Visual novel game as a new breakthrough in dental health education media for stunted children in Indonesia

1. Introduction

Oral health is an integral part of overall body health, meaning that general health cannot be separated from oral health [1]. The condition of oral health, nutritional status, and general health status are interrelated factors. This is because a person’s oral health status can influence their nutritional intake, particularly in children. Poor dietary intake can significantly impact a child’s growth and development, potentially leading to stunting [2].

Stunting is a growth and developmental disorder in which children appear shorter than their peers due to insufficient nutritional intake [3]. According to data from the World Health Organization (WHO) in 2024, 23.2% of 12.2 million children globally experienced stunting [4]. With the highest population among all the provinces in Indonesia, West Java has a significant influence on the country. The stunting prevalence in West Java Province in 2021 dropped just by 1.7%, while the prevalence in Indonesia dropped by 3.3%. With Java in 2021 at 24.5%, West Java has the highest stunting prevalence. Additionally, 29.6% of Indonesian children are stunted, with Bojongsari, Depok, West Java, identified as one of the regions with the highest prevalence of stunting [5].

In the literature, stunting can occur in both direct and indirect aspects; one such association exists between oral health status and educational level [4, 6]. A child’s level of education can affect their oral health and nutrition because childhood, especially primary school, is a crucial time for growth and development, with the emergence of permanent teeth [7]. It is crucial to make early efforts to protect and promote oral health during this period, as it will significantly impact oral health later in life [8].

Based on the 2023 Indonesian Health Survey (SKI) results, the Decay, Missing, Filling teeth (DMF-T) index shows that, on average, Indonesians have five problematic teeth, placing dental issues among the top ten health concerns treated in primary healthcare services [9]. Among children aged 6–9, an average of one tooth is decayed. West Java ranks 10th among Indonesia’s 38 provinces in terms of dental health issues, including caries. A study in West Java also revealed an average DMF-T index of 4.1, indicating that children typically have four decayed teeth [10].

The target area of this research is Sekolah Dasar Negeri (SDN; Public Elementary School) Pontir 2 and Madrasah Ibtidaiyah (MI; Islamic Elementary School) Hidayatul Athfal Curug Bojongsari, Depok, West Java. Situation analysis and data obtained from Bojongsari Health Center, indicates that 14 students at SDN Pontir 2 and 7 at MI Hidayatul Athfal Curug have experienced stunting. Analysis reveals that the health issues of dental caries and stunting are related to behavioral, environmental, and familial support factors. Elementary school-aged children generally have not yet developed formal thinking skills, as their logic is still in the concrete operational stage [11]. Thus, health promotion media are needed to help students understand and improve their oral and nutritional health standards [12]. Oral health education techniques and methods can be implemented in schools through diverse teaching methods, such as lectures, printed media, or digital technology [13].

In today’s digital era, children tend to have significant engagement with digital technology, a trend predicted to increase substantially in the coming years. It is undeniable that children in this digital age are highly drawn to gadgets [14]. This attraction is influenced by their high adaptability to technology. According to previous research, educational games offer benefits in four aspects: context creation, interactivity, instant feedback, and emotional experience [15]. Educational games are a type of game that not only provides entertainment but also conveys knowledge to it’s users. Educational games can serve as a medium for learning through play, representing an educational breakthrough; one example is visual novel games [16, 17].

Visual novel games are innovative and interactive creations that serve as a new approach to providing Android-based education aimed at improving oral health. The purpose of this study is to evaluate the effectiveness of educational media, specifically visual novel games, as an innovative tool for teaching oral health to stunted children in elementary schools, particularly in the Bojongsari area of Indonesia. Accordingly, the null hypothesis of this study is that the use of visual novel games as educational media has no significant effect on improving oral health among stunted elementary school children. In contrast, the alternative hypothesis is that the use of visual novel games as educational media has a significant effect on improving oral health among stunted elementary school children.

2. Material and methods

This study used a quantitative approach with a quasi-experimental one-group pre-test and post-test design to evaluate the effectiveness of visual novel game educational media on improving oral health knowledge in stunted children in Indonesia, which was then reinforced with in-depth interviews as supporting qualitative data. Researchers recruited 101 children aged 6–8 years who were classified as stunted according to the WHO criteria (height-for-age z-score < −2 Standard Deviation (SD)), selected based on the high prevalence of stunting and caries.

The recruitment of study participants involved several essential steps. First, clear information was provided about the purpose of the research, which was to determine children’s knowledge of oral health care and their level of satisfaction after playing a visual novel game. Participants were required to complete a pre-test questionnaire, watch and simulate playing the visual novel game, participate in a quiz and question-and-answer session, and complete a post-test questionnaire and a satisfaction survey.

Additionally, the recruitment process included reading or explaining the information sheet and assent form to the child and their parent/guardian, providing an opportunity to ask questions, and ensuring that all questions were answered adequately. Consent was given freely and voluntarily, without any coercion, with full awareness that participation could be refused or withdrawn at any time without any cost or other consequences.

The study was guided by purposive sampling and cross-sectional research design, and was conducted in Madrasah Ibtidaiyah (MI; Islamic Elementary School) Hidayatul Athfal Curug, Bojongsari Subdistrict, Depok, West Java on 11 October 2024 and Sekolah Dasar Negeri (SDN; Public Elementary School) Pontir 02 Bojongsari Subdistrict, Depok, West Java on 14 October 2024. Furthermore, questionnaires were created. The questionnaires of SDN Pontir 02 Bojongsari and MI Hidayatul Athfal Bojongsari have been added in the Supplementary material.

The quantitative instrument was a knowledge questionnaire on dental health using a 4-point Likert scale that was developed by the researcher and had undergone validity and reliability tests before use. The same questionnaire was used in the two intervention schools, namely SDN Pontir 2 and MI Hidayatul Athfal, to allow comparison of knowledge levels between the locations. A pre-test was conducted before the intervention, and a post-test was conducted seven days after the intervention, where children played the educational Visual Novel Game for 20–30 minutes per day for one week.

Data were analyzed using a paired sample t-test to determine the difference in knowledge before and after the intervention and a chi-square test was used to assess the relationship between nutritional status and knowledge level. Knowledge was measured using a questionnaire, whose scores were categorized into two groups, namely good and poor, based on predetermined assessment scores. Satisfaction with educational media was measured using a 1–10 Likert scale, with a score of 1 indicating very low satisfaction and a score of 10 indicating very high satisfaction. In-depth interviews were conducted as a deepening of qualitative data with five teachers using a semi-structured approach to explore their perceptions, experiences, and understanding of the educational media provided.

The visual development in the game was designed attractively and adapted to the age characteristics of the children, as shown in Fig. 1. This educational game can be accessed online through the following link: https://bit.ly/myprofile-online. The study obtained ethical approval from the Dian Nuswantoro University Research Ethics Committee with Number 002795/UNIVERSITAS DIAN NUSWANTORO/2024, and informed consent was obtained from parents or guardians of participating children.

Fig. 1.Development design of visual novel game.

3. Results

4. Discussion

This study aimed to assess the effectiveness of a visual novel game as a medium for improving oral health knowledge among stunted children aged 6–8 years in two elementary schools in Bojongsari, Depok. The results revealed a notable increase in knowledge after the intervention, particularly in key areas such as the correct timing for brushing teeth and when to replace a toothbrush. This suggests that visual, narrative-based educational media can enhance knowledge retention among children in the concrete operational stage of development, who are still forming logical reasoning and benefit from interactive, concrete learning experiences.

The use of game-based media aligns with existing literature emphasizing the effectiveness of digital interventions in promoting oral health education. Prior studies have shown that interactive games increase engagement, stimulate memory, and support emotional and cognitive development in young learners. The findings of this study are consistent with the work of Moreira et al. [18] who reported that smartphone-based educational games significantly improved children’s knowledge about oral health. Similarly, classroom observations and teacher interviews in this study confirmed that students responded enthusiastically to the visual novel game, discussing the content with peers and showing greater interest in the material compared to traditional methods. These results underscore the importance of engaging, age-appropriate health promotion strategies for vulnerable groups such as stunted children.

In general, pre-test results indicate that respondents’ knowledge from both schools, Sekolah Dasar Negeri (SDN; Public Elementary School) Pontir 2 and Madrasah Ibtidaiyah (MI; Islamic Elementary School) Hidayatul Athfal Curug in Bojongsari, Depok, regarding oral health, remains relatively low especially for children with stunted growth. This is supported by the findings that two specific pre-test items namely, the appropriate time for brushing teeth and when to replace a toothbrush scored very low [11]. This may be influenced by the fact that most respondents were aged 6–8 years, an age where they are still in the concrete operational stage of cognitive development and have yet to fully develop logical thinking [12]. This outcome suggests a need for an effective health promotion medium to help children absorb new information.

Health promotion media targeting elementary school children is a crucial strategy to enhance and maintain oral health. Research indicates that educational interventions utilizing audiovisual game-based media are effective in stimulating learning among school-aged children [19]. Engaging game-based interventions, such as crossword puzzles, augmented reality, and other interactive media, have been suggested as beneficial learning tools for promoting dental health. Using games for dental health education can serve as an alternative to teaching fundamental health concepts, supporting cognitive development, and building children’s confidence [20].

The findings from this study align with previous research showing that educational media games increase participants’ knowledge and engagement [21]. For instance, Moreira et al. [18] found that using a gamified smartphone application positively affected the knowledge levels of young children involved in the study. This evidence suggests that game-based education can effectively attract children’s interest, delivering information in a more enjoyable and engaging format [22]. Other research supports that games used as educational media can enhance various cognitive aspects, such as memory, attention, multitasking, and learning effectiveness, and can benefit motor, social, motivational, and emotional development [23].

Moreover, studies highlight positive behavioral changes and satisfaction with using games in educational settings. The use of games as a teaching method creates an enjoyable atmosphere, which attracts children’s interest and increases their satisfaction with the educational approach [24]. Game-based health education, particularly when delivered on mobile devices, can act as a reminder to educate and entertain children, motivating them to maintain good oral health practices and leading to positive behavioral changes. Additionally, these behavioral changes are often attributed to an increase in knowledge following game-based education [25].

This study’s findings also align with research by Wardani et al. [26] demonstrating that dental and oral health education positively impacts knowledge levels among elementary students at SDN 02 Tiron Madiun. Other research by Gurav et al. [27] revealed significant differences in dental and oral health status among school children aged 5–16 following health education. A study by Saidah et al. [28] similarly found a meaningful difference in children’s oral health knowledge before and after educational interventions on proper brushing techniques among children in Rejowinangun.

Contrastingly, findings from this research differ from other literature that shows only marginal improvement in oral health after similar interventions. This discrepancy may be due to factors like a limited sample size and shorter observation periods. Providing health education that integrates engaging, game-based learning can boost children’s knowledge and promote positive behavior change. For instance, research by Aljafari et al. [29] demonstrated that game-based education enhanced children’s knowledge and contributed to healthier dietary habits, thereby reducing caries risk and improving their oral health status.

Qualitative interviews with teachers from both schools supported the effectiveness of using visual novel games for learning. The teachers observed that students were enthusiastic and eagerly engaging with the educational game. This finding echoes the study’s principle observation that game-based learning aligned well with the existing curriculum and served as an effective teaching medium. Beyond the health material itself, students enjoyed socializing and discussing the game content with their peers, creating an interactive and enjoyable learning experience [30].

Oral health education aims to provide knowledge that closely relates to daily actions in maintaining dental and oral health. The selection of health education materials is prioritized to foster behaviors like regular brushing and mindful consumption of certain foods, such as sweets. Selecting appropriate educational materials and prioritizing the target audience is essential, considering the impact and urgency of addressing dental health issues [31].

5. Conclusions

This study highlights the effectiveness of game-based education, specifically through a visual novel game, as an innovative approach to improving dental health knowledge among stunted children in Indonesia. Statistical analysis shows that there is a significant difference between pre-test and post-test knowledge scores in stunted children at Sekolah Dasar Negeri (SDN; Public Elementary School) Pontir 2 and Madrasah Ibtidaiyah (MI; Islamic Elementary School) Hidayatul Athfal Curug with a p-value < 0.05. It shows that interactive and engaging educational media can successfully raise awareness and understanding of important oral health practices. The findings underscore that visual novel games not only enhance cognitive comprehension but also foster positive behavioral changes and satisfaction among users.

In conclusion, the integration of digital game-based media into health education could serve as an important investment in preventive healthcare for young populations. By increasing access to health knowledge and encouraging positive habits, educational games offer a scalable, adaptable solution to promote long-term health improvements. Future studies could expand on these findings by examining the impact of sustained game-based interventions and exploring similar strategies for other health education areas.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding authors upon reasonable request.

Author contributions

EG and HDP—conceptualized the manuscript; carried out data analysis; drafted the manuscript. AFHM and GJB—carried out the methodology; edited the manuscript. CFT and BMB—supervised the project, provided critical revisions of intellectual content, and oversaw project administration. All authors subsequently revised the drafts. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical approval for this study is granted by the Research Ethics Committee of Universitas Dian Nuswantoro, Indonesia (Code of ethics: 002795/UNIVERSITAS DIAN NUSWANTORO/2024). The clearance is predicated on seven WHO 2011 Standard and Guidance part III, namely the Ethical Basis for Decision-making, with regard to the adherence to the 2016 CIOMS Guideline. Informed consent was obtained from all parents/caregivers of participants included in the study.

Acknowledgment

The authors would like to thank all participants who willingly took part in this research. The authors also acknowledge that the article processing charge is funded by the Faculty of Dentistry, Universitas Indonesia, awarded to CFT.

Funding

This research is supported by the PUTI Pascasarjana Program of Universitas Indonesia (Grant no. NKB-90/UN2.RST/HKP.05.00/2024) to CFT.

Conflict of interest

The authors declare no conflict of interest.

Supplementary material

Supplementary material associated with this article can be found, in the online version, at https://oss.jocpd.com/files/article/2006280892987654144/attachment/Supplementary%20material.docx.