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Can Gaming Increase Antibiotic Awareness in Children? A Mixed-Methods Approach

Can Gaming Increase Antibiotic Awareness in Children? A Mixed-Methods Approach Background: e-Bug is a pan-European educational resource for junior and senior school children, which contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home. Objective: The aim of this study was to appraise young people’s opinions of 3 antibiotic games on the e-Bug student website, exploring children’s views and suggestions for improvements, and analyzing change in their knowledge around the learning outcomes covered. The 3 games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses. Methods: A mixed methodological approach was undertaken, wherein 153 pupils aged 9-11 years in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe questions, before and after playing 3 e-Bug games for a total of 15 minutes. The after questionnaire also contained open-ended and Likert scale questions. In addition, 6 focus groups with 48 students and think-aloud sessions with 4 students who had all played the games were performed. Results: The questionnaire data showed a significant increase in knowledge for 2 out of 7 questions (P=.01 and P<.001), whereas all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game “Body Busters” was the most popular, closely followed by “Doctor Doctor,” and “Microbe Mania” the least popular. Conclusions: This study shows that 2 of the e-Bug antibiotic educational games are valuable. “Body Busters” effectively increased antibiotic knowledge in children and had the greatest flow and enjoyment. “Doctor Doctor” also resulted in increased knowledge, but was less enjoyable. “Microbe Mania” had neither flow nor knowledge gain and therefore needs much modification and review. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games. (JMIR Serious Games 2017;5(1):e5) doi: 10.2196/games.6420 KEYWORDS antibiotic resistance; computer games; children; education; e-Bug http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al concentration, a sense of control of the situation, an altered Introduction personal experience of time, and a loss of reflective self-consciousness [13]. To access the flow state, an activity There has been a continuous rise in the number of infections such as playing a computer game needs to create a balance caused by antibiotic resistant bacteria, which, in part, has been between the difficulty of the challenge and the skills of the driven by misuse of antibiotics by prescribers and patients [1-4]. player [14]. The World Health Organization (WHO) has stated that antibiotic resistance has the potential to affect anyone [5], and therefore In recent years, Web-based tools have been increasingly used is a serious and growing problem that has been labeled as “a in schools and other settings for education. Many studies have ticking time bomb, not only for the United Kingdom but also looked at the effectiveness of serious games, particularly those for the world” [6]. The National Institute of Clinical Excellence that cover health topics. A meta-analysis showed that serious has advised that schools should teach all ages about prevention games have a small but positive effect on healthy lifestyles and of infections, self-care, and antibiotic use [7]. knowledge improvement [15]. Serious games are defined as games which have a primary goal of education, rather than The e-Bug project is a pan-European initiative that aims to help entertainment [16]. “reduce the incidence of antibiotic resistance across Europe by educating future prescribers and users on prudent antibiotic use” Many educational games focus around health and science [8]. The e-Bug website contains 2 sections, junior and senior, subjects. In public health, these include smoking cessation [17] aimed at pupils aged 9-11 years and 12-15 years respectively. and diet and exercise [18]. Web-based tools such as Twitter and These include downloadable classroom lesson plans for teachers social media have also been used to raise awareness and educate and fact files, quizzes, and revision guides for students. The about antibiotics [19,20]. An antibiotic game to educate e-Bug website also hosts several games, to be used at school or clinicians exists [21], but no material has been published on the in the home, aimed at improving young people’s understanding development or evaluation of Web-based antibiotic educational of respiratory and hand hygiene, and responsible antibiotic use games for children. [9,10]. We aimed to determine the effectiveness, flow, and value of Since the 1970s, the global market for computer games has the e-Bug junior games as a resource for increasing antibiotic grown exponentially and games have advanced in terms of knowledge and awareness in primary school pupils and receive complexity, graphics, interaction, and narrative; attracting an their suggestions for improvement. We selected 3 e-Bug games ever-increasing number of gamers. Different theories explain for this study based on their learning outcomes on antibiotic how and why these games are so popular and can immerse a use, antibiotic resistance, and viruses or bacteria. The games player for extended periods. Csikszentmihalyi theorized “flow” are summarized in Figure 1. The aim of the e-Bug website is [11], which he described as “the state in which people are so that children play the games in a classroom or at home, involved in an activity that nothing else matters” [12]. The flow therefore, we evaluated the effect of playing all 3 games in state has particular characteristics, including intense sequence. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Figure 1. The three 3 e-Bug games evaluated in this study. Recruitment Methods Three schools that expressed initial interest were sent detailed information. This included a parental information sheet with an Setting opt-out form attached, a teacher consent form, and examples of The authors invited, by email and telephone, 53 primary schools the questionnaire, focus group and think-aloud material to be and 3 residential summer holiday schools in the Bristol and used. Schools that expressed no interest were not recontacted. Gloucestershire area, which had not previously used the e-Bug Two residential summer and 2 primary schools withdrew as the resources in this setting, to participate. No incentives were timing of the study did not fit their lesson schedule. offered. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Sample Size Quantitative Data Collection A convenience sample of 153 pupils was used from the school The data collection process is outlined in Figure 2. The pregame and summer school that responded to the invitation to participate questionnaire asked 7 simple multiple-choice questions adapted in the study. from a previous e-Bug evaluation [22]. Pupils’ responses were recorded as right or wrong. The answers to the questions were Ethics either available directly from information in the games or Ethics approval was gained from the University of the West of implied by in-game action (Multimedia Appendix 1) . The England Faculty Research Ethics Committee (UWE FREC). postgame questionnaire had identical questions. The Written consent was obtained from teachers at the participating questionnaires were matched to allow evaluation of knowledge schools, and the parents and pupils involved were given the change in individual pupils. The postgame questionnaire also option for pupils to opt out at any point of the data collection. asked how much the pupils liked each game, using a 10-point Likert scale and open-ended free text questions. All year, 5 and 6 pupils aged 9-11 years at the primary school and all pupils aged 9-11 years at the summer holiday school All incomplete answers in section 1 of the questionnaire were had the opportunity to evaluate the games. All data collection marked as wrong for data analysis. Questions with more than was carried out under the supervision of teachers in computer 1 answer ticked and incomplete answers in section 2 of the suites in the schools. The research was carried out in groups of questionnaire were not included in the data analysis. We used around 30 pupils at a time. Before and after spending 15 minutes a McNemar test to compare the pre- and postgame questionnaire playing the 3 games, the groups of pupils completed answers, as this can compare 2 paired dichotomous variables. questionnaires in silence, to ensure no comparison of answers. As statistical package for the social science (SPSS) version 20 They played each of the 3 games (Doctor Doctor, Microbe does not provide a McNemar test without the Yates Correction Mania, and Body Busters) for 5 minutes, always in that order (a correction for continuity used in the McNemar test that is to maintain consistency across the schools. Time was also often considered to be too conservative [23]), we employed a monitored to maintain consistency. During the game play time, macro written by Marcia Garcia-Granero to remove the Yates pupils were allowed to talk freely, which allowed the researcher correction [24]. to gather verbal feedback on the games. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Figure 2. Data collection process. the games section of the website and assess the pupils’ change Qualitative Data Collection in awareness of antibiotics. Before participation, pupils were After questionnaire completion, a random number generator informed of the purpose of the focus group, that it would be was used to select 6 to 8 pupils to take part in a focus group at recorded, and that they could opt out at any point. The focus each venue. The focus group aimed to explore the usability of group guide asked simple open-ended questions relating to the http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al pupils’ thoughts on the games. Each focus group lasted at least were recruited from a music-based summer school in ten minutes. Gloucestershire. In total, 153 pupils completed pre- and postgame questionnaires; 135 pupils completed the qualitative A think-aloud session followed the focus group. One pupil was section of the post questionnaire. Forty-eight pupils completed selected randomly from the focus group at each venue and asked 6 focus groups (3 groups in each venue with 8 pupils in each to describe their thoughts and feelings as they played the games. group) and 4 pupils (1 from the primary school and 3 from the The researcher prompted the pupil to continue talking at all summer school) participated in think-aloud sessions. times and aimed to make each think-aloud session last at least five minutes. Throughout all data collection, the researcher Likert Scale Data recorded general observations and comments relating to the Body Busters had the highest mean score of 8.2 on the Likert games in note form. scale, for how much participants reported enjoying playing the game (Figure 3). Microbe Mania had a mean score of 4.7, and The researcher made verbatim transcripts of each session and Doctor Doctor had a mean score of 6.8. Distribution of the the data were analyzed using NVivo qualitative analysis scores for each game (Figure 4) shows that 73.1% (106/145) of software (QSR International). Comments and interactions were the scores for Body Busters were 8 to 10 whereas the scores for marked as either positive or negative toward an aspect of the Microbe Mania were more evenly distributed across 1-10, with games and further divided into subgroups that related to only 18% (26/148) scoring 8-10. Scores for Doctor Doctor were comments about usability, style, learning experiences, or general mostly distributed between scores 4-7 and 8-10 with only 5.4% comments. (8/147) scoring 1-3. Results Recruitment Ninety-three pupils aged 9-11 years were recruited from one primary school in the Bristol area and 60 pupils aged 9-11 years Figure 3. Comparison of the mean score given for each game in section 2 of the questionnaire. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Figure 4. Comparison of the distribution of scores between the 3 games. should give them antibiotics. [Student, focus group Qualitative Data 6] Doctor Doctor No participants in the think-aloud sessions or free text section of the questionnaires made any negative comments regarding Doctor Doctor received an overall positive review with many the learning experience. The small number of negative positive comments as well as suggestions for improvement. comments in the focus groups mostly came from pupils who I thought it was really fun in the fact that it was hard admitted that they did not read the introductory information on because there were 4 patients and only 3 beds how to play. One pupil mentioned that they thought the colors [Student, focus group 4] in the game worked really well together. Although the pupils Participants in the focus groups often agreed with comments mostly liked the characters, they expressed a wish for more made by other participants, with multiple pupils offering simple variation. statements of agreement whenever a positive or negative Microbe Mania statement was made. There were some negative comments Microbe Mania received an overall negative review, with many surrounding the game play, including comments on how hard negative comments and no positive comments regarding the the game was. in-game action. Common themes from the focus groups were I found it hard because I didn’t really understand too that the game did not have many “gaming” elements and it was well, you had to explore the controls for yourself, more like a quiz than a game. because the instructions aren’t that good. [Student, It wasn’t a game, it was just information. [Student, focus group 4] focus group 2] I think it was actually quite frustrating too because When we had to play microbe mania and it was the when they were about to die you couldn’t really cure same game over and over again. [Q 12, participant them at all and it was really really bad. [Student, 40] focus group 5] The pupils also said that the main problem was that the game There were also several suggestions to extend the game to needed expansion beyond the 2 short levels available, and some incorporate more role-playing, integrating more of a story and element of challenge. The pupils suggested the game could be characterization to increase immersion. improved by adding a time limit and having more and varied Instead of them dying you could like have another levels. Some of the comments regarding the lack of challenge level that they go into like an emergency area instead stem from the game’s mechanics that allow a player to guess of them dying. [Student, focus group 6] the answers without repercussions, taking away the need to read The learning experience of Doctor Doctor was well received. any of the information, a factor that was noted by the pupils Many of the pupils demonstrated awareness of the topics and increased some of the negative opinions of the games. covered during the gameplay. It also lets you do it as many times as you want to, If you got a virus then you’d know to give the patient you could literally just go for every one. [Student, water and rest and if they had a bacteria then you focus group 2] http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al The microbe mania needs to be longer and less some are bad for you. These are antibiotics and are boring. [Q 13, participant 130] good at killing bad bacteria, so the ones that make you ill. The apparently poor gameplay of Microbe Mania meant the pupils lacked interest, offering many comments of “boring” in P: There are good bacteria as well. the focus groups. Microbe Mania was consistently commented R: There are good bacteria as well. [Focus group 3, on as the worst game in the free text section of the P: participant, R: researcher] questionnaires. This correlates with observations in the Several comments suggested improvements to the game, researcher’s field notes, that showed that the pupils very quickly including improvement to the overall design. became bored with this game and wanted to move on to a more interesting one. Their lack of enjoyment affected the learning Maybe for the pacmanish game it could have more experience that accompanied the game; almost no comments characteristics for the viruses and stuff. [Student, showed a positive learning experience in any of the data focus group 1] collection methods. In some brief instances pupils demonstrated And maybe more lives so you don’t die as soon as the knowledge available in the game but many said that they you touch them. [Student, focus group 1] just guessed the answers. Quantitative Data Body Busters After playing, there was a small increase in the number of Body Busters was the most popular of the 3 games played by participants answering each question correctly (Multimedia the pupils. When asked, the pupils consistently said that this Appendix 1). This increase ranged from 2.0% for the question, was their favorite game. The free text questionnaire section also “Which of these microbes causes coughs and colds” to a 13.1% showed that Body Busters was very popular, with a large number increase for the question, “Which of these would antibiotics be of pupils writing that it was their favorite section. used for?” However, the increase was only significant for the 2 questions (5 and 7) which tested pupil’s knowledge about the What I like about the game is that the more you play effectiveness of antibiotics against bacteria and viruses (P<.05). it and you collect the more pills the less, the smaller In question 5, 26.8% pupils (41/153) answered incorrectly before amount of bacteria and viruses, which makes it easier. and correctly after playing the games; in question 7, 15% pupils [Think-aloud 2] (23/153) answered incorrectly before and correctly after playing Yeah that was so cool, the main ones didn’t go away the games. so it was fun and challenging. [Student, focus group 4] The highest knowledge in the prequestionnaire came in the question “most coughs and colds get better without antibiotics,” My favourite was when we had to run away from the with 68.6% (105/153) of pupils answering correctly. The lowest germs. [Q 11, participant 112] knowledge in the prequestionnaire was in question 7, which The few negative comments about the game mostly arose from focused around what antibiotics do. Only 9.2% (14/153) pupils not knowing how to play but such comments were very rare in answered this correctly, although this saw one of the largest comparison to positive comments. increases in knowledge in the postquestionnaire. It didn’t really explain, I don’t know if there was a how to play on the advert, I didn’t see it. [Student, Discussion focus group 2] Principal Findings Overall, a generally positive learning experience appeared to This study indicates that playing the 3 games consecutively in accompany the game, although when asked what they had learnt, one session had a small significant effect on pupils’ knowledge none of the comments were linked to the learning objectives of antibiotics. Body Busters, which teaches that antibiotics kill (“you must finish the whole course of your antibiotics,” and bacteria and that you must finish your whole course of “antibiotics kill bacteria”). This was the only game that antibiotics, was the most effective game for generating prompted further discussion directly related to any of the discussion about and increasing awareness of antibiotics. It subjects addressed. Although the other games prompted some promoted the most positive discussion about flow and enjoyment antibiotic or microbe-related questions, Body Busters prompted in the focus groups and ranked the highest on the Likert scales. a brief discussion (below) that showed the beginning of some This suggests that enjoyment of a game is an important factor change in awareness about antibiotic use. in learning and in the amount of awareness a game is able to P: I thought pills were bad for you. impart. Data from Doctor Doctor supports this suggestion; it R: You thought pills were bad for you? received generally positive reviews but was not as successful at changing knowledge as Body Busters. None of the questions P: Because sometimes people die from having pills. that linked to Microbe Mania had any significant change in R: Those are bad pills though, there are lots of knowledge, and qualitative data showed that it was neither different sorts. popular, interesting, nor a good learning experience. This P: Aren’t they drugs, the pills? accords with Csikszentmihalyi’s theory of flow, that suggests R: Antibiotics? Pills just hold things; they can hold that if a player is enjoying a game then they will become more lots of different things so some are good for you and engaged with it and take in more of the available information http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al [11-13]. The data gathered in relation to Body Busters could game that contribute to flow, user engagement, and enjoyment demonstrate that it creates a flow-like state in players, whereas include the colorful and exciting visuals, the simple, relatable Microbe Mania does not. and easily understood gameplay, and the fast-paced action. Pupils suggested very few improvements other than overall Strengths and Limitations expansion. An increase in knowledge on the learning outcomes The strengths of this study were that the data were collected in could be supported by including more information in the a school environment, emulating the environment where the introductory text, making the difference between viruses and games would normally be played as part of structured e-Bug bacteria more obvious, and creating a steady increase in lessons. This removes distractions that would come from difficulty as the game progresses. carrying out the study in an environment unfamiliar to the pupils. The Doctor Doctor game is also well suited to its role in e-Bug, Another strength is that the games were played together, showing an increase in awareness for its learning objective simulating what a pupil may do during unstructured use. Finally, (antibiotics are used to treat bacterial infections). Similar to antibiotics are not covered in the national curriculum at this Body Busters, this game uses exciting and colorful visuals and age, allowing a more accurate reflection of knowledge change simple gameplay to encourage flow and user engagement, as due to game play. well as other successful elements such as a strong narrative to All postgame data collection was done immediately after playing “save the patients,” and progressively harder and more the games, therefore we do not know if the increased awareness challenging gameplay. A further increase in knowledge for the and knowledge was either maintained or changed future learning outcomes could be attained by lengthening the game, behavior. The choice to collect data immediately after the pupils either with further levels using different scenarios, or a wider played the games was governed by the time constraints variety of difficulties. If further levels are included, asking the prevailing on the researcher and the teachers and educators at player to answer questions between levels, with in-game the institutions where the research was carried out. rewards, would benefit both knowledge on the leaning objectives and the flow. Another limitation was that the think-aloud methodology is not well suited to being used with young pupils. The pupils aged Microbe Mania would benefit from more significant design and 9-11 years who participated in this study often found it difficult gameplay changes, as it offers no benefit to the website and to vocalize their thoughts beyond simple sentences or reading may even detract from the overall purpose of e-Bug. Although directly from the screen. The pupils’ poor responses may have there are a few previously identified elements of flow in this been due to the small sample size and chance, as the pupils were game, such as a colorful style, they do not come together to chosen at random from the group. Responses from the pupils form any sort of user engagement. Increasing the overall may have been affected by the type of questions; developing engagement and flow could be achieved through the use of simple multiple choice questions relating a complex topic such rewards for the correct answer, penalties for incorrect answers, as antibiotic resistance can limit or bias the answers. and/or time limits for completing each level. Other improvements include increasing the text size, a much broader The evaluation was done after the games were played for 15 range of questions and answers, more levels, and a quiz at the minutes in isolation, which may not mimic the natural end of the game. Although Microbe Mania has the potential to environment for game play. The games are likely to be more be more of an asset to the e-Bug website, feedback from teachers effective when used to reinforce teaching in the classroom, suggests that it should be moved to the teacher-led section of alongside the curriculum, but more work will be needed to the website, as teachers find the information useful to reinforce confirm this. A further study could ask pupils to play the games learning outcomes in the microbes’ lessons. several times, to see if knowledge increases over time. The similar questions in the pre- and postgame questionnaires may This study could stand as a basis for a much larger study cause the pupil to learn through the questionnaire rather than identifying the role of educational games as teaching resources the game. Varying the questions asked while assessing the same and as a broader evaluation of the e-Bug material. The e-Bug learning outcomes could address this issue. project will hopefully continue to increase awareness of antibiotics in Europe and help reduce antibiotic use, thereby Implications reducing the rise in superbugs. The Body Busters game was shown to be a good tool for changing awareness of antibiotics. Particular elements of the Acknowledgments We thank all the schools, summer schools, teachers, and students who participated in the evaluation. We would also like to thank Laura Collett and Aislinn Watkins for their support and advice. Conflicts of Interest None declared. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Multimedia Appendix 1 Questions and answers, where answers were available in game, and percentage of pupils that answered correctly before and after playing the games for each question (N=153). 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Can Gaming Increase Antibiotic Awareness in Children? A Mixed-Methods Approach

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JMIR Publications
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2291-9279
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10.2196/games.6420
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Abstract

Background: e-Bug is a pan-European educational resource for junior and senior school children, which contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home. Objective: The aim of this study was to appraise young people’s opinions of 3 antibiotic games on the e-Bug student website, exploring children’s views and suggestions for improvements, and analyzing change in their knowledge around the learning outcomes covered. The 3 games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses. Methods: A mixed methodological approach was undertaken, wherein 153 pupils aged 9-11 years in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe questions, before and after playing 3 e-Bug games for a total of 15 minutes. The after questionnaire also contained open-ended and Likert scale questions. In addition, 6 focus groups with 48 students and think-aloud sessions with 4 students who had all played the games were performed. Results: The questionnaire data showed a significant increase in knowledge for 2 out of 7 questions (P=.01 and P<.001), whereas all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game “Body Busters” was the most popular, closely followed by “Doctor Doctor,” and “Microbe Mania” the least popular. Conclusions: This study shows that 2 of the e-Bug antibiotic educational games are valuable. “Body Busters” effectively increased antibiotic knowledge in children and had the greatest flow and enjoyment. “Doctor Doctor” also resulted in increased knowledge, but was less enjoyable. “Microbe Mania” had neither flow nor knowledge gain and therefore needs much modification and review. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games. (JMIR Serious Games 2017;5(1):e5) doi: 10.2196/games.6420 KEYWORDS antibiotic resistance; computer games; children; education; e-Bug http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al concentration, a sense of control of the situation, an altered Introduction personal experience of time, and a loss of reflective self-consciousness [13]. To access the flow state, an activity There has been a continuous rise in the number of infections such as playing a computer game needs to create a balance caused by antibiotic resistant bacteria, which, in part, has been between the difficulty of the challenge and the skills of the driven by misuse of antibiotics by prescribers and patients [1-4]. player [14]. The World Health Organization (WHO) has stated that antibiotic resistance has the potential to affect anyone [5], and therefore In recent years, Web-based tools have been increasingly used is a serious and growing problem that has been labeled as “a in schools and other settings for education. Many studies have ticking time bomb, not only for the United Kingdom but also looked at the effectiveness of serious games, particularly those for the world” [6]. The National Institute of Clinical Excellence that cover health topics. A meta-analysis showed that serious has advised that schools should teach all ages about prevention games have a small but positive effect on healthy lifestyles and of infections, self-care, and antibiotic use [7]. knowledge improvement [15]. Serious games are defined as games which have a primary goal of education, rather than The e-Bug project is a pan-European initiative that aims to help entertainment [16]. “reduce the incidence of antibiotic resistance across Europe by educating future prescribers and users on prudent antibiotic use” Many educational games focus around health and science [8]. The e-Bug website contains 2 sections, junior and senior, subjects. In public health, these include smoking cessation [17] aimed at pupils aged 9-11 years and 12-15 years respectively. and diet and exercise [18]. Web-based tools such as Twitter and These include downloadable classroom lesson plans for teachers social media have also been used to raise awareness and educate and fact files, quizzes, and revision guides for students. The about antibiotics [19,20]. An antibiotic game to educate e-Bug website also hosts several games, to be used at school or clinicians exists [21], but no material has been published on the in the home, aimed at improving young people’s understanding development or evaluation of Web-based antibiotic educational of respiratory and hand hygiene, and responsible antibiotic use games for children. [9,10]. We aimed to determine the effectiveness, flow, and value of Since the 1970s, the global market for computer games has the e-Bug junior games as a resource for increasing antibiotic grown exponentially and games have advanced in terms of knowledge and awareness in primary school pupils and receive complexity, graphics, interaction, and narrative; attracting an their suggestions for improvement. We selected 3 e-Bug games ever-increasing number of gamers. Different theories explain for this study based on their learning outcomes on antibiotic how and why these games are so popular and can immerse a use, antibiotic resistance, and viruses or bacteria. The games player for extended periods. Csikszentmihalyi theorized “flow” are summarized in Figure 1. The aim of the e-Bug website is [11], which he described as “the state in which people are so that children play the games in a classroom or at home, involved in an activity that nothing else matters” [12]. The flow therefore, we evaluated the effect of playing all 3 games in state has particular characteristics, including intense sequence. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Figure 1. The three 3 e-Bug games evaluated in this study. Recruitment Methods Three schools that expressed initial interest were sent detailed information. This included a parental information sheet with an Setting opt-out form attached, a teacher consent form, and examples of The authors invited, by email and telephone, 53 primary schools the questionnaire, focus group and think-aloud material to be and 3 residential summer holiday schools in the Bristol and used. Schools that expressed no interest were not recontacted. Gloucestershire area, which had not previously used the e-Bug Two residential summer and 2 primary schools withdrew as the resources in this setting, to participate. No incentives were timing of the study did not fit their lesson schedule. offered. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Sample Size Quantitative Data Collection A convenience sample of 153 pupils was used from the school The data collection process is outlined in Figure 2. The pregame and summer school that responded to the invitation to participate questionnaire asked 7 simple multiple-choice questions adapted in the study. from a previous e-Bug evaluation [22]. Pupils’ responses were recorded as right or wrong. The answers to the questions were Ethics either available directly from information in the games or Ethics approval was gained from the University of the West of implied by in-game action (Multimedia Appendix 1) . The England Faculty Research Ethics Committee (UWE FREC). postgame questionnaire had identical questions. The Written consent was obtained from teachers at the participating questionnaires were matched to allow evaluation of knowledge schools, and the parents and pupils involved were given the change in individual pupils. The postgame questionnaire also option for pupils to opt out at any point of the data collection. asked how much the pupils liked each game, using a 10-point Likert scale and open-ended free text questions. All year, 5 and 6 pupils aged 9-11 years at the primary school and all pupils aged 9-11 years at the summer holiday school All incomplete answers in section 1 of the questionnaire were had the opportunity to evaluate the games. All data collection marked as wrong for data analysis. Questions with more than was carried out under the supervision of teachers in computer 1 answer ticked and incomplete answers in section 2 of the suites in the schools. The research was carried out in groups of questionnaire were not included in the data analysis. We used around 30 pupils at a time. Before and after spending 15 minutes a McNemar test to compare the pre- and postgame questionnaire playing the 3 games, the groups of pupils completed answers, as this can compare 2 paired dichotomous variables. questionnaires in silence, to ensure no comparison of answers. As statistical package for the social science (SPSS) version 20 They played each of the 3 games (Doctor Doctor, Microbe does not provide a McNemar test without the Yates Correction Mania, and Body Busters) for 5 minutes, always in that order (a correction for continuity used in the McNemar test that is to maintain consistency across the schools. Time was also often considered to be too conservative [23]), we employed a monitored to maintain consistency. During the game play time, macro written by Marcia Garcia-Granero to remove the Yates pupils were allowed to talk freely, which allowed the researcher correction [24]. to gather verbal feedback on the games. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Figure 2. Data collection process. the games section of the website and assess the pupils’ change Qualitative Data Collection in awareness of antibiotics. Before participation, pupils were After questionnaire completion, a random number generator informed of the purpose of the focus group, that it would be was used to select 6 to 8 pupils to take part in a focus group at recorded, and that they could opt out at any point. The focus each venue. The focus group aimed to explore the usability of group guide asked simple open-ended questions relating to the http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al pupils’ thoughts on the games. Each focus group lasted at least were recruited from a music-based summer school in ten minutes. Gloucestershire. In total, 153 pupils completed pre- and postgame questionnaires; 135 pupils completed the qualitative A think-aloud session followed the focus group. One pupil was section of the post questionnaire. Forty-eight pupils completed selected randomly from the focus group at each venue and asked 6 focus groups (3 groups in each venue with 8 pupils in each to describe their thoughts and feelings as they played the games. group) and 4 pupils (1 from the primary school and 3 from the The researcher prompted the pupil to continue talking at all summer school) participated in think-aloud sessions. times and aimed to make each think-aloud session last at least five minutes. Throughout all data collection, the researcher Likert Scale Data recorded general observations and comments relating to the Body Busters had the highest mean score of 8.2 on the Likert games in note form. scale, for how much participants reported enjoying playing the game (Figure 3). Microbe Mania had a mean score of 4.7, and The researcher made verbatim transcripts of each session and Doctor Doctor had a mean score of 6.8. Distribution of the the data were analyzed using NVivo qualitative analysis scores for each game (Figure 4) shows that 73.1% (106/145) of software (QSR International). Comments and interactions were the scores for Body Busters were 8 to 10 whereas the scores for marked as either positive or negative toward an aspect of the Microbe Mania were more evenly distributed across 1-10, with games and further divided into subgroups that related to only 18% (26/148) scoring 8-10. Scores for Doctor Doctor were comments about usability, style, learning experiences, or general mostly distributed between scores 4-7 and 8-10 with only 5.4% comments. (8/147) scoring 1-3. Results Recruitment Ninety-three pupils aged 9-11 years were recruited from one primary school in the Bristol area and 60 pupils aged 9-11 years Figure 3. Comparison of the mean score given for each game in section 2 of the questionnaire. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Figure 4. Comparison of the distribution of scores between the 3 games. should give them antibiotics. [Student, focus group Qualitative Data 6] Doctor Doctor No participants in the think-aloud sessions or free text section of the questionnaires made any negative comments regarding Doctor Doctor received an overall positive review with many the learning experience. The small number of negative positive comments as well as suggestions for improvement. comments in the focus groups mostly came from pupils who I thought it was really fun in the fact that it was hard admitted that they did not read the introductory information on because there were 4 patients and only 3 beds how to play. One pupil mentioned that they thought the colors [Student, focus group 4] in the game worked really well together. Although the pupils Participants in the focus groups often agreed with comments mostly liked the characters, they expressed a wish for more made by other participants, with multiple pupils offering simple variation. statements of agreement whenever a positive or negative Microbe Mania statement was made. There were some negative comments Microbe Mania received an overall negative review, with many surrounding the game play, including comments on how hard negative comments and no positive comments regarding the the game was. in-game action. Common themes from the focus groups were I found it hard because I didn’t really understand too that the game did not have many “gaming” elements and it was well, you had to explore the controls for yourself, more like a quiz than a game. because the instructions aren’t that good. [Student, It wasn’t a game, it was just information. [Student, focus group 4] focus group 2] I think it was actually quite frustrating too because When we had to play microbe mania and it was the when they were about to die you couldn’t really cure same game over and over again. [Q 12, participant them at all and it was really really bad. [Student, 40] focus group 5] The pupils also said that the main problem was that the game There were also several suggestions to extend the game to needed expansion beyond the 2 short levels available, and some incorporate more role-playing, integrating more of a story and element of challenge. The pupils suggested the game could be characterization to increase immersion. improved by adding a time limit and having more and varied Instead of them dying you could like have another levels. Some of the comments regarding the lack of challenge level that they go into like an emergency area instead stem from the game’s mechanics that allow a player to guess of them dying. [Student, focus group 6] the answers without repercussions, taking away the need to read The learning experience of Doctor Doctor was well received. any of the information, a factor that was noted by the pupils Many of the pupils demonstrated awareness of the topics and increased some of the negative opinions of the games. covered during the gameplay. It also lets you do it as many times as you want to, If you got a virus then you’d know to give the patient you could literally just go for every one. [Student, water and rest and if they had a bacteria then you focus group 2] http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al The microbe mania needs to be longer and less some are bad for you. These are antibiotics and are boring. [Q 13, participant 130] good at killing bad bacteria, so the ones that make you ill. The apparently poor gameplay of Microbe Mania meant the pupils lacked interest, offering many comments of “boring” in P: There are good bacteria as well. the focus groups. Microbe Mania was consistently commented R: There are good bacteria as well. [Focus group 3, on as the worst game in the free text section of the P: participant, R: researcher] questionnaires. This correlates with observations in the Several comments suggested improvements to the game, researcher’s field notes, that showed that the pupils very quickly including improvement to the overall design. became bored with this game and wanted to move on to a more interesting one. Their lack of enjoyment affected the learning Maybe for the pacmanish game it could have more experience that accompanied the game; almost no comments characteristics for the viruses and stuff. [Student, showed a positive learning experience in any of the data focus group 1] collection methods. In some brief instances pupils demonstrated And maybe more lives so you don’t die as soon as the knowledge available in the game but many said that they you touch them. [Student, focus group 1] just guessed the answers. Quantitative Data Body Busters After playing, there was a small increase in the number of Body Busters was the most popular of the 3 games played by participants answering each question correctly (Multimedia the pupils. When asked, the pupils consistently said that this Appendix 1). This increase ranged from 2.0% for the question, was their favorite game. The free text questionnaire section also “Which of these microbes causes coughs and colds” to a 13.1% showed that Body Busters was very popular, with a large number increase for the question, “Which of these would antibiotics be of pupils writing that it was their favorite section. used for?” However, the increase was only significant for the 2 questions (5 and 7) which tested pupil’s knowledge about the What I like about the game is that the more you play effectiveness of antibiotics against bacteria and viruses (P<.05). it and you collect the more pills the less, the smaller In question 5, 26.8% pupils (41/153) answered incorrectly before amount of bacteria and viruses, which makes it easier. and correctly after playing the games; in question 7, 15% pupils [Think-aloud 2] (23/153) answered incorrectly before and correctly after playing Yeah that was so cool, the main ones didn’t go away the games. so it was fun and challenging. [Student, focus group 4] The highest knowledge in the prequestionnaire came in the question “most coughs and colds get better without antibiotics,” My favourite was when we had to run away from the with 68.6% (105/153) of pupils answering correctly. The lowest germs. [Q 11, participant 112] knowledge in the prequestionnaire was in question 7, which The few negative comments about the game mostly arose from focused around what antibiotics do. Only 9.2% (14/153) pupils not knowing how to play but such comments were very rare in answered this correctly, although this saw one of the largest comparison to positive comments. increases in knowledge in the postquestionnaire. It didn’t really explain, I don’t know if there was a how to play on the advert, I didn’t see it. [Student, Discussion focus group 2] Principal Findings Overall, a generally positive learning experience appeared to This study indicates that playing the 3 games consecutively in accompany the game, although when asked what they had learnt, one session had a small significant effect on pupils’ knowledge none of the comments were linked to the learning objectives of antibiotics. Body Busters, which teaches that antibiotics kill (“you must finish the whole course of your antibiotics,” and bacteria and that you must finish your whole course of “antibiotics kill bacteria”). This was the only game that antibiotics, was the most effective game for generating prompted further discussion directly related to any of the discussion about and increasing awareness of antibiotics. It subjects addressed. Although the other games prompted some promoted the most positive discussion about flow and enjoyment antibiotic or microbe-related questions, Body Busters prompted in the focus groups and ranked the highest on the Likert scales. a brief discussion (below) that showed the beginning of some This suggests that enjoyment of a game is an important factor change in awareness about antibiotic use. in learning and in the amount of awareness a game is able to P: I thought pills were bad for you. impart. Data from Doctor Doctor supports this suggestion; it R: You thought pills were bad for you? received generally positive reviews but was not as successful at changing knowledge as Body Busters. None of the questions P: Because sometimes people die from having pills. that linked to Microbe Mania had any significant change in R: Those are bad pills though, there are lots of knowledge, and qualitative data showed that it was neither different sorts. popular, interesting, nor a good learning experience. This P: Aren’t they drugs, the pills? accords with Csikszentmihalyi’s theory of flow, that suggests R: Antibiotics? Pills just hold things; they can hold that if a player is enjoying a game then they will become more lots of different things so some are good for you and engaged with it and take in more of the available information http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al [11-13]. The data gathered in relation to Body Busters could game that contribute to flow, user engagement, and enjoyment demonstrate that it creates a flow-like state in players, whereas include the colorful and exciting visuals, the simple, relatable Microbe Mania does not. and easily understood gameplay, and the fast-paced action. Pupils suggested very few improvements other than overall Strengths and Limitations expansion. An increase in knowledge on the learning outcomes The strengths of this study were that the data were collected in could be supported by including more information in the a school environment, emulating the environment where the introductory text, making the difference between viruses and games would normally be played as part of structured e-Bug bacteria more obvious, and creating a steady increase in lessons. This removes distractions that would come from difficulty as the game progresses. carrying out the study in an environment unfamiliar to the pupils. The Doctor Doctor game is also well suited to its role in e-Bug, Another strength is that the games were played together, showing an increase in awareness for its learning objective simulating what a pupil may do during unstructured use. Finally, (antibiotics are used to treat bacterial infections). Similar to antibiotics are not covered in the national curriculum at this Body Busters, this game uses exciting and colorful visuals and age, allowing a more accurate reflection of knowledge change simple gameplay to encourage flow and user engagement, as due to game play. well as other successful elements such as a strong narrative to All postgame data collection was done immediately after playing “save the patients,” and progressively harder and more the games, therefore we do not know if the increased awareness challenging gameplay. A further increase in knowledge for the and knowledge was either maintained or changed future learning outcomes could be attained by lengthening the game, behavior. The choice to collect data immediately after the pupils either with further levels using different scenarios, or a wider played the games was governed by the time constraints variety of difficulties. If further levels are included, asking the prevailing on the researcher and the teachers and educators at player to answer questions between levels, with in-game the institutions where the research was carried out. rewards, would benefit both knowledge on the leaning objectives and the flow. Another limitation was that the think-aloud methodology is not well suited to being used with young pupils. The pupils aged Microbe Mania would benefit from more significant design and 9-11 years who participated in this study often found it difficult gameplay changes, as it offers no benefit to the website and to vocalize their thoughts beyond simple sentences or reading may even detract from the overall purpose of e-Bug. Although directly from the screen. The pupils’ poor responses may have there are a few previously identified elements of flow in this been due to the small sample size and chance, as the pupils were game, such as a colorful style, they do not come together to chosen at random from the group. Responses from the pupils form any sort of user engagement. Increasing the overall may have been affected by the type of questions; developing engagement and flow could be achieved through the use of simple multiple choice questions relating a complex topic such rewards for the correct answer, penalties for incorrect answers, as antibiotic resistance can limit or bias the answers. and/or time limits for completing each level. Other improvements include increasing the text size, a much broader The evaluation was done after the games were played for 15 range of questions and answers, more levels, and a quiz at the minutes in isolation, which may not mimic the natural end of the game. Although Microbe Mania has the potential to environment for game play. The games are likely to be more be more of an asset to the e-Bug website, feedback from teachers effective when used to reinforce teaching in the classroom, suggests that it should be moved to the teacher-led section of alongside the curriculum, but more work will be needed to the website, as teachers find the information useful to reinforce confirm this. A further study could ask pupils to play the games learning outcomes in the microbes’ lessons. several times, to see if knowledge increases over time. The similar questions in the pre- and postgame questionnaires may This study could stand as a basis for a much larger study cause the pupil to learn through the questionnaire rather than identifying the role of educational games as teaching resources the game. Varying the questions asked while assessing the same and as a broader evaluation of the e-Bug material. The e-Bug learning outcomes could address this issue. project will hopefully continue to increase awareness of antibiotics in Europe and help reduce antibiotic use, thereby Implications reducing the rise in superbugs. The Body Busters game was shown to be a good tool for changing awareness of antibiotics. Particular elements of the Acknowledgments We thank all the schools, summer schools, teachers, and students who participated in the evaluation. We would also like to thank Laura Collett and Aislinn Watkins for their support and advice. Conflicts of Interest None declared. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Hale et al Multimedia Appendix 1 Questions and answers, where answers were available in game, and percentage of pupils that answered correctly before and after playing the games for each question (N=153). 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Two proportions test (related) - SPSS URL: http://www.how2stats.net/2011/09/ two-proportions-test-related-spss.html [accessed 2016-07-26] [WebCite Cache ID 6jHwArxJJ] Edited by G Eysenbach; submitted 28.07.16; peer-reviewed by E de Quincey, A Ridgway, D Dockterman; comments to author 20.11.16; revised version received 20.12.16; accepted 18.02.17; published 24.03.17 Please cite as: Hale AR, Young VL, Grand A, McNulty CAM JMIR Serious Games 2017;5(1):e5 URL: http://games.jmir.org/2017/1/e5/ doi: 10.2196/games.6420 PMID: 28341618 ©Alexander R Hale, Vicki Louise Young, Ann Grand, Cliodna Ann Miriam McNulty. Originally published in JMIR Serious Games (http://games.jmir.org), 24.03.2017. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2017/1/e5/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e5 | p. 11 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious Games – JMIR Publications

Published: Mar 24, 2017

Keywords: antibiotic resistance; computer games; children; education; e-Bug

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