Gender differences were not taken into account in the analysis. The researchers coded the data together. The coded data were compared and the percentage of agreement as %88 was found.

Setting

In the study Scratch, Wisc-online, Wordwall and Genially educational digital game sites with entertaining content for primary school students (9-10 years age) were selected and it is aimed to contribute to health education (Hainey et al., 2019; Sanchez & Roldan-Ortiz, 2021; Dabbous et al., 2022; Safitri et al., 2022). Various visual templates that appeal to primary school students have been created by the researchers on the game sites.

Initially, prototypes of educational digital health games were developed by researchers and students in selected educational game applications and designated health areas. Game prototypes were presented to expert opinion and student opinions. Changes and arrangements were made in the prototypes in line with the opinions. In all developed games there are questions about healthy daily life, dental health, hygiene/cleaning, diseases and coronavirus disease. Children have played a different game every week. The game playing time is determined as 40 minutes + 40 minutes (10 minute break) for each game every week. When students give wrong answers while playing the game, they lose points or the game. In this case, the students were guided by the researchers about why they lost and what the correct knowledge was.

The visuals of the educational digital games developed by the researchers and the students weekly are given in Table 1 and Table 2.

It was expected that the health themes that the students would choose for the games while designing the games were the same as the themes of the health games they played developed by the researchers. Thus, it is aimed that students both reinforce what they have learned from the first stage and develop their own creativity.

In order to ensure validity and reliability in this study, the study period lasted 15 weeks and the interaction with the students took a long time. Expert opinion was sought in the development of data collection tools in the study. The data obtained were examined and verified by another researcher.The subject, participants and context of the study are explained in detail (Ravitch & Carl, 2019).

In the interview form applied, there are themes and questions related to the themes. The results are also given as themes and sub-questions.The answers given by the students to the question before and after the implementation are given in tables.

Theme 1: Healthy daily life

Question 1: “What is a healthy daily life?”

The answers given by the students to question 1 are given in Table 3.

Table 3. Students’ codes question of “What is a healthy life?” in before and after implementation

Codes	Before	After
With quarantine	S1
Staying away from people	S1
Wearing mask	S2,S3,S4,S6,S7,S8,S10,S12
Not eating too much junk food	S5,S11
Balanced diet		S1,S2,S3,S4,S5,S6,S7,S8,S9,S10,S11,S12
Sport		S1,S3,S4,S10,S11
Hygenie		S5,S6,S7,S8,S12
Sleeping regularly		S2,S4,S7,S9,S11
Drinking plenty of water		S6,S11
Brushing teeth regularly		S9,S10

After the implementation, “Balanced diet”, “Sport”, “Hygenie”, “Sleeping regularly”, “Drinking plenty of water" and "Brushing teeth regularly" which were not included before the implementation were answered.

An example of an answer given after the implementation:

“If we eat a balanced diet and do sports, we will have a healthy life. Our sleep should be regular and we should drink plenty of water during the day” (S11, boy).

Question 2: “Can you give an example of personal behavior that comes to mind about a healthy life?”

The answers given by the students to question 2 are given in Table 4.

Table 4. Students’ codes question of “Can you give an example of personal behavior that comes to mind about a healthy life?” in before and after implementation

Codes	Before	After
Not eating harmful things	S1, S3, S9
Using sneezing and coughing wipes	S2, S7,S10	S2, S7, S10
Not have bad habits	S8
Dressing for the season	S12
Usign disinfectant	S4	S5, S7
I do not know	S5, S6, S11
Not to skip meals		S1, S4, S11
Washing our face		S1
Having breakfast		S2, S5, S6, S7
Washing hands frequently		S2,S4
3 meals a day		S3, S8
Sport		S3, S5, S6, S9, S11, S12
Having bath frequently		S3, S6, Ö8, S12
Brushing teeth frequently		S4, S9,S11
Eating healthy		S9
Sleeping early		S10, S12
Drinking plenty of water		S10, S12

Question 3: What is the importance of drinking water regularly for a healthy life? How much water should we drink a day?

The answers given by the students to question 3 are given in Table 5.

Table 5. Students’ codes question of “What is the importance of drinking water regularly for a healthy life? How much water should we drink a day?” in before and after implementation

Codes	Before	After
We can die of thirst	S1,S6, S8	S4,S6, S8
I do not know	S2,S3,S4,S5,S7,S9,S11
Our mouth is dry	S10,S12	S10
Our body temperature rises	S11
Makes us healthy		S1,S3,S4,S6,S10,S11,S12
Organs work better		S1,S2,S3,S8
Most of our body is water		S2
Provides digestion		S3, S7
We gain weight		S4, S5
We can sick		S7,S8, S9, S11
We get thirsty		S5,S9
Amount of water drinking
I do not know	S1,S3,S4,S6,S7,S8
A little water	S2,S5,S9,S10,S12
2 liters per day		S1,S2,S5,S12
8 glasses a day		S3,S4,S6,S8,S10
1,5 liters per day		S7,S9,S11

An example of an answer given before the implementation:

“If we do not drink water or forget to drink water, we may die of thirst because our body cannot bear it” (S8, boy).

Question 4: “What is the importance of sports for a healthy life? How can we exercise? Give an example.”

The answers given by the students to question 4 are given in Table 6.

Table 6. Students’ codes question of “What is the importance of sports for a healthy life? How can we exercise? Give an example” in before and after implementation

Codes	Before	After
Runners needed to win the race	S1
It melts what we eat	S2
We get sick	S3	S5, S10,S11
I do not know	S4,S5,S6,S7,S9,S10,S11,S12
Provide be active	S8	S1,S5,S8,S12
Provide have fun		S6,S9
Protect from obesity		S2,S3,S7,S9,S10
Prepare to next the day		S4, S8
Provide be strong		S11, S12
Example of exercices
Physical education lesson	S1,S2,S4,S6,S8,S9,S10,S12
Going karate	S3
Running		S1,S2,S5,S10,S11,S12
Walking	S7	S1,S2,S3,S4,S5,S6,S7,S8,S9,S10,S11
Go to the gym	S10,S12	S1
With home gym equipment	S11	S11
Weight lifting		S2,S3,S6,S8,S11
Jumping		S4
Cycling		S4,S9,S12
Playing basketball/volleyball	S5	S4,S5,S6,S11
Doing exercise		S7
Body-building		S7,S8,S10
Dancing		S8
Water sports		S9

As stated in the table, students gave various sports examples after the implementation.

“I think, maybe we can use sports equipment if we have it at home, for example, dumbbells or something, maybe like a rope ball. We can do sports with them.” (S11, boy).

Question 5: “What is the importance of our sleep for a healthy life?”

The answers given by the students to question 5 are given in Table 7.

Table 7. Students’ codes question of “What is the importance of our sleep for a healthy life? How many hours should we sleep a day?” in before and after implementation

Codes	Before	After
I do not know	S1,S3,S4,S6,S8,S11
Be energetic	S2,S10	S2,S3,S4,S6,S9,S10,S12
Eyes deteriorate	S5,S7	S1,S5,S6,S7,S8,S11
Feel happy		S2,S5,S7,S12
Get sick		S4,S6,S8,S9
Provide rest	S9,S12	S7,S9,S10,S12
Better learning		S1,S6,S11
Getting taller		S5,S8,S9
Amount of sleep per day
I do not know	S1,S2,S4,S8,S11
7 hours a day	S3,S5,S6,S7,S10,S12
At least 8 hours		S1,S3,S4,S8,S10,S11
10-11 hours		S2,S5,S6,S7,S9,S12

An example of an answer given after the implementation:

"When I get home from school, I have little time. I have dinner with my family, I do my homework. Before, I had no idea how much sleep we needed. I go to bed earlier now."(S4,boy).

Theme 2 : Dental health

Question 6: What should we do to protect the health of our teeth?

The answers given by the students to question 6 are given in Table 8.

Table 8. Students’ codes to question of “What should we do to protect the health of our teeth?” in before and after implementation

Codes	Before	After
Brushing every day	S1,S3,S7,S8,S9,S10,S11	S1,S3,S5,S8,S9,S10,S11,S12
Not eating too much sugar	S2,S4,S6,S7	S1,S3,S4,S5,S6,S8,S10
Eating healthy foods	S5,S9	S6,S7,S9,S11,S12
Brushing 3 times a day	S5,S6,S9	S1,S2,S3,S4,S5,S6,S7,S8,S9,S10,S11,S12
Consuming milk and dairy products		S1,S2,S3,S7
Not eating hard things		S2,S9,S10
Not eating junk food		S4,S6,S8
Going to dentist		S5,S7,S11,S12
Going for a dental check-up	S12	S2,S5,S7,S11,S12

An example of an answer given after the implementation:

“We should brush our teeth after breakfast, lunch and dinner. Also, we should not eat hard things like walnuts for the health of our teeth. Otherwise, our teeth will break.” (S10,boy).

Theme 3 : Hygiene/cleaning

Question 7: “How should we clean our hands?”

The answers given by the students to question 7 are given in Table 9.

Table 9. Students’ codes question of “How should we clean our hands?” in before and after implementation

Codes	Before	After
With water	S1,S3,S4,S6,S7,S8
With disinfectant	S1 S3,S4,S6,S8,S10,S12
With soap	S2,S5,S9,S10,S11,S12
We must wash for at least 20 seconds		S2,S4,S5,S7,S9,S10,S11
We should wash and rub it all over with plenty of soap and water		S1,S3,S4,S6,S7,S8,S9,S11 S12
With using disinfectant /cologne		S1,S3,S4,S5,S6,S8,S10,S12
We must wash our hands		S2

When the Table 9 is examined, the answers that were not specified before the implementation were given after the implementation.

Question 8: “What happens if we don't clean our hands?”

The answers given by the students to question 8 are given in Table 10.

Table 10. Students’ codes question of “What happens if we don't clean our hands?” in before and after implementation

Codes	Before	After
Germs don’t go	S1, S2,S3,S8,S11,S12
We get sick	S4,S6,S8,S12	S1,S2,S3,S4,S5,S6,S7,S8,S9,S10,S11,S12
Our hands stay dirty	S5,S7,S9,S10	S5,S7,S9,S10,S11
Microbes pass into the body		S8,S11,S12

Question 9: “When should we wash our hands and our face?”

The answers given by the students to question 9 are given in Table 11.

Table 11. Students’ codes question of “When should we wash our hands and our face?” in before and after implementation

Codes	Before	After
When we wake up	S1,S2,S10,S12	S1,S2,S3,S4,S5,S6,S7,S8,S9,S10 S11,S12
When come from outside	S1,S3,S5,S10,S11	S1,S5,S8,S10,S11,S12
When gets dirty	S4,S6,S8,S9
Falling to the ground	S11
Before and after meals	S2,S5,S10	S1,S2,S3,S4,S5,S6,S7,S8,S9,S10 S11,S12
Before and after the toilet	S7,S12	S1,S2,S3,S4,S5,S6,S7,S8,S12
Touch to place/something		S2,S4,S7,S10,S12

An example of an answer given after the implementation:

"In the games we played, it showed the handwashing times. Me and my brother were not washing before the meal, now I warn him to wash with me. I used to wash my hands when I came out of the toilet, but now I wash them before. My brother also agrees”(S6,boy).

Question 10 : “What will happen to us if we do not pay attention to the hygiene rules?”

The answers given by the students to question 10 are given in Table 12.

Table 12. Students’ codes question of “What will happen to us if we do not pay attention to the hygiene rules?” in before and after implementation

Codes	Before	After
I do not know	S1,S4,S6,S7,S10,S11
We have microbes in our body	S2
We have a bad smell	S3,S5,S9	S3,S5,S9
We can get corona	S8	S9,S10
We can get sick	S12	S1,S2,S3,S4,S6,S7,S8,S9,S10,S11,S12
We infect others		S1,S11

The question of “What will happen to us if we do not pay attention to the hygiene rules?” , one of the students (S2, boy) answered as “Microbes come to our bodies, they become a herd and they circulate easily”. This answer is coded as “We have microbes in our body”.

Theme 4: Diseases

Question 11: “What should we do to be protected from diseases?”

The answers given by the students to question 11 are given in Table 13.

Table 13. Before and after codes to the question of “What should we do to be protected from diseases?” in before and after implementation

Codes	Before	After
I do not know	S1,S3,S4,S5,S6,S7,S9,S12
Shouldn't touch to any place	S2,S8,S10	S2,S8,S10
Not be in the crowd	S2
Dress according to the season	S11
Washing hands often		S1,S2,S3,S4,S8,S9,S10,S11,S12
Having balanced diet		S1,S2,S4,S5,S6,S10,S11,S12
Brushing teeth frequently		S1,S9,S12
Paying attention to hygiene		S1,S2,S9,S11,S12
Taking regular baths		S3,S7,S8
Paying attention to social distance		S3,S6,S7
Using disinfectant		S3
Do not go out when sick		S4,S5,S6,S7

One of the students (S11, boy) answered as “In cold weather, we should take coats on ourselves, we should dress thickly. In hot weather, we should dress thinly and we should wear hats if necessary” to the question of “What should we do to be protected from diseases?”. This answer was coded as “Dress according to the season”.

Theme 5 : Coronavirus disease

Question 12: How can we protect ourselves from the coronavirus disease?

The answers given by the students to question 12 are given in Table 14.

Table 14. Students’ codes question of “How can we protect ourselves from the coronavirus disease?” in before and after implementation

Codes	Before	After
Wearing a mask	S1,S2,S3,S4,S5,S7,S8,S9,S10,S11	S1,S2,S3,S4,S5,S6,S7,S8,S9,S10 S11,S12
Following social distancing	S1,S8,S9,S10,S11	S1,S2,S3,S6,S7,S8,S9,S10,S11
Using sneezing and coughing wipes		S1,S8
By not touching	S2,S5	S2,S3,S4,S5,S8
With cologne	S3
With quarantine	S6,S7,S12	S6,S7,S12
With vaccine	S12	S1,S2,S12
Being careful about hygenie		S3,S10,S12
Washing hands frequently		S4,S5,S6,S7,S9
Eating healthy		S4,S5,S6,S8,S11

These codes of "Eating healthy", "Washing our hands frequently" and "Being careful about hygiene" which were not stated by the students before the implementation, were expressed by the students after the implementation. Another point is that while 1 or 2 precautionary suggestions were received from the students before the implementation, at least 3 precautionary suggestions were received from the students after the implementation.

In the study, both current and very important health themes for all segments of society such as healthy daily life, dental health, hygiene/cleaning, diseases and coronavirus disease were examined and primary school students were raised awareness and become more knowledgeable. According to the study, primary school students gave insufficient answers to the pre-application questions; it was found that the students gave sufficient and correct answers to the questions after the study. Thus, a alternative new generation learning environment was created for children and a significant positive development was recorded in the targeted health awareness of primary school students.

Similarly, Tsakpounidou et al. (2020) also found that health education improves the health awareness of the preschool childrens. Also, Mitchell et al. (2021), a digital health game was developed and it was found that the health knowledge of the undergraduate students who played the game increased. Mulchandani et al. (2022), in a study with university students, shows that the educational digital health game increases their awareness of diseases and also persuades them to be more conscious about taking precautions.

Also, among the additional findings in the study, it can be said that the soft skills of the students were also positively affected. In the study, it was found that there was a positive change in the time management and teamwork soft skills of primary school students who participated in educational digital game-based health education. When the tables and evidence in the findings are examined, indicate the amount of sleep, hand and face washing times in time management; the fact that they show team sports as an example shows that there is a positive development in the tendency to team work. When the literature is examined, in the study of Eklund & Roman (2019) it found that digital games can be effective in time management. In another study by Cela-Ranilla et al. (2014), it was found that digital games positively affect teamwork.

This study contributes to the literature in the direction of digital health games as educational tools in today's health education. In order to generalize the research, health education supported by digital games can be carried out with students studying at other school levels. The study is limited to 15 weeks, longer digital health game implementations can be made. In addition, the study includes students aged 9-10 and the games developed are limited to a few digital game platforms. In order to generalize the study, students in different age groups and game sites are needed.

Author contributions

All authors contributed to study design and evaluation. Material preparation, data collection and analysis were carried out by [Efe, Hacer] and [Umdu Topsakal, Ünsal]. The introduction and conclusion of the article were written by [Efe, Hacer] and all authors reviewed and commented on the versions of the article. All authors have read and approved the final article.

Compliance with Ethical Standards

Disclosure of potential conflicts of interest

No potential conflict of interest was reported by the author(s).

Research involving Human Participants and/or Animals

Ethics committee permission was obtained from the university and written permission was obtained from the parents of the participants.

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Digital advances in health education with fun health games for children

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