The effectiveness of games in learning antihypertensive drugs on medical students: A cross-sectional study

Abstract Developing innovation in medical education is a vital part of improving the learning outcomes. One such learning innovation in medical education is to learn using game as a tool. The Husenynov antihypertensive drug game (HAG) was developed as an innovation to assist the learning process for studying pharmacology. The study was conducted to compare the effectiveness of HAG and traditional educational method (lecture) on knowledge and perception of medical students. A quantitative cross-sectional study was conducted with 221 second year students from the Universitas Padjadjaran Faculty of Medicine. There were two subject groups: the game group and the lecture group. Duration (two hours) and learning content were similar for both activities. A pre-post test was performed to compare the percentage of students with increased knowledge between groups, while a questionnaire of perception was distributed at the end of the study. The number of students who experienced increased knowledge (post-test score better than pre-test score) was higher in the game group than the lecture group (68% vs 54%, respectively). Students who played the game had a knowledge score 1.8 times higher compared to those who had the lecture (crosstab, OR 1.8 (95% CI 1.04–3.09)). Furthermore, a significantly higher proportion of students had positive perceptions regarding the learning method in the game group (83% vs 45%, p < 0.01). The Husenynov antihypertensive drug game (HAG) promotes better-increased knowledge and positive perceptions than the traditional educational method (lecture).

Abstract: Developing innovation in medical education is a vital part of improving the learning outcomes. One such learning innovation in medical education is to learn using game as a tool. The Husenynov antihypertensive drug game (HAG) was developed as an innovation to assist the learning process for studying pharmacology. The study was conducted to compare the effectiveness of HAG and traditional educational method (lecture) on knowledge and perception of medical students. A quantitative crosssectional study was conducted with 221 second year students from the Universitas Padjadjaran Faculty of Medicine. There were two subject groups: the game group and the lecture group. Duration (two hours) and learning content were similar for both activities. A pre-post test was performed to compare the percentage of students with increased knowledge between groups, while a questionnaire of perception was distributed at the end of the study. The number of students who experienced increased knowledge (posttest score better than pre-test score) was higher in the game group than the lecture ABOUT THE AUTHOR Enny Rohmawaty earned a PhD from Universitas Padjadjaran's Doctoral Program in Biomedical Sciences Faculty of Medicine. As an associate professor, she teaches and conducts research in the fields of medical sciences, pharmacology, and medical education. Ike Rostikawati Husen earned a master of science degree from Universitas Padjadjaran's Magister Program of Biomedical Sciences Faculty of Medicine. She is an assistant professor who specializes in pharmacology and works as a lecturer and researcher. She possesses various intellectual property rights in the area of innovation education. Novi Vicahyani Utami earned a master of science degree from Universitas Padjadjaran's Magister Program of Biomedical Sciences Faculty of Medicine. She is a pharmacology lecturer and researcher. Afiat Berbudi is a lecturer at the Parasitology Division of Universitas Padjadjaran's Faculty of Medicine. He has been involved in several medical education studies involving the evaluation of instructional approaches. He earned a doctorate from the University of Bonn, Germany.

PUBLIC INTEREST STATEMENT
Understanding pharmacology is essential for medical students since it serves as the foundation for medical treatment and disease intervention. As a high-prevalence disease with several comorbidities and a high death rate, a physician should be well in treating hypertension. To aid in a thorough understanding of pharmacology, particularly antihypertensive medicines, a learning technique that promotes critical thinking, incorporates contextually, encourages metacognitive thinking, but is also pleasant and makes students feel at ease and passionate about learning is required. The Husenynov antihypertensive game (HAG) (stands for Ike Husen, Enny, Novi) is developed to integrate basic pharmacology with clinical settings in multiple levels of games that help students to learn seriously while also having fun. When compared to standard learning approaches, this analysis revealed that utilizing HAG to learn antihypertensive medicines enhances learning outcomes and student perceptions.

Introduction
Hypertension is currently a global health issue; in 2013, for example, more than 360,000 American deaths included high blood pressure as a primary or contributing cause. Numerous dangerous health conditions are caused by high blood pressure, such as heart attack, stroke, chronic heart failure, and kidney disease (Mozaffarian et al., 2015). Approximately seven in ten U.S. adults with high blood pressure use medications to treat the condition. In 2009, Americans visited their health care providers more than 55 million times to treat high blood pressure (Merai et al., 2016). A recommended strategy to reduce and control blood pressure is engaging the patient, the primary care provider, and other health care providers as team-based care (Thota, 2014).
As the main health care providers, doctors play an extremely important role in health services. This is largely determined by the process of good medical education, to which an effective medical education process makes a significant contribution. Traditional learning methods have drawbacks such as a lack of active engagement, dearth of individual or group activities, potentially ignore the gradual development of students' knowledge (Khalaf & Zin, 2018). In this method, students' memory is quite poor because memories are better and more precise when they are experienced and rich in context cues (Cherney, 2008).
Innovation development in medical education is important to enhance learning outcomes such as increased understanding and retention of memory, thus having a positive impact on the production of highly competent health professionals. Innovations must be able to encourage the metacognitive skills in learning process. Many studies shown that students who have metacognitive skills have been demonstrated to perform better study achievement (Hong et al., 2015;Parker et al., 2016). Innovations must be able to encourage students to learn more actively and independently, but still in an enjoyable way. Students' retention of concepts improves with active learning, especially when they design their own learning (Cherney, 2008) as innovation in education, games and simulations are commonly used, and the results differ in a range of aspects, such as student achievement, engagement, and learning motivation (Vlachopoulos & Makri, 2017).
Serious games are one potential learning method that might encourage motivation, present important concepts contextually, stimulate the retrieval of previous knowledge, and provide simulations. These components are particularly valuable in a learning process resulting in a deep understanding and long-term memory. According to game-based learning theory, educational games can attract interest, provide important learning aspect information, and stimulate the retrieval of previous knowledge. Consequently, metacognition thinking processes are encouraged and the formation of important knowledge perceptions is stimulated. These games can be developed as a guide to different stages within the learning process yet simultaneously offer an opportunity to monitor the understanding of the concepts, deliver important feedback, and provide scientific explanations for the user. Here, in addition to increased knowledge retention, interactive learning processes are especially important (Greitzer et al., 2007;Virvou et al., 2005).
Games are appropriate media for higher or medical education since they empower enjoyable active learning, have contextual and interactive features, attract repetitive playing, and provide continuous feedback and self-evaluation. These valuable characteristics run in accordance with the four main pillars of learning: attention, active learning, feedback and consolidation (Diehl et al., 2015;Drummond et al., 2017;Teschner, 2016).
The HAG was developed as an innovation to assist pharmacological learning processes. This game is expected to help medical students in understanding the physiology of blood pressure regulation and pharmacological aspects of various antihypertensive drugs. It has just been developed and therefore requires evaluation. This study compares the effectiveness of the HAG and a traditional educational method (lecture) on the knowledge and perception of medical students.

Materials and methods
The HAG is a serious game developed by a multidisciplinary team including physiologists, pharmacologists, experts in medical education, and serious game designers. This study was cross-sectional in nature with two groups of 221 second-year medical students at Universitas Padjadjaran, divided based on faculty schedule (121 in the game group, 100 in the lecture group). Those who had played HAG previously, were unwilling to participate in this research, or did not sign informed consent sheets or submit the questionnaires were excluded. Research variables in this study were game effectiveness in increasing knowledge and students' perceptions of the learning method. In the lecture group subjects attended an interactive lecture, whereas in the game group subjects played HAG on a computer at the same time. Duration and contents were similar for both activities.
Knowledge on antihypertensive drugs was measured by a questionnaire with true or false items as a pre and post-test, which were applied at two-time points: baseline and immediately after the interventions. Twenty-five items out of a hundred were selected randomly; these items were developed based on a blueprint consisting of blood pressure regulation, basic pharmacology, including the mechanism of actions, effects, adverse effects, indications and contraindications, and applied pharmacology in clinical case problems.
Data were analyzed using the General Linear Model (GLM). Perception about the HAG was assessed using 16 Likert-scale questions, which were asked immediately after the corresponding interventions. The internal consistency (reliability) of the questionnaires was measured by estimation of the Cronbach's alpha coefficient using SPSS 20.0 (SPSS Inc., New York).

Students' score comparison between lecture and game group
The results indicated an increase in pre-post test score in both groups. In terms of the score increment between pre and post-test, the game group performed better in comparison to the lecture group (Table 1). In the following boxplot chart (Figure 1), there is no obvious difference between the pre and post-test score for the lecture group when compared to the game group. The average scores of students within the lecture group are generally similar (a median score of 13 before the lecture and 13.5 after the lecture).

The increase of students' score were higher in the game group compared to lecture group
Students in the game group gained significantly higher improvement in knowledge compared to the lecture group, and this is clearly demonstrated in the linear graph below (Figure 2). The gaming method effectively increases students' knowledge about hypertension drugs by an average of 14%.
Data analysis using GLM SPSS software ver.20 indicates that the score changes after treatment were significant (p value 0.018) ( Table 2).
The number of students who experienced better performance (post-test score better than pretest score) was higher in the game group than the lecture group (68% vs 54%, respectively). In terms of a decrease in scores (post-test worse than pre-test), the number of students in the game group was fewer compared with the lecture group (26% vs 34%, respectively), while the number of students whose post-test score remained the same as the pre-test score in the game group was lesser than the lecture group (6% vs 12%, respectively). Students who played the game had knowledge scores that were 1.8 times higher than their counterparts (crosstab, OR 1.8 (95% CI 1.04-3.09)). Playing the game has proven to be significantly more effective than attending a lecture. The slight change can be attributed to the short duration of learning activities; thus, it is necessary to keep students focused and active in their learning process.

Assessment of Student Perceptions regarding the Delivery Method
The students' perceptions of the learning method in the game group were statistically more positive than those in the lecture group at 83% (78/94) vs 45% (52/115), respectively (p < 0.01) ( Table 3).
Sixty one percent students who had positive perceptions (43/70) experienced an improvement in their post-test score, although the knowledge scores did not show a significant relationship with perception (p> 0.05) ( Table 4).

Discussion
The HAG is provided in five levels with different settings for each level. The first level, for example, consists of five questions about the physiology of blood pressure regulation. To provide a challenging reward, the player is awarded several achievements after they finish the task and are promoted to the next level. Each level has a different storyboard and achievement to avoid boring condition. It is important to avoid boredom in order to maintain the attention of the learner. Attention is one of the four pillars of learning, with the others being active learning, feedback, and consolidation.   Based on cognitive science, an effective learning process should be supported by four strong pillars: attention, active learning, feedback, and thinking association. The meta-analysis results show that active learning with gaming is more effective than lectures. The thought process that facilitates the process of thinking association will strengthen material understanding. The first exposure requires strong thought concentration, but the repetition of exposure can ultimately accelerate the thinking process (Drummond et al., 2017).
In the game group, the students' knowledge was improved significantly compared to those who attended the lecture session. This is in line with existing research as, although several studies evaluating the effectiveness of learning through serious games have given various results, none of them have shown that a lecture produces better outcomes than playing games (Bellotti et al., 2013;Diehl et al., 2015;Wouters et al., 2009). In a preliminary study about the effectiveness of InsuOnline's (developed by a multidisciplinary team was assembled, consisting of clinicalendocrinologists, experts in medical education and software developers/game designers), a serious game, as a learning method on insulin therapy showed that a well-designed game can be at least as effective as traditional instruction in terms of improving knowledge, skills and beliefs (Diehl et al., 2013). Games also present other advantages, such as easy dissemination, customizable content, and flexibility of use, that make them excellent tools for large-scale medical education (Diehl et al., 2015). Furthermore, other studies have demonstrated that serious games are effective in improving learning motivation and learning achievement (Bellotti et al., 2013). For instance, a review of 28 studies with empirical data on learning achievement showed that serious games effectively improve cognitive learning outcomes and are also effective in terms of motor skills aspects and attitudes (Wouters et al., 2009).
The effectiveness of serious games is made possible through certain characteristics which are aligned with andragogy (Wouters et al., 2009). These positive characteristics include active learning experiences, which encourage players to learn directly and contextually. The players can directly link the material in the game with real-life; the content sometimes encourages emotional involvement, with immediate feedback available on an individual basis. Another characteristic of a serious game is that the activity of playing a game is strong enough to "bind" the player, who is then "forced" to devote his or her attention to the game in order to achieve the game challenge/ target (Barab et al., 2011;Wouters et al., 2009). In the game used for this study, the player starts with the opportunity to extend and consolidate the basic concept as prior knowledge learned in high school. These learning aids are available in the form of diagrams. The users are then given a challenging task to evaluate their understanding with the "wrap" of rewards as challenges.
A learning process will work properly if students enjoy the lessons, the environment, the material delivery process, and the perception of ongoing learning. Perception is the process of receiving, selecting, organizing, interpreting, testing and reacting to sensory or data stimuli and is closely related to the five senses because it occurs after a person sees, hears or feels something and organizes and interprets it. This process also occurs in students' perceptions of learning in the classroom (Fitriana & Budijanto, 2016). Perception arises because of the influence of the social environment around the individual. In line with this, Bloom states that the learning outcomes are influenced by the cognitive characteristics and affective behaviour of students combined with the quality of teaching and learning activities in the classroom. According to the Classroom Environment Scale (CES) (Moos and Trickett, 1974), students' perceptions of the learning environment can have a dramatic impact on the learning activities themselves (Fitriana & Budijanto, 2016;Raviv et al., 1990).
The game group showed significantly increased knowledge of antihypertensive drugs than the lecture group, with several logical explanations. Indeed, the learning achievement of the HAG was to maximize the students' ability in terms of applying and synthesizing basic concepts of antihypertensive drugs and their proper clinical use. Proper use of antihypertensive drugs should be based on basic concepts including the physiology of blood pressure regulation. Most students felt that playing the HAG has helped them to understand and remember the mechanisms of action of antihypertensive drugs. During this process, a high level of high memory retention is expected to be formed through affective and working memory. This memory retention is facilitated through repetitive questions, which are related to the various cases presented at higher game levels. By ensuring that they understand and remember the physiology of blood pressure regulation and the mechanism of actions of each drug, the HAG might help the students to understand both the effects and side effects of antihypertensive drugs on the human body. According to contextual and applicative questions related to the effects and side effects of drugs presented interactively, the benefits of playing the HAG in terms of understanding the effects of antihypertensive drugs were highlighted by 47.9% students (data not shown).
Interactive presentation of cases/problems has also been provided to establish an indication and contra-indication of drugs as a synthesis of the effects and side effects of the drugs on the body. With regards to the understanding of side effects, indications and contraindications of antihypertensive drugs, the HAG was believed to be useful by 40.4% of students (data not shown). Furthermore, students were encouraged to synthesize and evaluate concepts of antihypertensive drugs in an interactive case that was perceived by 48.9% of students. Sixty-three percent of students agreed that this game had fostered an understanding regarding the use of antihypertensive drugs, affirming that playing the HAG shows important things in the use of antihypertensive drugs. A serious application must be able to attract players and prevent boredom, thus encouraging students to learn again and use the application more than once. Students may feel motivated to learn about antihypertensive drugs and form a good perception of the game. Playing this game may form good perceptions because it facilitates the knowledge application in clinical settings, leading to a high memory retention rate. The learning process whereby the HAG is employed for contextual and applicative problems encourages the formation of affective and working memory. In this study, 66% of students agreed that this application encouraged further use and 69.1% agreed that the application is not boring (data not shown). In addition, as many as 72.3% of students felt that the HAG encouraged their interest to re-study.

Conclusion
Based on the evidence presented in this study, learning about antihypertensive drugs via the HAG as a serious game could be more effective in comparison to the traditional educational method (lecture). This is the first report on the effectiveness of a digital game for medical education involving antihypertensive drugs. We hope our game can contribute to improved quality of care for hypertensive patients on a global scale.