Digital serious games improved public health knowledge and attitudes versus traditional education in 19 countries

This systematic review and Bayesian network meta-analysis synthesized evidence from randomized controlled trials involving 8764 nonprofessional participants across 19 countries. The analysis evaluated the efficacy of digital serious games compared with traditional or noninteractive education methods for enhancing public health knowledge and attitudes. The study design allowed for a comprehensive comparison of intervention modalities while accounting for heterogeneity across diverse settings and populations. The primary outcomes assessed were changes in public health knowledge and attitudes, with secondary analyses exploring the impact of session frequency on these metrics.

The intervention consisted of digital serious games, while the comparator group received traditional or noninteractive education. The analysis revealed that digital serious games significantly improved knowledge compared with traditional education, with a standardized mean difference of 0.66 (95% CI 0.32-0.99). Similarly, attitudes were significantly improved, showing a standardized mean difference of 0.50 (95% CI 0.27-0.76). These findings suggest a robust advantage for game-based learning in educational settings, although the specific dosing or protocol details for the digital interventions were not detailed in the aggregated data.

Subgroup analysis indicated that multisession interventions yielded larger effects than single-session interventions. For knowledge outcomes, the effect size was 0.76 for multisession interventions versus 0.43 for single-session interventions. For attitude outcomes, the effect size was 0.53 for multisession interventions versus 0.30 for single-session interventions. This suggests that repeated engagement with digital serious games may be necessary to maximize educational impact, although the specific duration or frequency of sessions was not reported.

Safety and tolerability data were not reported in the included trials. Consequently, adverse events, serious adverse events, discontinuations, and general tolerability profiles remain unknown. The lack of safety reporting is a notable gap, as digital health interventions often require rigorous monitoring for potential psychological or behavioral side effects, particularly in vulnerable populations. Without this data, clinicians cannot fully assess the risk-benefit profile of implementing these tools in routine practice.

The certainty of the evidence was moderate for knowledge outcomes and low-to-moderate for attitude outcomes. This variation in certainty reflects differences in study quality, heterogeneity, and potential biases across the included trials. When compared to prior landmark studies in digital health education, these results align with the growing consensus that interactive digital tools can enhance learning outcomes. However, the specific magnitude of the effect observed here may differ from other contexts due to variations in participant demographics and intervention design.

Key methodological limitations include the lack of standardized frameworks for intervention delivery and the absence of longer follow-up periods. The inability to report on long-term retention of knowledge or attitudes limits the generalizability of these findings to real-world public health campaigns. Additionally, the lack of funding or conflict of interest disclosures for the included studies introduces potential bias, although this was not reported in the aggregate analysis.

Clinically, these findings guide scalable digital health education strategies by supporting the integration of serious games into existing curricula. Practitioners may consider adopting these tools to improve public health literacy, particularly when resources allow for multisession implementations. However, the moderate to low certainty of the evidence necessitates cautious interpretation and further validation in diverse settings.

Several questions remain unanswered, including the optimal duration and frequency of digital serious game sessions, the specific content areas where these tools are most effective, and the long-term sustainability of attitude changes. Future research requires adequately powered trials, longer follow-up, and standardized frameworks to address these gaps and provide more definitive guidance for clinical and public health decision-making.