Study procedure

The KAP assessment instrument was adapted from a previous study conducted by Nurul Akmar Ghani et al. ²⁶ The questionnaire used in this study was an improved version of the KAP assessment instrument on dengue fever prevention which was validated by Mohammad Nasir et al. ²⁷

The questionnaire was divided into six sections; (1) demographic; (2) knowledge (16 items); (3) attitude (15 items), (4) practice (15 items) in preventing dengue, (5) interest to vaccinate against dengue (1 item); and (6) usability of the serious game adapted from the System Usability Scale (SUS) solely by the intervention group.^28,29

The knowledge section contained 16 questions to test participants’ understanding on the symptoms, transmission, treatment, and prevention of dengue infection. Each correct answer received one point, while incorrect or ‘not sure’ response would not gain any point.

The attitude section contained 15 questions to assess participants’ attitude towards the disease and dengue prevention measures. The acceptable good attitude responses were scored one point and else zero point.

The practice section contained 15 questions to assess daily practice of participants in dengue prevention. The score was based on good practice and none for poor practice or if the participant answered ‘not relevant’.

The response of participants’ interest to vaccinate against dengue was scored separately.

The first (baseline) questionnaire for all participants contained 56 questions divided into sections 1 to 5.

The second questionnaire for the serious game group contained 58 questions divided into sections 2 to 6, while the control group responded to only sections 2 to 5.

The questions in section 6 were modified from the validated SUS to evaluate the usability of this serious game. ²⁸ The SUS had 10 statements, and a 5-point Likert scale was used to indicate the participant's agreement with the statements. The mean score was calculated from the intervention group and analysed. A score above 68 was above average and scores below 68 was below average in terms of system usability. ³⁰

Participants in both groups completed all questionnaires with their unique participant codes via a secured online platform, Form.sg. ³¹ Form.sg was used to create online questionnaires that capture classified data for this study. All items within each questionnaire had to be completed before participants could submit their response. Once the submission had been completed, participants would be unable to change their response. The platform does not store participants’ response data in its servers and all responses are sent directly to the study team's dedicated email address.

Participants who completed both questionnaires were reimbursed with a grocery voucher valued at SGD 10.

Participants in the intervention group installed a mobile application, ‘Sam's Mozzie Adventure’. They were inducted with a walkthrough of the serious game by the CRC, who assisted them in installing the game and performing a trial run on their phones. The participants were instructed to complete the game within two weeks.

‘Sam's Mozzie Adventure’ is a locally designed serious game which was co-created between SingHealth Polyclinics and AI Innovation Labs (AI2 Labs) Private Limited, specifically for this study. The PI reviewed existing publicly available information on dengue prevention, including those on the NEA ‘Stop Dengue’ website, and provided the relevant content and pedagogical knowledge to the team of app developers from AI2 Labs. After creating the syllabus, the developers deployed their technological knowledge to integrate the dengue prevention information into the serious game. The serious game was revised after pilot trials and were conducted in several cycles amongst the study team members to enhance the user interface.

‘Sam's Mozzie Adventure’ version 0.5.30 was uploaded to both Apple App Store and Google Play Store and used solely for this study. As this mobile application was made intentionally inaccessible without a unique passcode, only participants who had been verified by the CRCs would be able to play this game on their mobile phones and participate in this study. De-identified data containing the progress of gameplay, such as the highest achievement (maximum game stars) attained by the participants, was recorded and uploaded to the developer's secured data server at the completion of the serious game.

The game story was centred around the character Sam. As Sam travelled through four different everyday scenarios at home, bus-stop, school and workplace, the goal was to help Sam identify potential dengue breeding sites and learn about dengue prevention measures so as to create a ‘Mozzie-free world’ (Figure 2).

Overview of Sam's Mozzie adventure.

Through each scenario, the game was designed to trigger the participant to click on potential dengue breeding sites such as vase, potted plants, and water containers without lids. When correctly selected, Sam would be activated to do an animated action to rectify the problem and a pop up containing the relevant dengue information would be presented to the participant (Figure 3).

Home scenario with potential dengue breeding sites and activated trigger.

Behavioural change technique using reward and threat was used in the design of ‘Sam's Mozzie Adventure’. A correct answer or action would earn the participant more ‘stars’, while an incorrect move would result in a lower score or require the participant to repeat the task.

Participants could also view dengue posters or participate in quiz while exploring the interactive environment to learn about dengue prevention measures (Figure 4).

Class quiz time and interactive game.

To improve the user interface, hints were prompted at the start of each scenario to lead the participant towards identifying the triggers within the game so as to achieve the maximum desired outcome with minimum effort on the participant's part (Figure 5).

Improving user interface with hints.

The control group accessed the NEA ‘Stop Dengue’ website ³² which contained dengue prevention information in the forms of online articles, posters and video. The participants were instructed to complete reading the online resources within two weeks.

A reminder via SMS (Short Message Service) was sent to both groups to complete the second questionnaire at the end of the study. The second questionnaire assigned to the intervention group consisted of an additional 10 questions to assess the usability of the serious game.