The study, published in BMC Medical Education, enrolled 106 primary healthcare nurses working across 16 primary healthcare units in Indonesia. The units, rather than individual nurses, were randomized to one of two arms of the trial, a design choice that guards against the contamination that would inevitably occur if colleagues within the same clinic experienced different training formats and shared what they learned. Eight units received the board game-based education, while the other eight received a traditional lecture covering the same dengue-related content. Fifty nurses were trained with the game and fifty-six with the lecture, and all participants completed assessments at three time points: before the intervention, immediately afterward, and one month later.

The theoretical architecture behind the game is what distinguishes it from a casual quiz night. The developers grounded the intervention in Kolb’s Experiential Learning Theory, a framework that describes learning as a cycle moving through concrete experience, reflective observation, abstract conceptualization, and active experimentation. Rather than passively receiving information, players encounter realistic dengue scenarios on the board, reflect on the decisions they make, connect those decisions to underlying clinical principles, and then apply revised understanding in subsequent rounds of play. The design was further shaped by the ARCS motivational model, which structures instruction around Attention, Relevance, Confidence, and Satisfaction, four conditions that educational psychologists consider essential for sustaining learner engagement.

The rationale for the work rests on the specific role primary healthcare nurses play in dengue-endemic settings. In Indonesia, where dengue remains a major public health burden, these nurses are responsible for early case detection, initial management, referral decisions, and community-level prevention. Their knowledge and confidence directly shape how quickly a febrile patient is recognized as a potential dengue case and how effectively households in their catchment areas are advised to eliminate mosquito breeding sites. Yet workplace-based dengue education in such settings is still commonly delivered through lectures, a format the researchers note may not fully support active engagement among busy frontline staff who learn best when instruction fits the rhythms of clinical practice.

When the results were analyzed using linear mixed-effects models, a statistical approach that accounts for both the clustering of nurses within units and the repeated measurements taken from the same individuals over time, a clear pattern emerged for knowledge. Dengue-related knowledge showed a statistically significant group-by-time interaction, with F equal to 4.48 and a p-value of .01. In practical terms, the two groups started at similar levels, with the intervention group averaging 4.04 on the knowledge measure at baseline and the control group averaging 4.54, but the game-trained nurses climbed to 5.72 immediately after the intervention while the lecture group reached only 5.43. The board game, in other words, produced a steeper and statistically distinguishable jump in what nurses knew about dengue right after training.

The picture was more nuanced for the other two outcomes. Attitudes toward dengue prevention, measured with a validated Indonesian-language instrument, improved in both groups but did so at statistically similar rates, with the group-by-time interaction falling just short of significance at F equal to 2.57 and p equal to .08. Confidence, assessed with the Indonesian version of the Confidence Scale, rose comparably in both arms as well, with an interaction statistic of F equal to 0.28 and p equal to .76. The authors interpret this convergence carefully: both educational approaches succeeded in improving knowledge, attitudes, and confidence, and the game’s advantage was confined to the immediate knowledge gain rather than extending to how nurses felt about prevention or how assured they were in their own abilities.

One important caveat tempers the headline finding. The board game session was longer than the lecture session, which means the intervention group effectively received more instructional time. The authors explicitly caution that the greater immediate knowledge improvement should be interpreted with this imbalance in mind, since additional exposure to the material, regardless of format, could plausibly account for part of the difference. Disentangling the motivational power of play from the simple effect of longer contact time would require a trial in which the two formats are matched for duration, a refinement that future studies in this line of research will need to address.

What the trial does establish is that a game-based approach is feasible, acceptable, and at least as effective as the status quo. Learning satisfaction was high in both groups, suggesting that neither format alienated participants, but the experiential design of the game aligns with a substantial body of educational theory indicating that active, scenario-driven learning promotes deeper processing than passive listening. For overstretched primary care clinics, the appeal of a board game also lies in its practicality: it requires no digital infrastructure, no internet connectivity, and no specialized equipment, making it a low-cost tool that can be deployed in resource-limited settings where high-tech training platforms are impractical.

The trial was rigorously conducted by the standards of educational research. It was registered with ClinicalTrials.gov under identifier NCT07028411 on 19 June 2025, with the first participant enrolled on 8 August 2025. Ethical approval came from the Institutional Review Board of Universitas Gadjah Mada in Indonesia, and the study was carried out in accordance with the Declaration of Helsinki, with written informed consent obtained from all participants. The reporting followed CONSORT guidelines for randomized trials, and the analysis employed restricted maximum likelihood estimation within the mixed-model framework, with model fit considerations informed by Akaike and Bayesian Information Criteria. The work received no specific grant from any funding agency, and the authors declare no competing interests.

The broader significance of the study extends beyond dengue. Gamified and experiential learning interventions are attracting growing attention in health professional education, but rigorous cluster randomized evidence comparing them head-to-head with conventional instruction remains scarce, particularly in low- and middle-income countries where the educational burden is heaviest. By demonstrating a measurable knowledge advantage, even one tempered by session-length differences, this trial offers a template for how serious games can be evaluated with the same methodological rigor applied to drugs and devices. As the authors conclude, the board game may serve as a promising supplementary approach for dengue education among frontline primary healthcare nurses in endemic settings, a modest cardboard intervention with the potential to reinforce the knowledge that early detection and community prevention depend upon.

Subject of Research: Effects of a board game versus lecture-based education on dengue-related knowledge, attitudes, and confidence among primary healthcare nurses in Indonesia

Article Title: Effects of a board game on dengue-related knowledge, attitudes, and confidence among primary healthcare nurses: a cluster randomized controlled trial

Article References: Hertanti, N. S., Kuo, S.-Y., Kuo, C.-L., Ko, N.-Y., Chung, M.-H., & Chuang, Y.-H. (2026). Effects of a board game on dengue-related knowledge, attitudes, and confidence among primary healthcare nurses: a cluster randomized controlled trial. BMC Medical Education. https://doi.org/10.1186/s12909-026-10561-8

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10561-8

Keywords: dengue, board game, nursing education, cluster randomized controlled trial, primary healthcare, Indonesia, experiential learning, ARCS motivational model, workplace education, knowledge gain, continuing education, public health

The study, conducted across 13 clerkship blocks, took advantage of the natural sequencing of a curriculum rather than random assignment. Seven blocks received the game-based learning activity during the first or second week of the rotation, forming what the researchers called the game-based group, while six blocks followed conventional teaching until after the week-four post-test and only then received the game, serving as a delayed-exposure comparison group. All students sat the same pre-test and post-test, allowing the team to compare adjusted post-test scores between the two schedules using a linear mixed-effects model that accounted for pre-test performance and for clustering within clerkship blocks.

The results were striking. The adjusted mean post-test score was 3.671 in the game-based group against 2.635 in the conventional teaching group, an adjusted difference of 1.036 points with a 95 percent confidence interval running from 0.560 to 1.513 and a p-value below 0.001. In practical terms, students who encountered the game early in their clerkship retained substantially more child development knowledge at the end of the rotation than peers who had not yet played it. The authors are careful, however, to note the limits of this design: differences in assessment timing and the intervening clerkship exposure mean the advantage cannot be attributed to game-based learning alone.

What makes the study unusual is its second layer of analysis. Rather than treating the educational game as a single undifferentiated intervention, the researchers asked students to appraise ten distinct game elements individually and measured their flow states using the Flow State Questionnaire. Flow, a concept from positive psychology, describes the absorbing state in which challenge and skill are balanced, attention narrows, and time seems to dissolve. Educational theorists have long proposed that flow is a key mechanism through which games promote learning, making it a natural target for empirical scrutiny.

Students rated all ten game elements highly, indicating that the game was well received across the board. When the researchers examined how these appraisals related to flow, patterns emerged quickly. Nine appraisal-flow associations met the false discovery rate criterion set by Benjamini-Hochberg procedures: six involving enjoyment, two involving sense of control, and one involving engagement. In other words, the students who found particular game elements enjoyable, controllable, or engaging were also the ones most likely to report deep immersion during play. The experiential side of the game clearly worked as intended.

The cognitive side told a different story. Among models linking game-element appraisals to adjusted post-test performance, only one association reached statistical significance, and it ran in an unexpected direction. Teamwork appraisal showed an inverse marginal association with test performance, with a coefficient of -0.811, a 95 percent confidence interval from -1.283 to -0.339, and an FDR-adjusted q value of 0.0113. Students who rated the teamwork element more highly tended, if anything, to score slightly lower on the knowledge test. None of the Flow State Questionnaire subscales was significantly associated with post-test performance at all.

These findings lead the authors to a provocative hypothesis: experiential and cognitive outcomes of game-based learning may involve partly distinct processes. A game can succeed brilliantly at generating enjoyment, engagement, and flow while having little detectable relationship to how much factual knowledge students retain. This does not mean the flow experience is worthless in medical education, but it does challenge the common assumption that immersion is the engine of learning in game-based settings. The authors emphasize that this hypothesis requires prospective testing before firm conclusions can be drawn.

The course itself focused on child development, a core competency in pediatric training that includes developmental screening concepts such as those embodied in the Denver Developmental Screening Test. The content aligned with standards from the Council on Medical Student Education in Pediatrics, and the game was designed to let students apply developmental principles in a low-stakes, interactive format. The study protocol was approved by the Institutional Review Board of MacKay Memorial Hospital, with a waiver of written informed consent covering educational records generated between January 2024 and December 2025.

For medical educators, the study carries a double message. On one hand, it adds to the evidence that well-designed games can improve knowledge outcomes in demanding professional curricula, with an effect size that translated into a full point of adjusted difference on the post-test. On the other hand, it warns against evaluating games solely through the lens of learner experience. High ratings of enjoyment and strong reports of flow do not guarantee cognitive gains, and educators who want games to teach as well as entertain may need to design and assess the two dimensions separately.

The research team, drawn from MacKay Memorial Hospital, MacKay Children’s Hospital, and National Taiwan University College of Medicine, suggests that future work should prospectively test whether separating experiential from cognitive design goals improves both. As game-based learning spreads through medical schools worldwide, studies like this one provide a template for moving beyond the blunt question of whether games work toward the sharper question of which components of a game do the teaching, and which simply make the teaching enjoyable.

Subject of Research: Game-based learning and flow experience in medical education for child development

Article Title: Game element appraisals and learning outcomes in a game-based child development course for medical students

Article References: Ten, C.-W., Ko, M. H.-J., Peng, C.-C., Chiu, Y.-L., & Chen, H.-L. (2026). Game element appraisals and learning outcomes in a game-based child development course for medical students. BMC Medical Education. https://doi.org/10.1186/s12909-026-10461-x

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10461-x

Keywords: game-based learning, medical education, child development, flow state, pediatrics clerkship, board game, flow state questionnaire, medical students, BMC Medical Education, learning outcomes, false discovery rate, curriculum design