Impact of a digital game-based intervention on dengue knowledge and prevention in students from an endemic region of Peru

Highlights

• •Pueblo Pitanga improved student knowledge and preventive actions on dengue.
• •Digital tools such as video games can support public health learning.
• •More studies should test long-term effects and create new digital dengue tools.

Abstract

Objectives

Dengue is a public health problem that requires a comprehensive approach to reduce its incidence in endemic areas. Playful learning, particularly through low-cost educational video games, could be an effective tool for adoption of knowledge and preventive practices in resource-limited settings. Therefore, this study aimed to assess the impact of an educational video game on the level of knowledge and preventive practices against dengue in schoolchildren in Ucayali, Peru.

Methods

A quasi-experimental, prospective, and longitudinal study was conducted to evaluate the effectiveness of an educational video game on the level of knowledge and preventive practices against dengue. Participants played the video game for four sessions, one per week. Subsequently, a post-test was performed to compare the results.

Results

Overall, 51% of the population was female, and 43% had a history of previous dengue infection—a statistically significant increase in knowledge and preventive practices after the intervention was found.

Conclusions

Educational video games are effective tools for improving knowledge and preventive practices in public health, specifically in the prevention of dengue.

Introduction

Dengue is a viral disease transmitted by the Aedes aegypti mosquito, with high prevalence in tropical regions such as Southeast Asia, Central America, and South America [1]. In 2024, the Pan American Health Organization (PAHO) reported 13,063,434 dengue cases in the Americas, with Peru ranking second in the Andean subregion after Colombia [2]. In early 2024, the Peruvian Ministry of Health (MINSA) issued an alert on the increase in cases, with the vector present in 21 of 24 departments. Ucayali ranked among the top three departments, with Coronel Portillo province and Yarinacocha district being heavily affected [3].

Dengue remains a major public health concern in Peru. MINSA has implemented strategies to improve knowledge and promote preventive practices to address social and environmental determinants of the disease [4]. However, the COVID-19 pandemic disrupted dengue control efforts, leading to an increase in cases [5]. While many studies focus on health personnel and adults, few target the school population [6]. The Ministry of Education (MINEDU) has introduced preventive activities in schools, but their impact remains limited [7]. Thus, new strategies are needed to enhance students’ engagement in dengue prevention and control.

Playful education is highly recommended for schoolchildren as it fosters creativity, dialogue, and behavioral changes through play [8]. Costa Rica’s Ministry of Health developed the educational video game “Pueblo Pitanga: Enemigos Silenciosos (PPES),” endorsed by PAHO as an effective tool for educating youth on dengue prevention, contributing to reduced cases in Costa Rica [9]. In light of Peru’s increasing dengue cases and the limited success of current strategies, this study aimed to assess the impact of the video game PPES on knowledge and preventive practices against dengue in schoolchildren in Ucayali, Peru.

Methods

A quasi-experimental, prospective, and longitudinal study was conducted between November and December 2022. A total of 98 students, ranging from the fifth grade of primary school to the final year of high school, participated. They were drawn from two educational institutions: one in which the intervention was implemented and another that served as the control group.

The sample was selected through census and purposive sampling, including students aged 10-17 years who were enrolled in the current academic year. Informed consent from parents or legal guardians and assent from the students were obtained before participation. Students with physical or mental conditions that prevented them from using the video game or completing the assessments were excluded. Since no formal sample size calculation was performed before the intervention, a post hoc analysis was conducted to determine the statistical power of the study. The power analysis revealed a moderate effect size (Cohen’s d = 0.65 for knowledge; d = 0.60 for preventive practices) and statistical power >95% for both comparisons, with a significance level of α = 0.05, confirming the robustness of the findings.

All participants completed a pre-test before the intervention. In the intervention group, students engaged with an educational video game over a 4-week period, with one session per week lasting approximately 1 hour. The game, PPES, was developed by Green Lava Studios in collaboration with PAHO/WHO. It follows a young protagonist as he discovers and addresses the causes of dengue in his community, focusing on eliminating mosquito breeding sites (Figure 1). The game was installed on school computers, and students completed the first two dengue-related episodes. After the intervention, a post-test was administered to assess changes in knowledge and preventive practices.

Figure 1.

Screenshots showing various segments of the game teaching about the disease (a), mosquito cycle (b), transmission (c), and prevention measures (d).

Two structured questionnaires were used: one on dengue knowledge (6 multiple-choice items on transmission, symptoms, and the mosquito vector) and another on preventive practices (14 multiple-choice items on actions at home and school). Each correct answer was scored as 1, and incorrect answers as 0. Study variables included age, sex, history of dengue, level of knowledge, and preventive behaviors. For the validation of the instrument, the questionnaire was evaluated by six subject-matter experts, who independently assessed its objectivity, internal consistency, content relevance, structural clarity, and overall item quality. The expert review yielded an average agreement of 89.9%, indicating acceptable content validity for use in this study.

A control group was formed using students of similar age and academic level from a nearby school (Jose Olaya School), with no exposure to the video game. Baseline equivalence between the intervention and control groups was verified through statistical comparisons of demographic and outcome variables (P >0.05), helping attribute any observed post-intervention differences to the educational strategy. The size of the control group reflects the total number of eligible students enrolled in the comparison school during the study period. All assessments in the control group were conducted during the same timeframe as those in the intervention group, thereby ensuring temporal comparability and reducing potential measurement bias.

Data were compiled in Microsoft Excel® and analyzed with Stata v16. Descriptive statistics, frequency distributions, and inferential tests were applied, including chi-square, Mann-Whitney U, and Wilcoxon signed-rank tests, depending on variable type and distribution.

The study was approved by the Ethics Committee of the Universidad Nacional Hermilio Valdizán (OFICIO VIRTUAL N° 33-2022-CE-FM/UNHEVAL). Informed consent and student assent were obtained in compliance with ethical standards.

Results

The proportion of female students (51%) was slightly higher than that of male students (48%). Regarding the history of dengue, 43% of the students reported having had the disease, 38% had not, and 19% were unsure whether they had experienced dengue. The most common age among participants was 13 years, with a median of 13 years (interquartile range, 11-13) (Table 1).

Table 1.

Epidemiological characteristics of school students of the Institución Educativa Cristiana Privada “SHADDAI” (n = 98) and Institución Educativa Publica Jose Olaya (n = 32), Yarinacocha.

Variable	Pre-intervention (98)		Control group (32)		P-value
	Frequency	Percentage (%)	Frequency	Percentage (%)
Gender					0.47a
Male	48	48.9	18	56.3
Female	50	51.1	14	43.8
History of dengue fever					0.08a
Yes	42	42.8	18	56.3
No	37	37.8	13	40.6
Unknown	19	19.4	1	3.1
Age (years)
10	6	6.1	4	12.5
11	18	18.4	4	12.5
12	13	13.3	4	12.5
13	29	29.5	8	25
14	10	10.2	4	12.5
15	10	10.2	4	12.5
16	9	9.2	4	12.5
17	3	3.1	0	0
Median	13.2		12.5		0.36b

^aChi-squared

^bMann-Whitney’s U.

The intervention (n = 98) and control (n = 32) groups presented baseline equivalence in all sociodemographic and knowledge variables evaluated (all P >0.05; Table 1, Table 2).

Table 2.

Comparative analysis between the intervention group and the non-intervention group in the characteristics of knowledge and preventive measures.

	Intervention				Pa
	Yes (98)		No (32)
	Median	RIC	Median	RIC
Knowledge	4;	(3-5)	2;	(1-3)	0.24
Preventive Practices	5;	(5-6)	3.5;	(3-4.5)	0.17

^aMann-Whitney’s U.

After the intervention, a significant increase in knowledge and preventive practices was observed. Using the Wilcoxon signed-rank test, both variables showed significant values, evidencing a notable change in knowledge and preventive practices before and after the intervention (Table 3).

Table 3.

Bivariate analysis between knowledge and preventive practices and the intervention through the video game (n = 98).

	Intervention (98)				P
	Pre		Post
	Median	IQR	Median	IQR
Knowledge	4;	(3-5)	5;	(5-6)	<0,01a
How do you contract dengue fever?	71	72.5	90	91.8	<0.01
What is the name of the mosquito that transmits dengue?	41	41.8	94	95.9	<0.01
What are the characteristics of the dengue mosquito?	57	58.2	94	95.9	<0.01
Where does the dengue mosquito prefer to live?	52	53.1	64	65.3	0.03
What are the main symptoms of dengue fever?	51	52.1	86	87.8	<0.01
What should you do if you suspect that you, a family member, or someone you know has dengue?	78	79.6	90	91.8	<0.01
Preventive Practices	7;	(5-8)	10.5;	(10-12)	<0,01a
Use of repellent	49	50	68	69.4	<0.01
Number of times repellent is applied per day	3	3.1	44	44.9	<0.01
Part of the body where repellent is applied	24	24.5	84	85.7	<0.01
Type of clothing worn to prevent mosquito bites	46	46.9	79	80.6	<0.01
Fumigation	74	75.5	82	83.7	0.11
Use of mosquito nets	36	36.7	66	67.4	<0.01
Water storage for consumption	48	48.9	52	53.1	0.51
Location where water is stored	15	15.3	78	79.6	<0.01
Washing and covering water storage containers	74	75.5	85	86.7	0.04
Use of flower vases and/or potted plants with water	46	46.9	55	56.1	0.15
Changing water in flower vases and potted plants	68	69.4	88	89.8	<0.01
Identification of breeding sites	44	44.9	76	77.6	<0.01
Disposal of unusable containers	71	72.5	94	95.9	<0.01
Elimination of stagnant water	63	64.3	91	92.9	<0.01

P-value: McNemar test.

^aWilcoxon signed-rank test.

Discussion

Dengue is a public health priority in Peru, particularly in Ucayali, where cases have increased significantly since 2000, surpassing previous years [10]. Pucallpa, the second-largest city in the Peruvian Amazon, with a population of 370,791, has been especially affected, including during a major outbreak in 2012. However, the determinants of dengue epidemics in the region remain unclear [11].

This study addresses a crucial gap in dengue prevention for pediatric populations in low and middle-income countries (LMICs) by focusing on schoolchildren in Ucayali, a high-risk tropical region. Unlike traditional methods, the PPES video game uses readily available digital tools in LMIC schools at minimal cost. The PPES intervention proved effective, likely due to its interactive nature and consistent reinforcement of preventive practices, which enhanced children’s and adolescents’ knowledge and practices [9].

Information and Communication Technologies (ICTs) have shown promise in enhancing epidemiological surveillance and disease prevention, including HIV and arboviruses [12]. Research confirms their role in increasing knowledge and preventive behaviors, especially among children and adolescents, who are highly receptive to such strategies [[13], [14], [15]].

The level of knowledge and preventive practices directly influences dengue incidence [6]. Studies demonstrate that improving these aspects reduces the risk of morbidity and mortality [16]. School-based interventions, such as talks and participatory activities, are effective in raising awareness, with schoolchildren serving as agents of change [17]. Educational technologies are well-accepted and can significantly enhance knowledge and practices among this population [[18], [19], [20]].

Given the specificity of the intervention, the school-based context, and the short-term evaluation window, the findings should be interpreted within these parameters. While the results indicate that this particular video game was effective in the studied population, broader generalizations about all digital educational tools should be made with caution. Future research should assess long-term retention and scalability in diverse settings.

It is important to note that not all preventive practice items showed statistically significant improvement after the intervention. For example, the fumigation item did not change substantially, likely because fumigation is an activity carried out by municipal or health authorities rather than by students or their families, and therefore lies outside the scope of behaviors reinforced by the game [21]. Similarly, practices such as water storage for consumption and the use of flower vases showed limited variation, which may reflect behaviors that are either less modifiable in the short-term or determined by household routines beyond the student’s direct control [22]. These findings highlight that the intervention was more effective for actions that students can personally perform and monitor, while practices dependent on household norms or institutional efforts may require complementary strategies.

A key strength of this study was the implementation of a validated educational video game in a real-world, endemic setting, combined with a longitudinal assessment and a comparison group. However, several limitations must be acknowledged. First, the non-random assignment of schools may introduce selection bias, although baseline equivalence analyses did not reveal significant differences between groups. Second, the study assessed only immediate post-intervention effects, preventing conclusions regarding medium- or long-term retention of knowledge and practices. Finally, variations in participation and attention during gameplay could have influenced results. These factors should be considered when interpreting the findings.

Conclusion

This study demonstrates that an educational video game can improve short-term knowledge and preventive practices related to dengue among schoolchildren in an endemic Peruvian region. Although the results are promising, they apply specifically to this intervention and evaluation context. Further research is warranted to assess the sustainability of these improvements and the potential for broader implementation.

Funding

The current article processing charges (publication fees) were funded by the Facultad de Ciencias Médicas (FCM) (2-03-01-01), Universidad Nacional Autonoma de Honduras (UNAH), Tegucigalpa, MDC, Honduras, Central America (granted to Zambrano).

Ethics statement

The authors declare that the published work reflects an investigation and analysis carried out truthfully and completely. The ethics committee of the Universidad Nacional Hermilio Valdizán approved the project (OFICIO VIRTUAL N° 33-2022-CE-FM/UNHEVAL).

Author contributions

Kiara Lijarza-Ushiñahua (conception, data acquisition), Kovy Arteaga-Livias (supervision, data curation, formal analysis), Vicky Panduro-Correa (supervision, investigation, formal analysis), Sofia E. Romero (methodology, supervision), Isabel Colan-Rojas (data acquisition, data curation) Lysien Zambrano, Alfonso J. Rodriguez-Morales (funding, supervision, investigation). All authors agreed to be responsible for all aspects of the work to ensure the accuracy and integrity of the published manuscript.

Data availability

Data will be available from the corresponding author upon request.

Declaration of competing interest

The authors have no competing interests to declare.