Designing for Engagement in Primary Health Education Through Digital Game-Based Learning: Cross-National Behavioral Evidence from the iLearn4Health Platform

This study evaluates design effectiveness in Digital Game-Based Learning (DGBL) for primary health education through systematic teacher assessment of the iLearn4Health platform. Rather than measuring educational transformation, the research investigates how DGBL design principles influence user engagement patterns and platform usability as evaluated by education professionals. The study contributes to design optimization frameworks for primary school digital health education applications by examining the distinction between DGBL and superficial gamification approaches in creating engaging educational interfaces. The iLearn4Health platform underwent comprehensive design evaluation by 337 teachers across 24 schools in five European countries (Greece, Cyprus, Romania, Poland, and Spain). Teachers served as design evaluators rather than end-users, assessing platform engagement mechanisms through systematic interaction analysis. The study employed multiple statistical approaches-descriptive analysis, correlation analysis, ANOVA, regression modeling, and cluster analysis-to identify design engagement patterns and their predictors, tracking completion rates, progress trajectories, and interaction time as indicators of design effectiveness. Design evaluation revealed a distinctive bimodal engagement distribution, with 52.8% of teacher-evaluators showing limited platform exploration (progress ratio 0.0-0.2) and 35.3% demonstrating comprehensive design assessment (progress ratio 0.8-1.0). A strong positive correlation (r = 0.95, <i>p</i> < 0.001) between time spent and steps completed indicated that design elements successfully sustained evaluator engagement. Multiple regression analysis identified initial design experience as the strongest predictor of continued engagement (β = 0.479, <i>p</i> < 0.001), followed by country-specific implementation factors (Romania vs. Cyprus, β = 0.183, <i>p</i> = 0.001) and evaluator age (β = 0.108, <i>p</i> = 0.049). Cluster analysis revealed three distinct evaluator profiles: comprehensive design assessors (35.3%), early design explorers (52.8%), and selective feature evaluators (11.9%). Cross-national analysis showed significant variations in design engagement, with Romania demonstrating 53% higher average progress ratios than Cyprus (0.460 vs. 0.301, <i>p</i> < 0.01). Teacher evaluation validates effective design implementation in the iLearn4Health platform for creating engaging primary health education experiences. The platform successfully demonstrates DGBL design principles that integrate health concepts into age-appropriate interactive environments, distinct from gamification approaches that merely overlay game elements onto existing content. Identifying initial engagement as the strongest predictor of sustained interaction highlights the critical importance of onboarding design in determining user experience outcomes. While this study establishes design engagement effectiveness through educator assessment, actual educational transformation and student learning outcomes require future implementation studies with primary school populations. The design validation approach provides essential groundwork for subsequent educational effectiveness research while contributing evidence-based design principles for engagement optimization in digital health education contexts.