Designing for Engagement in Primary Health Education Through Digital Game-Based Learning: Cross-National Behavioral Evidence from the iLearn4Health Platform

Abstract

'Charitini-Maria Skoulidi' 'Panagiotis Anastassopoulos' 'Alexandra Cornea' 'Begoña Inchaurraga' 'Jaione Santurtun' 'Ainhoa de la Cruz Mancha' 'George Giorgakis' 'Kleri Kouppas' 'Stella Timotheou' 'Maria Jose Moreno Juan' 'Miren Muñagorri' 'Marta Harasiuk' 'Alfredo Garmendia Lopez' 'Efi Skoulidi' 'Apostolos Vantarakis' 'Ian Turner'] This study evaluates design effectiveness in Digital Game-Based Learning (DGBL) for primary health education through systematic teacher assessment of the iLearn4Health platform. Rather than measuring educational transformation, the research investigates how DGBL design principles influence user engagement patterns and platform usability as evaluated by education professionals. The study contributes to design optimization frameworks for primary school digital health education applications by examining the distinction between DGBL and superficial gamification approaches in creating engaging educational interfaces. The iLearn4Health platform underwent comprehensive design evaluation by 337 teachers across 24 schools in five European countries (Greece, Cyprus, Romania, Poland, and Spain). Teachers served as design evaluators rather than end-users, assessing platform engagement mechanisms through systematic interaction analysis. The study employed multiple statistical approaches-descriptive analysis, correlation analysis, ANOVA, regression modeling, and cluster analysis-to identify design engagement patterns and their predictors, tracking completion rates, progress trajectories, and interaction time as indicators of design effectiveness. Design evaluation revealed a distinctive bimodal engagement distribution, with 52.8% of teacher-evaluators showing limited platform exploration (progress ratio 0.0-0.2) and 35.3% demonstrating comprehensive design assessment (progress ratio 0.8-1.0). A strong positive correlation (r = 0.95, p < 0.001) between time spent and steps completed indicated that design elements successfully sustained evaluator engagement.