An Evidence-Based Serious Game App for Public Education on Antibiotic Use and Resistance: Randomized Controlled Trial
Authors: Huang Zhilian , Ow Jing Teng , Tang Wern Ee , Chow Angela 
Published: July 2024

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 ongoing health 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 and interaction 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 to complete 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 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.

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