Abstract
Objectives:
To evaluate the impact of the serious game DiaPed on the knowledge of children with type 1 diabetes (T1D).
Introduction:
Type 1 diabetes in children requires lifelong insulin therapy along with comprehensive therapeutic patient education (TPE). Traditional TPE approaches often fall short, highlighting the need for innovative tools such as serious games.
Methods:
A pre-post interventional study was conducted with 40 children with T1D at a pediatric diabetes clinic in Tunisia. Participants engaged with DiaPed, a serious game designed to teach the basics of T1D, insulin therapy, and hypoglycemia management.
Results:
Knowledge scores improved significantly following gameplay, increasing from 29.8 ± 6.02 to 68.6 ± 1.58 (P < .001). The effect size, as measured by Cohen’s index, was 6.72. Satisfaction surveys indicated high levels of engagement and enthusiasm among participants.
Conclusion:
DiaPed significantly improved diabetes-related knowledge in children with T1D, highlighting its potential as an effective tool for TPE.
Introduction
Type 1 diabetes (T1D) is the most common endocrinopathy in children, affecting 1.52 million individuals worldwide. 1 It accounts for 85% of diabetes cases in children and requires lifelong insulin therapy. 2 Managing T1D requires regular blood sugar monitoring, a balanced diet, regular physical activity, and strict compliance with medical advice.
Therapeutic patient education (TPE) plays a crucial role in managing T1D by improving patients’ health outcomes and quality of life while promoting essential self-care skills. 3 However, traditional TPE methods often fall short, leading to poor disease management and control. Structured activities and digital tools can be used in TPE to help children manage their diabetes independently, through applications that offer interactive learning experiences. 4
In Tunisia, while serious games are emerging as educational tools, 5 their application in healthcare, particularly in TPE, remains limited. This study aimed to develop and evaluate the impact of a serious game on the knowledge of children with T1D to aid in TPE.
Methods
This was a descriptive, analytical, and pre-post interventional study conducted at the pediatric diabetes clinic from March to April 2024. Data was collected prospectively throughout the study period.
This study included children aged 6 to 12 with T1D, diagnosed for at least 6 months. All participants had previously received standardized traditional TPE, at the time of diagnosis, using the same materials, such as printed images and documents, with reinforcement provided during each follow-up consultation. Participants were required to complete all stages of the study. Children with other chronic conditions or cognitive impairments were excluded from participation.
A questionnaire was developed in Tunisian Arabic, consisting of 42 questions divided into 5 sections: sociodemographic informations, diabetes knowledge, insulin therapy, hypoglycemia management, and a satisfaction survey. The serious game, “DiaPed” (Figure 1), is an Android application accessible on mobile devices and developed using Android Studio, an app development tool. It was designed in the Tunisian dialect and includes 3 levels: one focused on general knowledge about T1D, another on insulin therapy modalities, and a third on understanding and managing hypoglycemia in children with T1D. Each child’s participation was personalized with their name, age and avatar to make the game more engaging and entertaining. Progression from one level to the next was only allowed after all correct answers were validated, with sufficient response time for each question. Each correct answer is rewarded with a score in the form of stars. The duration of the game ranged from 20 to 30 minutes depending on the child. To increase accessibility, the game was also made available online (Link: DiaPed.apk).
Screenshots from the serious game DiaPed. (a) Player registration screen requiring the input of name, gender, and age before starting the game. (b) Level selection interface presenting the 3 levels of the serious game. (c) Drag-and-drop activity where players select and apply the appropriate disinfection materials to the hands, insulin vial, and injection site, earning stars based on correct actions. (d) Reward screen displaying a congratulatory message and a star, indicating successful completion and allowing progression to the next level.
Participants completed a pre-test to assess their knowledge before playing DiaPed. The pre-test consisted of quiz questions developed based on the educational objectives of the standard TPE program implemented in our pediatric department. It focused on key areas such as insulin therapy, hypoglycemia management, and lifestyle adaptation, all essential components of diabetes education. Prior to this study, the quiz was tested on a sample of 10 children to ensure that the questions were age-appropriate, understandable, and aligned with the educational level of our target population.
After engaging with the serious game, they took an identical post-test to measure knowledge gains. A satisfaction survey was later conducted to evaluate the children’s experiences with the serious game. The survey included multiple-choice questions assessing ease of use, engagement, perceived usefulness, and overall enjoyment.
The final scores for each parameter were calculated across the entire sample. Knowledge scores were rated out of 70, as there were 70 distinct items. We categorized the levels of knowledge as follows: good if the score was greater than 50 (>50), average if the score was between 35 and 50 (≥35 and ≤50), and limited if it was less than 35 (<35). Pre- and post-test scores were compared to assess the impact of the serious game using Student’s t-test, and Cohen’s d index was calculated to evaluate the effect size of the educational intervention.
Ethical Approval and Informed Consent
Ethical standards were strictly respected by informing participants and obtaining consent from both the children and their parents. The study ensured data confidentiality and participant anonymity throughout the research process. Approval for this study was granted by the local medical ethics committee (approval number: 08/2024).
Results
This study included 40 children with T1D, 23 boys and 17 girls, with an average age of 9.12 years ± 1.9 [6-12 years] (Table 1). All children reported that they had received TPE about their condition through classic methods. However, none of them had been educated through gamified approaches or serious games.
Demographic and Clinical Characteristics of Participants with Type 1 Diabetes (N = 40).
Patients’ General Knowledge About Type 1 Diabetes
Half of the children believed that diabetes was a contagious disease. In addition, 55% thought that the disease could be managed with oral pills. However, 93% correctly identified insulin as the proper treatment for managing T1D. The questionnaire results highlighted that 68% of the children were able to correctly identify insulin as a hormone that helps to balance blood glucose levels, and 35% knew that insulin is absent in the bodies of those with T1D. When asked about the organ responsible for insulin production, only 35% correctly identified the pancreas.
Patients’ Knowledge About Insulin Therapy
All children recognized that insulin should be stored in the refrigerator. However, 47% of the children believed insulin should be used immediately after being removed from the refrigerator, while 37% thought it should be used after 5 to 10 minutes. Furthermore, half of the participants mistakenly believed that insulin has no expiration date. Regarding the steps involved in insulin administration, 68% of the children did not acknowledge the necessity of disinfecting the insulin vial before withdrawing the medication, and only 60% recognized the abdomen as an appropriate injection site, while 10% mistakenly believed the neck could be used. Additionally, 20% of the children reported compressing the injection site for 10 seconds post-injection.
Patients’ Knowledge About Hypoglycemia
Concerning the children’s understanding of hypoglycemia, 90% correctly identified fatigue and tremors as symptoms of hypoglycemia, and 68% recognized dizziness as well. When asked about the causes of hypoglycemia, 65% correctly attributed it to an overdose of insulin, and 88% noted that excessive physical exertion could lead to low blood sugar levels. Regarding interventions for hypoglycemia, 93% of the children correctly identified the need to consume fast-acting sugar, such as drinking juice, and 47% understood the importance of following up with a slow-acting carbohydrate, like eating a piece of bread, once the symptoms improve. Additionally, 60% recognized the need to regularly monitor blood glucose levels, and 55% mentioned the importance of eating more when engaging in strenuous physical activity.
The final average knowledge score for the children was 29.8 ± 6.02 [20-48], indicating that the overall level of understanding within the study population was limited.
Impact of the Serious Game on Children’s General Knowledge About Type 1 Diabetes
Statistical analysis revealed a significant improvement in children’s knowledge about the definition of T1D and insulin following the use of the serious game (Table 2).
Impact of Serious Game on Children’s Knowledge About Type 1 Diabetes.
Impact of the Serious Game on Children’s Knowledge About Insulin Therapy
In the evaluation of insulin therapy knowledge, no difference was observed between the pre-test and post-test results concerning the storage location of insulin; all children correctly identified that insulin must be kept in the refrigerator in both tests. However, significant differences were found in other items, such as the timing of insulin use, its shelf life, injection sites, and steps of injection (Table 3).
Effect of Serious Game on Children’s Knowledge About Insulin Therapy.
Impact of the Serious Game on Children’s Knowledge About Hypoglycemia
A significant improvement in children’s knowledge about hypoglycemia was observed after using the serious game. Post-test scores showed a marked increase in correct answers compared to pre-test scores across various items, including causes, symptoms, rapid intervention, complications, and prevention of hypoglycemia (Table 4).
Impact of Serious Game on Children’s Knowledge About Hypoglycemia.
The average final score for the children’s knowledge about T1D improved significantly from 29.8 ± 6.02 [20-48] out of 70 (considered limited) in the pre-test to 68.6 ± 1.58 [64-70] out of 70 (considered good) in the post-test, with a statistically significant difference (P < .001). The Cohen’s calculated index for the serious game was 6.72, indicating a very strong effect size.
Children’s Opinions on the Serious Game
All the children who participated reported that they acquired new knowledge and learned how to perform necessary actions related to their condition. The children found the game easy to use, and they all understood the language used. Additionally, 38 children (95%) stated that the duration of the game was appropriate for their attention span and learning capacity. They also mentioned that the images in the game helped them understand the steps needed for insulin administration and hypoglycemia management.
All the children confirmed that the images and sound were clear, making the gaming experience both enjoyable and educational. They also noted that the game helped them remember the maneuvers, boosting their confidence in managing their diabetic condition. Finally, all the participants highlighted the value of the serious game as an educational tool in T1D.
Discussion
Type 1 diabetes (T1D) is one of the most common chronic diseases in children and TPE plays a crucial role in its management. 6 Traditionally conducted through face-to-face sessions between the doctor and patient, advances in technology and audiovisual tools have made this education more personalized and engaging, thus facilitating learning. 7 In this study, we aimed to design and develop a serious game and assess its impact on the TPE of children with T1D. The average knowledge score improved significantly from 29.8 to 68.6 out of 70 after playing DiaPed (P < .001).
The study included 40 children with type 1 diabetes (N = 40) from the pediatric diabetes clinic. The observation that 80% of children used traditional insulin injections while only 20% used insulin analogs reflects the variability in insulin management approaches. This may be influenced by economic factors, and access to social security. Studies have indicated that insulin analogs offer benefits like reduced hypoglycemia and more flexible dosing, which could potentially improve quality of life in pediatric diabetes patients. 8 However, access to newer forms of insulin therapy can be limited by healthcare policies and costs, especially in lower-income countries.
Despite the fact that all the children included in the study had been diagnosed for more than 6 months and had already received TPE, their knowledge remains limited, which raises the question whether this traditional method is becoming insufficient. TPE helps children and families understand the disease, recognize early symptoms of complications, and manage day-to-day tasks, ultimately improving adherence to therapy and quality of life. 9 The insufficiency of TPE in these cases reflects a significant gap in diabetes care and insufficient healthcare provider-patient interactions, which is also observed in other studies, particularly in low and middle income countries.10,11
Furthermore, none of the children in the study had been exposed to gamified education approaches, which is an emerging trend in chronic disease management, especially for pediatric populations. Serious games offer an interactive and engaging platform for children to learn about diabetes in a manner that fits with their developmental stage and cognitive preferences. Research has shown that gamified TPE can lead to better retention of information and improve motivation to manage their condition. 12 This represents a missed opportunity in the current management practices and could be an area of intervention to enhance diabetes care.
Half of the children in our study believed that diabetes is a contagious disease, highlighting a significant misconception. This is consistent with other studies showing that misbeliefs about the nature of T1D are common, even among patients themselves. 13 Additionally, 55% of children incorrectly thought the disease could be managed with oral pills, which is irrelevant since oral hypoglycemic agents are used in type 2 diabetes, while managing T1D heavily relies on insulin administration. Moreover, 68% correctly identified insulin as a hormone that regulates blood sugar, and only 35% understood that insulin is absent in T1D, and the same percentage knew the pancreas is the organ responsible for its production. These gaps reflect a common lack of basic physiological knowledge in children, which may limit their ability to fully understand their disease. Proper knowledge of insulin and its role in glucose metabolism is crucial for effective self-management. 14 Here, serious games could be particularly useful in breaking down complex medical concepts into engaging, digestible formats for children.
All children knew insulin should be refrigerated, but many had wrong ideas about its use. For instance, 47% believed insulin should be used immediately after removal from the fridge, and 50% incorrectly thought insulin had no expiration date. These errors could lead to improper storage and usage, affecting the drug’s efficacy. Similarly, the misunderstanding about disinfecting insulin vials and appropriate injection sites, including the belief that the neck is a viable option, points to an urgent need for practical education. Serious games that simulate the steps of insulin administration could reinforce proper techniques and correct these errors in understanding. 15
The children’s general awareness of hypoglycemia symptoms, such as fatigue and tremors (90%), and dizziness (68%), as well as the correct identification of fast-acting sugars as treatment (93%), is promising. However, fewer children recognized the need for follow-up with slow-acting carbohydrates (47%). Hypoglycemia is one of the most serious complications of T1D, and children need to understand not just how to treat it but also how to prevent it by balancing insulin, food intake, and physical activity. 16
The overall knowledge score of 29.8 ± 6.02 [20-48] out of 70 indicates a low understanding of T1D among children but leaves significant room for improvement. Serious games could play a vital role in filling these gaps. Gamified learning approaches can help children retain better information, especially on complex topics like hypoglycemia management and insulin administration, as supported by studies showing that serious games improve engagement and learning outcomes in chronic disease education. 17
The serious game led to significant improvements in children’s understanding of T1D. For instance, all children were able to correctly identify after the intervention that T1D is a chronic disease, and none believed it was contagious, compared to 50% in pre-test. These results aligned with findings in the literature, where gamified learning environments have been shown to increase retention and understanding of health-related information. 17 Errors about the need for specific diets or diabetes management were also corrected, with 100% of children recognizing the necessity of a balanced diet after the serious game intervention (P < .001).
A significant improvement was observed in understanding the role of insulin, as all children correctly identified that insulin helps balance blood sugar after our intervention, compared to 68% before (P < .001). Additionally, knowledge about the organ responsible for insulin production, which is the pancreas, increased from 35% to 100%, indicating a better grasp of basic endocrinology after using the serious game. These results suggest that gamification can effectively simplify complex biological concepts, making them accessible to children, as supported by other studies in health education.18,19
The study also demonstrated significant gains in knowledge about insulin therapy. Notably, children improved in recognizing the appropriate waiting time before using insulin after refrigeration, with 98% understanding the need to wait 5 to 10 minutes, up from 37% in the pre-test (P < .001). The correction of misbeliefs, such as insulin having no expiration date (from 50% pre-test to 100% post-test), highlights the effectiveness of the game in improving practical, day-to-day management knowledge. The improvement in understanding the steps of insulin administration, such as disinfecting the vial and site of injection and the necessity of handwashing, shows the value of serious games in teaching hands-on procedures. 20 The increase in children recognizing appropriate injection sites (abdomen, arms, thighs) underscores the role of interactive learning in reinforcing correct practices (P < .001).
The serious game significantly improved children’s awareness of hypoglycemia, an essential aspect of diabetes management. After the intervention, all the children were able to correctly identify the symptoms of hypoglycemia and the appropriate interventions, compared to lower percentages before the game (P < .001). This is a crucial finding, as proper hypoglycemia management is a key to preventing severe complications in children with T1D. 16 Moreover, the fact that 100% of the children recognized the importance of eating a piece of bread after initial symptom relief (compared to 47% before) reflects a significant shift toward understanding the full cycle of hypoglycemia management. This highlights the serious game’s impact on improving the practical, real-world application of knowledge.
The increase in average knowledge scores from 29.8 to 68.6 out of 70 indicates that the serious game had a very strong effect on the children’s learning outcomes. Previous studies on serious games have demonstrated similar positive outcomes in improving health knowledge and behavior among children with chronic illnesses.21,22 In fact, serious games combine educational and entertaining aspects, using game-inspired elements to make learning engaging and comprehensible. They incorporate cognitive science principles such as attention, consolidation, active engagement, and feedback. 23 These findings reinforce a growing body of evidence that serious games and digital tools in general play an increasingly important role in TPE, enhancing knowledge acquisition, engagement, and adherence especially among pediatric populations, as demonstrated in previous studies.24 -26 The calculated Cohen’s d index of 6.72 may indicate an extremely large effect size. However, such a high effect size is unusual and may be influenced by factors such as a small sample size or a ceiling effect.
Our findings demonstrate the potential of serious games to significantly improve children’s understanding of T1D, insulin therapy, and hypoglycemia management. Given that many children with T1D have limited knowledge about their condition, incorporating serious games into TPE programs could be a highly effective strategy to bridge knowledge gaps and improve self-management skills. These results support the broader adoption of gamified learning tools in pediatric chronic disease management.
The unanimous approval of the serious game by the children suggests that gamified approaches are not only effective in improving knowledge but also enjoyable and accessible. All children reported gaining new knowledge, particularly in key areas such as insulin administration and hypoglycemia management, demonstrating the potential of serious games to serve as effective teaching tools in pediatric chronic disease management.
The children’s comments reflect several important aspects of the game’s success. The game was user-friendly, with all participants reporting that they found the language easy to understand. This is critical when designing educational tools for children, especially in complex medical contexts like diabetes management. Previous studies emphasize that ease of understanding is key to successful behavior change in children. 27
The use of images and sounds in the game helped reinforce the learning process, making the information easier to recall. Visual and auditory cues are known to enhance memory retention and engagement in children, especially in educational games. 20 The clarity of these elements made the game both an enjoyable and effective learning experience, which can increase children’s willingness to engage in repeated gameplay and reinforce critical skills.
Importantly, the children reported feeling more confident in performing essential diabetes-related tasks after playing the game. This increase in self-efficacy is crucial for managing chronic conditions like T1D, where the patient’s ability to autonomously handle insulin administration and hypoglycemia can prevent serious complications. Research has shown that confidence in self-management correlates with better health outcomes in young patients. 24
The vast majority (95%) of children felt the game duration was suitable for their attention span, indicating that the game was appropriately designed to maintain engagement without becoming overwhelming. This balance is essential in pediatric education, where attention spans can vary significantly across age groups. Furthermore, when developing the serious game, we chose to include only 3 chapters of the TPE program. This was to ensure a focused learning experience that targeted key concepts and to avoid cognitive overload, which can compromise retention and understanding in young learners. By limiting the content, we aimed to facilitate mastering essential skills for managing type 1 diabetes. Other chapters of the TPE program in T1D could be developed in the future and be included in other levels of the serious game.
The strong positive reception of the serious game by all participants highlights its potential as a highly effective and engaging educational tool. Beyond improving knowledge, the game appeared to enhance children’s confidence and ability to independently manage their condition, a critical factor in improving long-term health outcomes. This feedback aligns with existing literature on serious games in pediatric healthcare, where similar interventions have shown positive effects on learning and self-management. 24
Our study has some strengths and limitations. One major advantage is the reproducibility of the game, which can be replayed at any time, independent of the physician’s presence, and allows for an unlimited number of repetitions. This flexibility makes it a highly accessible and practical tool for reinforcing knowledge. However, a significant limitation is the game’s suitability for different age groups. Its design may not effectively engage children across a broad age range, posing a barrier to its universal applicability. We also acknowledge that a direct comparison with traditional TPE would provide stronger evidence of the game’s added value. Future studies should consider randomized controlled designs comparing it to conventional methods to strengthen the evidence base, with follow-up assessments to measure knowledge retention over time.
Conclusions
Our study highlights the pressing need for effective TPE for children with T1D and demonstrates the potential of serious games as impactful tools. The game significantly improved knowledge related to T1D, insulin therapy, and hypoglycemia management, with high levels of engagement and satisfaction among participants. To enhance this approach, future efforts should focus on creating age-appropriate serious games that address a broader range of patients. Regular updates must also be implemented to maintain the game’s relevance, incorporate additional aspects of diabetes management, and ensure inclusivity. Additionally, expanding accessibility, integrating games into treatment plans, and evaluating their long-term impact on self-management and clinical outcomes are crucial next steps. Serious games offer significant promise in improving the therapeutic care and quality of life for children with T1D and other chronic conditions.
Footnotes
Acknowledgements
Generative AI was used to review and correct spelling and grammar mistakes. The accuracy, validity, and appropriateness of the content were afterward verified by the authors.
Ethical Considerations
We obtained consent from all participants and their parents. The study ensured data confidentiality and participant anonymity throughout the research process. Approval for this study was granted by the local medical ethics committee (approval number: 08/2024).
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.