JMIR SERIOUS GAMES

Huang et al

Original Paper

An Evidence-Based Serious Game App for Public Education on
Antibiotic Use and Resistance: Randomized Controlled Trial
Zhilian Huang1, MPH, PhD; Jing Teng Ow1, BPsych; Wern Ee Tang2, MMed, MBBS; Angela Chow1,3,4, MBBS, MS,
PhD
1Department of Preventive and Population Medicine, Tan Tock Seng Hospital, Singapore, Singapore

2

Clinical Research Unit, National Healthcare Group Polyclinics, Singapore, Singapore

3

Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

4

Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore

Corresponding Author:
Zhilian Huang, MPH, PhD
Department of Preventive and Population Medicine
Tan Tock Seng Hospital
11 Jalan Tan Tock Seng
Singapore, 308322
Singapore
Phone: 65 6256 6011
Email: zhilian_huang@ttsh.com.sg

Abstract
Background: The misuse and overuse of antibiotics accelerate the development of antimicrobial resistance (AMR). Serious
games, any form of games that serve a greater purpose other than entertainment, could augment public education above ongoinghealth promotion efforts. Hence, we developed an evidence-based educational serious game app—SteWARdS Antibiotic
Defence—to educate players on good antibiotic use practices and AMR through a game quest comprising 3 minigames andinteraction with the nonplayer characters.
Objective: We aimed to evaluate the effectiveness of the SteWARdS Antibiotic Defence app in improving the knowledge of,attitude toward, and perceptions (KAP) of appropriate antibiotic use and AMR among the public in Singapore.
Methods: We conducted a 2-arm parallel randomized controlled trial, recruiting visitors aged 18-65 years from 2 polyclinics
in Singapore. Intervention group participants had to download the SteWARdS Antibiotic Defence app (available only in English
and on the Android platform) on their smartphones and complete the quest in the app. Participants took half a day to 2 weeks tocomplete the quest. The control group received no intervention. Knowledge questions on antibiotic use and AMR (11 binary
questions) were self-administered at baseline, immediately after the intervention, and 6-10 weeks post intervention, while attitudes
and perception questions (14 three-point Likert-scale questions) were self-administered at baseline and 6-10 weeks post intervention.
We also collected participants’ feedback on app usage.
Results: Participants (n=348; intervention: n=142, control: n=206) had a mean age of 36.9 years. Intervention group participants
showed a statistically significant improvement in mean knowledge score (effect size: 0.58 [95% CI 0.28-0.87]) compared with
controls after accounting for age, educational level, and exposure to advertisements on antibiotics and AMR. Intervention
participants also showed a statistically significant improvement in mean attitude-perception scores (effect size: 0.98 (95% CI
0.44-1.52)) after adjusting for marital status and race. A majority of participants agreed that the “SteWARdS Antibiotic Defence”
app improved their awareness on antibiotic use (135/142, 95.1%) and AMR (136/142, 95.8%). About 73.9% (105/142) of theparticipants agreed that the app is easy to use, 70.4% (100/142) agreed that the app was enjoyable, and 85.2% (121/142) would
recommend the app to others.
Conclusions: Our educational serious game app improves participants’ KAP on appropriate antibiotic use and AMR. Public
education apps should be engaging, educational, easy to use, and have an attractive user interface. Future research should assess
the effectiveness of interventions in facilitating long-term knowledge retention and long-lasting behavioral change.
Trial Registration: ClinicalTrials.gov NCT05445414; https://clinicaltrials.gov/ct2/show/NCT05445414
International Registered Report Identifier (IRRID): RR2-10.2196/45833

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Huang et al(JMIR Serious Games 2024;12:e59848) doi: 10.2196/59848
KEYWORDS
serious game application; randomized controlled trial; antimicrobial resistance; antibiotic use; public education; mobile phone

Introduction
The World Health Organization declared antimicrobial
resistance (AMR) as one of the top 10 global public healththreats in 2019 [1]. Antibiotic-resistant bacteria can cause humaninfections that are harder to treat, leading to higher medical
costs, decreased work productivity, and increased mortality[2-4]. By 2050, AMR is projected to cause 10 million annual
deaths and up to US $100.2 trillion in economic losses
worldwide if nothing is done to slow its progression [5]. The
widespread misuse and overuse of antibiotics, often driven by
the public’s lack of knowledge regarding appropriate antibiotic
use and AMR, contribute to AMR progression [6,7].
The need to educate the public on appropriate antibiotic use andAMR is apparent, as better knowledge of antibiotic use wasfound to be associated with favorable antibiotic attitudes, which
lowered the odds of expecting and receiving an antibiotic
prescription [8]. Despite yearly public outreach [9] and multiple
national educational campaigns on antibiotics and AMR [10],misconceptions about antibiotics—such as believing that
antibiotics treat viral infections—continue to persist among theSingaporean population [7,8]. Traditional efforts to educate thepublic on antibiotic use and AMR have shown ambiguous
effectiveness [11,12]. Hence, the lackluster effectiveness ofexisting efforts to prevent antibiotic misuse and overuse provides
an impetus to explore novel public education methods beyond
traditional modalities (eg, posters and pamphlets) [13].
Serious games have emerged as a promising tool for healtheducation and health promotion across various fields recently[14]. This learning modality encompasses online and offline
tools that use gamification—the use of game-playing
elements—to provide an enhanced learning experience. Studies
have shown promise of serious games in improving theshort-term health knowledge, attitudes, and beliefs of young
people, but the studies were too heterogeneous to prove theefficacy of this learning modality [15,16]. There were fewer
serious games studies with older adults, but a web-based serious
game co-designed with members of the public to raise pancreaticcancer awareness found a statistically significant improvementof pancreatic cancer awareness [17].
Serious games have also been used to promote good antibiotic
use behaviors [16,18]. Preliminary evidence of serious games
interventions on antibiotic use and AMR has shown promise inimproving the knowledge of appropriate antibiotic use [16,19].
However, these studies were primarily focused on children andstudents. Adults have greater access to antibiotics and are more
likely to pass down antibiotic use behaviors to the younger
generation [13]. Hence, it is essential to educate young adults
on appropriate antibiotic use. Existing studies also limited
participants to a controlled environment with restricted playing
time and may not fully capture real-world behavior.
Furthermore, many studies overlooked the importance ofhttps://games.jmir.org/2024/1/e59848

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long-term knowledge retention. The paucity of high-quality
randomized controlled trials (RCTs) in the real-world setting
highlights a pertinent gap in the evidence base of serious games
for public education.
Singapore offers an excellent environment for evaluating serious
game applications (apps) given its high smartphone penetration
rate (92%) [20] and emphasis on digital transformation [21].
Hence, we developed an evidence-based serious gameapp—“SteWARdS Antibiotic Defence”—to deliver adulteducation on appropriate antibiotic use and AMR and aimed toevaluate its effectiveness in improving knowledge of, attitude
toward, and perceptions (KAP) of antibiotic use and AMR in
Singapore. We also sought user feedback on the “SteWARdS
Antibiotic Defence” app.

Methods
Study Design
We conducted a parallel 2-arm RCT with a 6- to 10-weekfollow-up period. Participants in the intervention group had todownload and complete the quest in the “SteWARdS Antibiotic
Defence” app on their smartphones, while controls received nointervention.

Study Setting
We recruited patients and their caregivers from 2
government-funded primary care clinics (ie, polyclinics) in
Singapore. Recruitment occurred from January to March 2023,
and follow-up was completed in early June 2023. The 23
polyclinics in Singapore manage 20% of Singapore’s primary
health care needs by providing subsidized services such as
medical treatment for acute and chronic conditions, vaccinations,and health education [22]. Participants seen at the polyclinics
mainly have acute conditions that are managed outside the healthcare setting. Hence, while our study recruitment and baseline
data collection occurred in the policlinics, the study intervention
and follow-ups were administered outside the health care setting.

Eligibility Criteria
Participants were 18-65 years of age, had access to an Android
smartphone, and were English literate. We excluded those withvisual or cognitive impairment, not proficient with smartphone
apps, and those unable to install Android mobile apps from thestudy.

Intervention
App Development
The “SteWARdS Antibiotic Defence” app is an evidence-based
serious game mobile app developed by the study team, incollaboration with Temasek Polytechnic (a public tertiary
institution in Singapore), to educate the public on appropriate
antibiotic use and AMR. Players learn about appropriate
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uncomplicated upper respiratory tract infections by interactingwith the nonplayer characters (NPCs) releasing bite-sized
information and playing the minigames in the app. We derived
the educational content in the app from a rigorous review ofknowledge gaps [7,8,23], antibiotic guidance [24], and inputs
from health care professionals. The in-app messages were also
adapted to the local context to ensure their relevance to players[25]. A few knowledge questions in the postgame andpostintervention surveys were reverse scored to reduce tolearning effect on knowledge gains. The bite-sized messages
and knowledge questions can be found in Tables S1 and S2 in
Multimedia Appendix 1.
The pre- and postgame knowledge questions were embedded
at the beginning and the end of the quest to reinforce knowledge
retention (Figure 1). Completing the 11 baseline knowledge

Huang et alquestions is a prerequisite to proceed to the minigames while
completing the postgame knowledge questions is a prerequisite
to fulfill the requirements of the intervention. Players areallowed to play the minigames repeatedly once they pass thelevel, but they can complete the pre-post survey only once.
There is an in-app WhatsApp helpline for participants to contact
the study team should they encounter technical difficulties. The
feedback form link is also embedded in the app and appears
after the completion of the postknowledge survey. Study teammembers (data collectors) provided intervention group
participants with a onetime unique code to access the app during
recruitment. The unique code allowed us to track the pre-post
knowledge survey responses, time spent on the app, andinteractions with the NPCs anonymously. We did not analyze
the time spent on the app due to glitches that affected data
quality.

Figure 1. An example of a knowledge question embedded in the app. Participants are expected to complete 11 preintervention knowledge questions,followed by the game quest and 11 post–intervention knowledge questions to complete the intervention.

Game Components
There are 3 “worlds”—the “Supermarket,” “Park,” and “Trainstation”—that lead to the minigames in the app. Each “world”

comprises 2 NPCs and a minigame. The supermarket is linked
to the Tower Defence game; park is linked to the Match3 game;and train station is linked to the Endless Runner game (Figures
2-5).

Figure 2. Interaction with a nonplayer character (NPC) at the park. Bite-sized messages on good antibiotic use practices were released throughinteractions with the NPCs. The rightmost NPC leads to the Tower Defence game.

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Figure 3. The Tower Defence game consists of 9 levels. The top figure shows the game interface with C-Stin turrets and the super bug (level 9). The
subsequent figures show the messages released at the beginning of level 9 to teach players about the concept of antimicrobial resistance. Players haveto choose the appropriate turrets and strategically place them at appropriate locations to effectively target their enemies (bacteria or viruses).

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Figure 4. The Endless Runner game can be accessed via the train station (picture on top). The game reinforces the message that antibiotics are effective
only against bacteria and not viruses. Players collect coins while running and use the antibiotic gun or immunity gun to shoot at bacteria or virus obstacles,
respectively. Coins collected from the Endless Runner game can be used to purchase turrets in the Tower Defence game.

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Figure 5. The Match3 game can be accessed via the park (picture on top). The game educates players on good health habits by focusing on sleep
hygiene, nutrition, immunization, and physical exercise. Players are required to match 3 or more similar tiles within a specific time limit to successfully
clear each of the 10 levels. Bite-sized messages are released before the start of each game to remind players of maintaining a healthy lifestyle.

There are 9 levels in the Tower Defence game to teach players
about antibiotics and AMR. The first 2 levels teach players that
antibiotics are effective against bacteria and the next 2 introduce
the concept that antibiotics are bacteria-specific. Levels 5 and6 educate players that antibiotics are not effective against
viruses, levels 7 and 8 are reinforcements of previously taught
concepts, and the last level educates players on antibiotic
resistance by introducing a superbug that requires an expensive
antibiotic (turret) to cure (kill the superbug). Players have toearn coins by passing Tower Defence levels and playing the
Match3 and Endless Runner games.
The Endless Runner game is accessible via the train station.
The game reinforces the message that antibiotics are effective
only against bacteria and not viruses. Players collect coins whilerunning to purchase turrets in the Tower Defence game, anduse the antibiotic gun to shoot away bacteria obstacles and theimmunity gun to shoot the virus obstacles.

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The Match3 game is accessible via the park. The game educatesplayers on good health habits by focusing on sleep hygiene,
nutrition, immunization, and exercise. Players are required tomatch 3 or more similar tiles within a specific time limit tosuccessfully clear each of the 10 levels.
Further details of the design and principles of the “SteWARdS
Antibiotic Defence” app can be found in our published protocol[25]. Individual participants were followed up according torecruitment schedule from the point of recruitment. Participants
took between half a day to 2 weeks to complete the intervention.

Outcomes
The primary outcome of interest was the change in KAP scoresof antibiotic use and AMR. The secondary outcome was thelevel of user satisfaction for the “SteWARdS Antibiotic
Defence” app. Primary outcomes were assessed for theintervention and control groups at baseline, immediately postintervention (intervention group only), and 6-10 weeks post
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JMIR SERIOUS GAMESintervention (from baseline for controls) via self-administeredquestionnaires. Knowledge was measured via 11 True/False
questions, while attitudes and perceptions were measured via
14 questions on a 3-point Likert scale. Details of the KAPquestionnaire are available in our published protocol [25]. For
the intervention group, satisfaction with the “SteWARdS
Antibiotic Defence” app was measured with 4 questions on a
5-point Likert scale and the reason(s) for recommending or notrecommending the app to others, and suggestions for
improvement were obtained via open-ended questions uponquest completion.

Sample Size
Assuming an effect size of 0.334 (95% CI 0.260-0.407) basedon other serious games studies [18], we estimated a minimum
sample size of 142 per group to detect a significant change inthe knowledge score at a power of 80% and an a level of .05.
We initially planned to recruit 200 participants per arm toaccount for a 30% attrition rate. We later increased therecruitment numbers to 240 per arm to account for a 40%
attrition rate as we observed higher-than-expected dropout rates.

Study Procedures
Recruitment occurred on weekdays during the polyclinic’s
opening hours. Staff members of the polyclinics were trained
to recruit participants in their respective polyclinics. The datacollectors would walk through every level of the polyclinic
systematically to recruit participants daily. We also displayed
digital recruitment posters around the polyclinics, so thatinterested visitors could contact the study team. However, only
2 participants contacted the study team via digital posters.
Data collectors approached the patient or the visitor nearest tothem who seemed to fall in the eligible age category (18-65
years of age) to explain the study while systematically walking
around the polyclinic. Next, the data collectors explained thestudy to the persons they approached and informed them of thepossibility of being randomized into either the “survey group”(control) or the “app and survey” (intervention) group. Informed
consent was obtained from interested participants before asking
participants to pick a card to determine the group assignment.
Participants knew which group they were assigned to as theintervention group participants were asked to download the app
after their demographic data was collected. Baseline datacollection occurred after randomization because the pre-post
knowledge questions were built into the app. We collectedparticipants’ KAP responses and demographic data at baseline
and reimbursed them a small fee for completing the baseline
surveys. All participants received the same amount of
reimbursement at the baseline. Reimbursement was tiered to ahigher value for the follow-up surveys to motivate participants
toward task completion.

Baseline Data Collection
The baseline data collection process differed slightly between
the intervention and control group participants. Intervention
group participants had to complete the Attitudes-Perception
demographic questionnaire on an iPad and install the“SteWARdS Antibiotic Defence” app on their smartphones.
The data collector then provided the participant with a unique
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Huang et alcode to gain access to the app. Upon logging into the app,
participants had to complete 11 baseline knowledge questions,followed by a walk-through of the basic features of the app.
Controls completed the KAP and demographic questionnaire
on an iPad.

Control Group Follow-Up
A study team member (ie, data collector) sends participants a
detailed WhatsApp message 6 weeks after their recruitment
date to inform them to complete the postintervention KAPquestionnaire. The study team member sent a reminder if
participants did not complete the questionnaire 2 weeks after
the first WhatsApp message.

Intervention Group Follow-Up
Participants had to complete the “SteWARdS Antibiotic
Defence” game quest and satisfaction survey and inform thestudy team via WhatsApp upon intervention completion. Six
weeks after participants complete the intervention, a study teammember sends a detailed WhatsApp message to inform themto complete the postintervention KAP questionnaire. A study
team member reminded participants who did not complete thequest 2 weeks after recruitment and 2 weeks after sending thefirst KAP WhatsApp message.

Withdrawals and Loss to Follow-Up
Participants who became uncontactable during the study period
were classified as loss to follow-up cases while those who
indicated that they wished to be withdrawn from the study wereconsidered as withdrawn cases. Withdrawn cases were asked
to uninstall the app and were not further contacted.

Randomization
Eligible participants were 1:1 block randomized into theintervention or control group. Each block comprised 2
intervention and 2 control allocations. Participants determined
their allocation by picking cards in the block, which was reset
after all cards were drawn.

Blinding
Participants were not blinded to the intervention as the datacollectors had to explain the "SteWARdS Antibiotic Defence"
app to participants assigned to the intervention group. Apartfrom the data collectors, all other study team members(including the data analyst) were blinded to the groupassignment.

Data Analyses
We initially planned to take the intention-to-treat approach inanalyzing the study data but eventually took the per-protocol
approach, as our app usage data showed that participants who
did not complete the game quest had too few interactions withthe app to derive any benefit from the intervention. We
standardized the total Knowledge and Attitude-Perception scoresto 100% to illustrate the pre-post changes in scores. Correct
answers are coded as 1 while wrong answers are coded as 0.
Similarly, the “correct” attitudes are coded as 1 while neutraland “incorrect” attitudes are coded as 0.

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Chi-square tests and Mann-Whitney U tests were used for
univariate baseline comparisons. Weighted least squares
regressions (weighted on preintervention scores) were used toassess the effect of the intervention on knowledge and KAP
scores. The best regression model was chosen based on thelowest Akaike Information Criterion. All statistical assumptions
were checked to ensure the accuracy of analyses. STATA(version 15; StataCorp LLC) was used for all statistical analyses.
Participant feedback was analyzed qualitatively using thematic
analysis. OJT telephoned participants to elaborate on any
ambiguous feedback and categorized the feedback into themes.
ZH reviewed and discussed the categorization with OJT until
a consensus was reached.

Ethical Considerations
This study was approved by the National Healthcare Group
Domain Specific Review Board (2022/00479) in Singapore.
Informed consent was obtained from participants after the datacollector had fully explained the study to them. Each participant
was given a unique research ID linked to their personal details(eg, name and contact details). Only National Healthcare Group
Domain Specific Review Board–approved study team members
have access to participant data. All identifiable information isstored in password-protected files in the institutions’ server.
Data collected from the surveys and app contained only theparticipants’ research IDs. Participants were reimbursed SGD

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Huang et al
5 (US $3.82) for completing the baseline and demographic
survey, SGD 10 (US $7.64) for completing the postintervention
survey, and SGD 25 (US $19.10) for completing the app
intervention and satisfaction survey (intervention group
participants only).

Results
Participant Flow
We approached 1985 patients and visitors of polyclinics for 3
months, and 57.6% (1144/1985) of patients consented to takepart in our study. Of these consenting participants, 41.1%(470/1144) of them did not own an Android phone, 8.7%
(100/1144) did not meet our age requirements, 7.0% (80/1144)
of them were not proficient in the English language, 0.6%
(7/1144) of them had difficulty downloading the app, and 0.6%
(7/1144) of them had visual or cognitive impairment. We
block-randomized 42.0% (480/1144) of participants who werescreened for eligibility into 2 study arms. Of these randomly
assigned participants, 85.8% (206/240) of them in the control
group and 59.1% (142/240) of them in the intervention groupcompleted the study and had their outcomes assessed. About
40.8% (98/240) of intervention group participants did notcomplete the game quest (16 withdrew; 82 dropped out) in theapp (CONSORT [Consolidated Standards of Reporting Trials]
flowchart shown in Figure 6).

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Figure 6. CONSORT (Consolidated Standards of Reporting Trials) flow diagram of a 2-arm randomized controlled trial conducted on participants
recruited from government-funded primary care clinics between January 2023 and March 2023 in Singapore. A total of 1985 people were approached,1144 were screened for eligibility, and 480 were recruited into the study and randomized equally into the control or intervention group. The outcomesof 142 intervention participants and 206 controls were eventually assessed.

Recruitment
Recruitment occurred between January 2023 and March 2023,
and follow-up was completed by early June 2023. We ceased
recruitment when we achieved 240 participants per arm.

Baseline Data
Table 1 shows participants’ baseline characteristics. The
randomization produced comparable groups as there were no
significant between-group differences in participants’sociodemographic characteristics at baseline. Participants hada mean age of 36.9 (SD 12.2) years. Our participant profile fits
Singapore’s population profile in terms of ethnicity (252/348,
72.4% Chinese; 61/348, 17.5% Malay; and 24/348, 6.9%

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Indian), education level (128/348, 36.8% had tertiary education),and housing type (275/348, 79.0% residing in conventional
public housing flats). There were also no significant
between-group differences in the mean baseline knowledge
score of 8.4/11 (SD 1.6), but the attitude-perception score wassignificantly higher in controls (mean 9.6, SD 2.6) than inintervention participants (mean 8.8, SD 3.0). In addition, 60.1%(209/348) of participants had no exposure to advertisements on
antibiotic use at baseline.
The randomization produced comparable groups as there wereno significant between-group differences in participants’sociodemographic characteristics at baseline. Our participant
profile fits Singapore’s population profile in terms of ethnicity
and housing type.

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Table 1. Baseline characteristics of the randomized controlled trial participants recruited from government-funded primary care clinics between January2023 and March 2023 (N=348).
Baseline characteristics of respondents

All participants

Intervention group (n=142)

Control group (n=206)

P value

36.9 (12.2)

35.9 (12.0)

37.6 (12.3).21

Sociodemographic factors
Age (years), mean (SD)Sex, n (%)

.64

Male

181 (52.0)

76 (53.5)

105 (51.0)

Female167 (48.0)

66 (46.5)

101 (49.0)

Race, n (%).79

Chinese252 (72.4)

106 (74.7)

146 (70.9)

Malay

61 (17.5)

23 (16.2)

38 (18.5)

Indian24 (6.9)8 (5.6)

16 (7.8)

Other races

11 (3.2)

5 (3.5)6 (2.9)

Educational level, n (%).24

Tertiary educationa

128 (36.8)

47 (33.1)

81 (39.3)

Nontertiary education

220 (63.2)

95 (66.9)

125 (60.7)

Marital status, n (%).36

Married169 (48.7)

65 (45.2)

101 (49.3)

Unmarried

178 (51.3)

77 (54.2)

104 (50.7)

Housing, n (%).98

HDBb 3-room flat and below

81 (23.3)

33 (23.2)

48 (23.3)

HDB 4 or 5-room flat

194 (55.8)

80 (56.3)

114 (55.3)

Above HDB 5-room/private proper- 73 (21.0)ty

29 (20.4)

44 (21.4)

Knowledge, attitude, and perceptions on antibiotics and AMRc
Advertisement on antibiotic use, n (%)

a.34

Had seen advertisements

139 (39.9)

61 (43.0)

78 (37.9)

Had NOT seen advertisements

209 (60.1)

81 (57.0)

128 (62.1)

Knowledge score, mean (SD) (maximum 8.4 (1.6)
score: 11)

8.5 (1.6)

8.3 (1.7).16

Attitude-perception score, mean (SD)(maximum score: 14)

8.8 (3.0)

9.6 (2.6).004

9.3 (2.8)

Tertiary education: university and above.

b

HDB flat: flats developed by Singapore’s public housing authority.

c

AMR: antimicrobial resistance.

Change in Knowledge Score
The mean standardized knowledge score improved from 77.6%
at baseline to 82.4% postgame and 83.5% 6-10 weeks postintervention among intervention group participants, while
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78.1% at 6-10 weeks post baseline (Figure S1 in Multimedia
Appendix 1).
The multivariable regression analyses (Table 2) showed thatintervention group participants had greater improvement inknowledge than controls (between-group differences: 0.58, 95%
CI 0.28-0.87) after accounting for age, educational level, andexposure to advertisements on antibiotics and AMR.

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Table 2. Multivariable weighted least squares regression analysis of the association between the intervention and knowledge score at 6-10 weeks
postintervention.
Model variables

Outcome: 6-10 weeks of postintervention knowledge score
Effect size (95% CI)

P value

VIFa

0.58 (0.28 to 0.87)c

<.001

1.04

0.24 (0.17 to 0.32)c

<.001

1.08

26-35

–0.75 (–1.19 to –0.31)c

.001

1.91

36-50

–0.43 (–0.90 to 0.03)

.07

2.49

51-65

–0.45 (–0.99 to 0.08)

.09

2.05

–0.32 (–0.67 to 0.03)

.07

1.51

0.77 (0.45 to 1.09)c

<.001

1.13

.01

1.05

Randomization groupb (reference: control)Intervention
Knowledge
Baseline knowledge score
Age group (years; reference: 18-25 years)

Marital status (reference: not married)
MarriedEducation status (reference: nontertiary education)
Tertiary education

Advertisement on antibiotics and AMRd (reference: have not seen advertisements)
Have seen advertisementsa0.39 (0.09 to 0.69)c

VIF: variance inflation factor.

bIntervention group participants had greater improvement in knowledge than controls after accounting for age, educational level, and exposure toadvertisements on antibiotics and AMR.
c

P<.05.

d

AMR: antimicrobial resistance.

Change in Attitude-Perception Score
The mean standardized attitudes-perception score improved
from 62.6% at baseline to 77.7% post intervention amongintervention group participants, while controls had a modest
improvement of 68.9% from baseline to 71.9% post intervention(Figure S1 in Multimedia Appendix 1). The proportion ofintervention group participants with the “correct” attitudes andperceptions increased for all 14 statements post intervention(Figure S2 in Multimedia Appendix 1). However, intervention
group participants continue to have misconceptions about

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antibiotic use after completing the game quest. The proportionof participants with correct responses for the statement “I needantibiotics to recover from serious symptoms from the common
cold and flu” increased from 29.6% (42/142) pre- to 46.5%(66/142) postintervention, and for “I need antibiotics if I
continue to have flu symptoms after two weeks” increased from
22.5% (32/142) pre- to 38.7% (55/142) postintervention.
The multivariable regression analyses (Table 3) showed thatintervention group participants had greater attitudes-perception
improvement than controls (0.98 [0.44-1.52]) after accounting
for marital status and ethnicity.

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Huang et al

Table 3. Multivariable weighted least squares regression analysis of the association between the intervention and attitude-perception scores at 6-10
weeks postintervention.
Model variables

Outcome=6-10 weeks of postintervention attitude-perception score
Effect size (95% CI)

P value

VIFa

0.98 (0.44 to 1.52)c

<.001

1.30

0.46 (0.39 to 0.53)c

<.001

1.26

0.56 (–0.13 to 1.26)

.11

1.67

Malay

–2.86 (–3.56 to –2.15)c

<.001

1.84

Indian–1.28 (–2.19 to –0.36)c

.006

1.71

Others–0.19 (–2.10 to 1.72)

.85

1.03

–1.39 (–1.99 to –0.78)c

<.001

1.67

Randomization groupb (reference: control)Intervention
Attitude-perception
Baseline attitude-perception score
Education status (reference: nontertiary education)
Tertiary education
Ethnicity (reference: Chinese)

Marital status (reference: not married)
Marrieda

VIF: variance inflation factor.

bIntervention group participants had better attitudes-perception improvement than controls after accounting for marital status and ethnicity.

cP<.05.

App Satisfaction
The majority of participants agreed that the “SteWARdS
Antibiotic Defence” app improved their awareness on antibioticuse (135/142, 95.1%) and AMR (136/142, 95.8%). About 73.9%(105/142) of the participants agreed that the app is easy to use,
70.4% (100/142) agreed that the app was enjoyable, and 85.2%(121/142) would recommend the app to others (Table 4).

Table 4. Satisfaction in using the “SteWARdS Antibiotic Defence” app (N=142).
App satisfaction

Responses, n (%)

User experiencea: How far would you agree that the app:
Improved awareness on antibiotic use

135 (95.1)

Improved awareness on antimicrobial resistance

136 (95.8)

Is easy to use

105 (73.9)

Is enjoyable to use

100 (70.4)

User satisfaction
Would recommend the app to others

121 (85.2)

aUser experience was measured on a 5-point Likert scale. We report the proportion of respondents who agreed with the statements on user experience.
The majority of participants agreed that the “SteWARdS Antibiotic Defence” app improved their awareness on antibiotic use and AMR. More than
70% agreed that the app is easy to use, enjoyable, and would recommend the app to others.

Participants who would recommend “SteWARdS Antibiotic
Defence” found the app user-friendly, fun, enjoyable, andinteresting. Some participants also lauded the app’s uniquelearning modality and felt that the intervention addressed an
important public health topic, raised their awareness of AMR,
and improved their knowledge on appropriate antibiotic use(Table S3 in Multimedia Appendix 1).
It provides information about antibiotic resistance inan easy to understand, engaging way.

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It is much more engaging compared to reading or[looking] through long videos.
Participants who would not recommend the app mainly had apoor user experience and were frustrated with technicaldifficulties in navigating the app. Some technologically astute
players found the game boring, repetitive, and unfulfilling.
There were technical issues that made completing thegame annoying.
One participant found no value in recommending the app tofriends or family member working in health care. Those who
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JMIR SERIOUS GAMES
found the games difficult to play (mostly older adults) or
experienced usability issues (eg, small fonts) also expressed
dissatisfaction with the intervention.
Seniors may not be able to understand how to play
the games.

Suggestions for App Improvement
Suggestions to improve the quality of “SteWARdS Antibiotic
Defence” include the following (Table S4 in Multimedia
Appendix 1):

Refining Game Mechanics
Participants pointed out that the minigames should focus on
reinforcing concepts the study team intended to teach. For
example, 1 minigame leans toward self-care instead of teaching
about antibiotics use and AMR. Some participants alsosuggested improving the game’s instructional clarity, calibrating
the in-game economy to optimize the game’s difficulty level,
and increasing the number of interactive elements.
The upgrades in the Tower Defence Game isoverpowered and makes it too easy.
Let users know how much the coins earned from“endless runner” are worth. This ties into the othergame “tower defence” because you need coins tobuild the towers.

Enhancing the User Interface
Participants suggested having a consistent art style, larger word
fonts to cater to older adults, and graphics with a closer
resemblance to bacteria and viruses.
Maybe the educational message displayed before eachgame can be read out.
The 3D games can have better art style to match withthe other 2D games and environment.

Having More App Features
Suggested app features include adding music and sound effects
within the minigames, allowing players to create personal
profiles, and in-app game demonstrations.
More sound effects would be nice.

Bug Fixes
Participants suggested to improve the app’s responsiveness,sensitivity, speed, and fixing the glitches.
Developer to look into the app responsiveness andthe graphics.

Discussion
Main Findings
We evaluated the effectiveness of an evidence-based serious
game mobile app in improving the KAP of appropriate antibiotic
use and AMR among Singapore residents. To our knowledge,
this is the first RCT assessing the effectiveness of a serious
game mobile app intervention for public education on
appropriate antibiotic use and AMR. We also assessed theeffectiveness of the app in short-term knowledge retention athttps://games.jmir.org/2024/1/e59848

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Huang et al
6-10 weeks post intervention, which has often been overlooked.
Furthermore, we assessed the app in a real-world context in thecommunity and not in the controlled environment of anexperimental setting.
We observed a statistically significant effect size of 0.58 (95%
CI 0.28-0.87) in knowledge improvement, which concurs withother serious game studies on chronic disease management
among young people [26] and healthy lifestyle promotion [27].
However, a similar Singapore study on dengue prevention
observed significant improvements of participants’ knowledge,
attitudes, and practices from baseline but no between-groupmean differences [28]. The difference in observations is likely
attributed to the exposure of relevant information sources among
controls in the dengue study, which attenuated the effects of
the app intervention. Tertiary-educated adults were positively
associated with higher postintervention scores. They may farebetter at learning the more difficult AMR concepts as studies
have shown that AMR concepts are hard to teach. Participants
with no or limited understanding of the etiology of antibiotic
resistance would face difficulty connecting AMR with antibiotic
misuse [29]. Furthermore, misconceptions about antibiotic use
are generally hard to rectify.
We also observed a statistically significant effect size of 0.98
(95% CI 0.44-1.52) in attitude-perception improvement withthe “SteWARdS Antibiotic Defence” app. Other studies havefound mixed results in the effectiveness of serious games in
improving the adoption of healthy behaviors, such as fruit andvegetables intake among adolescents [15]. The effectiveness ofserious games in changing attitudes and perceptions are hardto measure as studies are often multifaceted. Therefore, it isessential to have well-designed interventions targeted at thecorrect population, well-accepted by participants, and withattainable goals for interventions to be successful. While we
recruited participants between 18 and 65 years of age, the app
was originally developed for young adults as this group ofpeople was found to have the lowest knowledge in antibiotic
use and AMR [7].
Our “SteWARdS Antibiotic Defence” app received an overall
positive rating, but the ratings should be interpreted with caution
as the satisfaction survey was only completed by participants
who finished the game quest in the app. It is unclear whether
participants dropped out of the intervention due to dissatisfaction
with the app or a lack of time to complete the quest. Other
studies assessing the effectiveness of serious games in healtheducation have observed high satisfaction among participants[30,31]. However, there is limited evidence on the satisfaction
with health education delivered via serious games in the general
population and even fewer studies report participant satisfaction.
Hence, the feedback and suggestions we gathered fromparticipants are valuable in identifying population-specificshortcomings of the intervention and informing app
enhancements that could increase the success of intervention
scale-ups.
Despite a modest improvement in KAP scores in the intervention
group, improved health literacy may not translate to desired
behavioral change [13,32]. Health literacy interventions have
led to improved health outcomes in some studies, but the links
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JMIR SERIOUS GAMES
between health literacy improvement and behavioral change
have not been established with higher-quality studies [33].
Effective interventions are also integral to attaining successful
behavioral change. One way to improve the learning outcomes,suggested by our participants, is to weave the intended learning
concepts into the game mechanics rather than displaying
informational text boxes for players to read. Such enhancements
would possibly improve user engagement and lead to better
learning outcomes [34].
A few limitations exist in our study. First, measurement errors
in KAP scores might occur if intervention group participants
had requested their friends or family members to help with study
completion. Nonetheless, controls could also have had help incompleting the postintervention survey. Therefore, any bias
which attenuates the intervention's true effect is likely toward
the null. Second, there is a ceiling effect for participants withnear-perfect baseline scores, which could attenuate the positiveeffects of the intervention. Third, we randomized participantsprior to baseline data collection because the knowledge
questions were embedded in the app. Fourth, there may be alearning effect in the intervention group as these participants
completed the knowledge questionnaire 3 times. Hence, thepositive effects observed in the intervention group could be a
combination of the serious game and learning effect from theimmediate postgame survey. Including a study group with a

Huang et al
traditional form of learning (eg, brochures) may enable us toassess the effect of the serious game app more accurately.
Finally, we included only attendees at 2 government-fundedprimary care clinics (polyclinics). Despite the limitations in
recruitment, the sociodemographic distribution of ourparticipants is representative of the Singaporean population.
Hence, our findings are generalizable to the rest of the country.
In addition, we noticed several older adults rejecting study
participation due to a lack of interest in completing the mobile
app quest. Their lack of interest implies an additional effort tochange their mindsets, and serious game interventions may not
be the best modality for educating older adults on public healthissues. Reminders were also integral in driving the appcompletion rate. Hence, the actual uptake rate may be lower inthe population. Future research should assess the effectivenessof interventions that facilitate long-term knowledge retention
and long-lasting behavioral change in antibiotic use and AMR[35].

Conclusions
Our educational serious game app improves participants’ KAP
on appropriate antibiotic use and AMR. Public education appsshould be engaging, educational, easy to use, and have an
attractive user interface. Interventions should also aim to achieve
long-term knowledge retention and long-lasting behavioral
change.

Acknowledgments
ZH and OJT had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of thedata analysis. The study team would like to acknowledge Tan Soon Peng, Khoo Jin Rong, Siti Shazwani Binte Sadimin, Nur
Atiqah Binte Surya Akmaja, and Karthiga Natarajan for their assistance in data collection and study administration. We would
also like to thank the staff and student interns from Temasek Polytechnic’s School of Engineering and School of Informatics &IT for their contribution in maintaining the “SteWARdS Antibiotic Defence” app and database during the study. This work is
supported by the National Centre for Infectious Diseases (National Centre for Infectious Diseases Catalyst grant FY2022HZ).

Data Availability
Deidentified data that support the findings of this study are available on request from AC or ZH.

Disclaimer
The research presented in this paper is solely the responsibility of the authors and does not reflect the views of the funder.

Authors' Contributions
ZH codeveloped the app, conceived the manuscript, obtained the catalyst grant, analyzed the data, and drafted the manuscript.
OJT administered the study, analyzed the data, and drafted the manuscript. WET provided inputs to the study design and support
for running the trial. AC codeveloped the app and provided inputs to the study design of the trial. All authors critically reviewed
the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Additional materials to support the findings of the study.
[DOCX File , 1338 KB-Multimedia Appendix 1]

Multimedia Appendix 2
CONSORT eHEALTH checklist (V 1.6.1).
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Huang et al[PDF File (Adobe PDF File), 8471 KB-Multimedia Appendix 2]

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Abbreviations
AMR: antimicrobial resistance
CONSORT: Consolidated Standards of Reporting Trials
KAP: knowledge of, attitude toward, and perceptions
NPC: nonplayer character
RCT: randomized controlled trial

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Edited by T Leung; submitted 23.04.24; peer-reviewed by P Sterkenburg, G Mboowa; comments to author 26.05.24; revised version
received 29.05.24; accepted 12.07.24; published 05.09.24
Please cite as:
Huang Z, Ow JT, Tang WE, Chow A
An Evidence-Based Serious Game App for Public Education on Antibiotic Use and Resistance: Randomized Controlled Trial
JMIR Serious Games 2024;12:e59848
URL: https://games.jmir.org/2024/1/e59848
doi: 10.2196/59848
PMID: 39235853©Zhilian Huang, Jing Teng Ow, Wern Ee Tang, Angela Chow. Originally published in JMIR Serious Games(https://games.jmir.org), 05.09.2024. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (https://creativecommons.org/licenses/by/4.0/), 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 https://games.jmir.org, as well as this copyright and license information must
be included.

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