JMIR Publications

ABSTRACT

Background:

Inadequate health literacy and low engagement remain persistent challenges to effective public health education worldwide. Digital serious games integrate learning with interactive, immersive experiences and have shown potential to enhance public health knowledge and attitudes. However, the comparative effectiveness of different game formats and design features remains unclear.

Objective:

This review aims to evaluate and compare the effectiveness of various digital serious game formats in improving public knowledge and attitudes in health education.

Methods:

A systematic review and Bayesian network meta-analysis were conducted in accordance with PRISMA 2020 guidelines. Seven databases (PubMed, CINAHL, Embase, PsycINFO, Cochrane Library, Scopus, and Web of Science) were searched for studies published from 1 January 2000 to 1 October 2025. Eligible studies were randomised controlled trials involving non-professional participants comparing digital serious games with traditional or non-interactive education. Standardised mean differences (SMDs) and 95% credible intervals (CrIs) were pooled using random-effects and Bayesian network models. Subgroup and meta-regression analyses examined moderators including population characteristics, intervention duration, health topic, and delivery format. Risk of bias was assessed using the Cochrane RoB 2 tool, and the certainty of evidence was rated using GRADE.

Results:

A total of 40 randomised controlled trials from 19 countries (n = 8764 participants) were included. Compared with traditional or non-interactive education, digital serious games significantly improved public health knowledge (SMD 0.66; 95% CrI 0.35–0.97; I² = 89.1%) and attitudes (SMD 0.50; 95% CrI 0.27–0.74; I² = 80.7%). Multi-session interventions produced greater effects than single-session interventions for both knowledge (0.76 vs 0.43; P < .05) and attitudes (0.53 vs 0.30; P < .05). Higher effects were observed among adolescents and non-patient groups and in studies conducted in Asia. Mobile-, computer-, and web-based games showed larger effects than video-, robot-, or VR-based formats. Game designs incorporating adaptive feedback, progressive difficulty, and narrative engagement were associated with superior learning and attitudinal outcomes. The certainty of evidence was moderate for knowledge and low-to-moderate for attitudes, primarily limited by methodological heterogeneity and possible publication bias.

Conclusions:

Digital serious games were associated with improvements in public health knowledge and attitudes across a range of disease-related contexts, but substantial heterogeneity should be acknowledged. Their effectiveness appears to depend more on adaptive feedback, progressive task structure, and emotional engagement than on technological sophistication alone. As serious games are increasingly integrated into multimodal digital education environments, educators and health agencies should prioritise accessibility, usability, and sustained engagement when implementing such interventions. Establishing standardised evaluation frameworks and shared data infrastructures will be crucial to enhancing comparability and building cumulative evidence. Future research should include adequately powered, longer-term trials in adult and older populations and examine mediating and moderating factors such as exposure frequency, interactivity level, and feedback mechanisms to inform equitable, scalable, and sustainable applications in public health education. Clinical Trial: None