The effectiveness of game-based interventions has garnered increasing attention across various domains, including education, healthcare, and skill development. Research consistently highlights the potential of games to enhance engagement and motivation, which are crucial factors in learning and behavioural change. Studies have demonstrated that game-based learning can significantly improve knowledge acquisition and cognitive skills. For instance, reviews have shown that game-based learning applications across multiple curricular subjects effectively facilitate student learning [1]. Furthermore, the immersive and interactive nature of games can foster problem-solving, critical thinking, and collaboration skills, contributing to deeper learning experiences [1]. Reviews analysing game-based learning in early childhood education, have shown that game-based learning has a moderate to large effect on cognitive, social, emotional, motivational, and engagement outcomes [2]. This supports the need to integrate game-based learning into curricula. Given its moderate to large effect on cognitive, social, emotional, motivational, and engagement outcomes, game-based learning is a powerful tool for foundational learning and development. Games can simultaneously foster critical thinking, problem-solving, social interaction, emotional regulation, intrinsic motivation to learn, and sustained engagement, all of which are crucial for young children. This research reinforces the long-held understanding that children learn best through playing. Game-based learning formalizes and structures this natural inclination, leveraging it for targeted developmental gains. While the effects of games are clear, continuous exploration of specific game types, contexts, and implementation strategies can further optimize the benefits of game-based learning for diverse early childhood settings. In the medical field, game-based interventions have proven effective in enhancing medical students’ knowledge and engagement compared to traditional teaching methods highlighting the potential for games to provide safe and engaging learning environments.

The game of Snakes and Ladders, with its simple mechanics and compelling narrative of fortune and misfortune, holds a significant place in the history and study of games. Recent research highlights the educational benefits of Snakes and Ladders, particularly for young children. The game provides a playful context for developing foundational numeracy skills, such as counting, number recognition, and understanding numerical order [3]. The linear progression along the numbered squares visually reinforces the concept of sequence and magnitude [4]. Furthermore, the unpredictable nature of the snakes and ladders introduces elements of chance and probability in a simple and engaging manner [5]. The game provides an intuitive and concrete entry point for young children to grasp abstract mathematical concepts like chance and probability. Without needing formal instruction, players experience randomness through dice rolls and observe how different outcomes lead to varied progressions on the board. This experiential learning can lay a foundational understanding for more complex statistical reasoning later in life. In a world where outcomes are not always certain, the game helps children develop resilience by teaching them that sometimes, despite their best efforts, an unlucky landing on a “snake” can set them back; on the other hand, a “ladder” can offer an unexpected boost. This mirrors real-life situations where success and setbacks are part of the journey, fostering an understanding that not everything is within one’s control. The inherent fun and unpredictable nature of the game make learning about chance highly engaging. Children are motivated to play, and through repeated play, they naturally encounter and internalize probabilistic ideas. This informal learning environment can be more effective than rote memorization, especially for young learners. The game can spark conversations whereby children might start to intuitively predict outcomes or discuss why certain squares are “better” or “worse.” This fosters critical thinking and encourages them to observe patterns, even if they don’t yet have the formal language to describe probabilities. Beyond mathematics, the game can also foster social skills such as turn-taking, patience, and coping with both success (climbing a ladder) and setbacks (sliding down a snake) [4].

Snakes and Ladders, originating in ancient India as Mokshapatam, has a rich cultural history deeply intertwined with philosophical and moral teachings [4]. The ladders traditionally represented virtues, while the snakes symbolized vices, illustrating the karmic consequences of good and bad deeds on the path to liberation [3]. This historical context underscores the game’s initial purpose as a tool for moral instruction and the transmission of cultural values across generations [5]. While the overt moralistic elements may be less emphasized in contemporary versions, the underlying narrative of upward progress and unexpected setbacks continues to resonate across different cultures [4].

The enduring appeal of Snakes and Ladders lies in its simplicity, accessibility, and the inherent drama of chance encounters [5]. The game requires no complex strategies or prior knowledge, making it enjoyable for players of all ages and skill levels [3]. Its straightforward mechanics have also lent themselves to various adaptations and digital versions, further extending its reach and appeal in the modern era [4]. These adaptations often incorporate new themes, visual designs, and sometimes modified rules, while retaining the core elements of climbing ladders and avoiding snakes [3].

The game also offers insights into basic psychological and social dynamics. The experience of unexpectedly advancing due to a ladder evokes feelings of joy and excitement, while the sudden descent down a snake can lead to frustration or disappointment [4]. Observing these emotional responses in oneself and others can provide a rudimentary understanding of how chance events can influence feelings and outcomes [5]. Playing the game in a social setting also encourages interaction, communication, and the shared experience of both good and bad luck [3].

The study was conducted in Bunyala Sub-County, located in the lower region of Busia County, Western Kenya. The sub-county consists of four administrative wards: Bunyala West, Bunyala Central, Bunyala South, and Bunyala North. The region is geographical defined by its proximity to large water bodies and a high-water table, which significantly influences the daily behaviors of school-aged children.

The study targeted primary school pupils, who represent the most active demographic in terms of environmental interaction and are the primary focus of the National School-Based Deworming Program. The study excluded pupils in grade 1 to 3 due to developmental and cognitive considerations, as their limited literacy, shorter attention spans, and less developed self-reporting abilities could compromise data accuracy and engagement with the game-based intervention. Similarly, pupils from private schools, boarding schools, and special needs primary schools were excluded to ensure the homogeneity of the study population and manage contextual variations; these settings often present different socioeconomic backgrounds, distinct daily routines, varied WASH infrastructure that could confound the study’s results and generalizability to the target population of public day schools. Furthermore, newly enrolled pupils in the selected schools were excluded to minimize the influence of varying prior school experiences.

The researcher collected demographic data to characterize the study participants and to ensure comparability between the Treatment and Control groups at baseline. This similarity is crucial in a quasi-experimental design. It helps confirm that any differences observed after the intervention are attributable to the intervention rather than to pre-existing group differences. The analyzed characteristics included school, age, gender, religious affiliation, and academic grade. The study achieved a strong level of similarity between the two groups. The gender distribution was almost equal. Females made up 49.6% of the Treatment group and 52.0% of the Control group. A Chi-square test showed no significant difference in gender distribution (χ² = 0.144, p = 0.704). This suggested that the results would not be affected by gender-based learning differences. Religious affiliation was mostly Christian in both groups, with over 95% reflecting the local demographic of Bunyala Sub-county. Additionally, pupils were evenly distributed across Grades 4, 5, and 6 (p = 0.867), ensuring their cognitive developmental levels were comparable.

The participants’ ages, ranged mainly from 10 to 14 years. The inclusion criteria targeted Grade 4 to 6 pupils. However, two outliers (aged 15 and 17) were found in the raw data. These represent “over-age” pupils, a common phenomenon in rural public schools due to late enrolment. Despite these outliers, independent samples t-test test showed no statistically significant difference in the average age between the Treatment (M = 12.1) and Control (M = 11.9) groups (p = 0.25). Overall, the absence of statistically significant differences across all demographic variables (p > 0.05) indicated that the two groups were equivalent at baseline. This provided a solid basis for evaluating the effectiveness of the game-based intervention (Table 1).

Table 1. Demographic characteristics of study participants.

The effectiveness of the Game-based intervention was evaluated by comparing pre-intervention scores and post-intervention scores across domains of knowledge on the causes, transmission mode and prevention practices using a paired samples t-test. This involved data collected from a sample of 125 pupils (df = 124) in the selected primary schools in the treatment group. Regarding knowledge of on causes of the diseases, pupils demonstrated a significant increase in their understanding of the causes of SCH, with an increase in mean scores by 2.088 points (t (124) = −23.727, p < 0.001). Similarly, knowledge regarding the causes of STH improved significantly by a mean of 1.192 (t (124) = −14.456, p < 0.001). The overall knowledge on the causes of the common NTDs showed a substantial and statistically significant gain of 3.280 points (t (124) = −26.078, p < 0.001). These findings suggest that the Game-based intervention was highly successful in clarifying the cause of the diseases. Likewise, a similar trend was observed in the participants’ understanding of transmission routes for the common NTDs. A great improvement was observed in the knowledge of SCH mode of transmission, which increased by a mean of 2.472 (t (124) = −28.194, p < 0.001); while knowledge on STH mode of transmission was low (Mean = 0.456), but it remained statistically significant (t (124) = −8.657, p < 0.001). The overall knowledge of transmission modes across the common NTDs in the region showed a robust mean increase of 2.928 points, indicating that pupils became significantly more aware of how these parasites are contracted and spread within the community.

Finally, the study assessed whether these gains in knowledge on the cause and modes of transmission of the common NTDs would translate into improved health behaviors by assessing the pupils’ awareness of the prevention practices. The results revealed significant increases in awareness of prevention practices for both SCH (Mean increase = 0.456, p< 0.001) and STH (Mean increase = 0.736, p < 0.001). The overall awareness of prevention practices score saw a significant cumulative increase of 3.120 points (t (124) = −21.091, p< 0.001) (Table 2).

Table 2. Paired T-test results on game-based WASH intervention.

Overall, the results indicated a statistically significant improvement in all measured variables, as evidenced by p-values of less than 0.001 across all pairs. The 95% confidence intervals for all measures remained entirely below zero, further confirming that the post-intervention scores were consistently higher than pre-intervention levels. Jointly, these results provide strong empirical evidence that the Game-based WASH intervention was effective not only in enhancing theoretical knowledge but also in promoting the awareness of safer health practices among the pupils.

Additionally, to check for the effectiveness of game-based WASH intervention versus the traditional WASH sensitization, an independent sample t-test was carried out. The results showed that the Treatment group demonstrated significant greater gains as compared to the Control group in all categories. The most substantial difference was seen in the overall knowledge on the cause of the NTDs, where the Treatment group improved by an average of 3.280 compared to 0.952 observed in the Control group (t = −10.81, p < 0.001). Even though the Control group recorded zero improvement in the knowledge on transmission routes of STH, the Treatment group showed a statistically significant, although smaller gain of 0.456 (t = −2.93, p = 0.004). Furthermore, the independent samples t-test results confirmed that the Game-based WASH intervention achieved a statistically significant greater improvement in the pupils’ knowledge on prevention and control practices compared to the control group. The exceedingly low p-values (p < 0.001) indicate that the differences in improvement were not due to chance. Table 3

Table 3. Mean improvement between the treatment and control groups.

The results on the demographic characteristics indicated that the treatment and control groups were balanced well across key demographic indicators, which is a critical requirement for quasi-experimental research to minimize selection bias [8]. The gender distribution was nearly equal, with females representing 49.6% of the treatment group and 52.0% of the control group. This parity is essential in educational research to ensure that intervention effects are not confounded by gender-based learning differences. Similarly, both groups were mainly Christian (>95%). The study mirrors research that emphasized that demographic homogeneity in school-based interventions helps in attributing changes in the dependent variable to the intervention rather than socio-cultural background [9].

The majority of participants were concentrated in the 11 - 12 age bracket and across Grades 4 to 6; which is a developmental stage that is crucial for cognitive interventions. This study is similar to a quasi-experimental study regarding primary school interventions, which revealed that a balanced distribution across grades ensures that the results are generalizable [10]. The slight variance in age distribution between the control and treatment groups (specifically the higher concentration of 11 - 12 age range in the control group (51.2%) vs the treatment group (46.4%)) is a common occurrence in quasi-experimental studies where random assignment is not possible [11].

This demographic spread aligns with standard educational research protocols. For instance, a study argues that, achieving a percentage difference of less than 5% between groups in major categories (e.g. Grade or Religion) in non-equivalent group designs, strengthens the argument for baseline equivalence [12]. The data provided meets this threshold, suggesting that any subsequent differences in post-intervention scores are likely to be attributed to the treatment rather than pre-existing group differences.

The results of this study demonstrate a substantial and statistically significant improvement in knowledge on the cause, mode of transmission and prevention practices on Schistosomiasis and Soil-Transmitted Helminths following the Game-based WASH intervention. The consistent p-values of less than 0.001 across all pairs indicated that the observed gains were as a direct result of the Game-based WASH intervention, but were not due to chance. The significant increase in knowledge on the causes and transmission modes of the common WASH-related NTD infections (SCH & STH) aligns with recent global findings. In a study carried out in Nigeria, it was reported that health education interventions increased good knowledge of schistosomiasis from 27.5% to 87.0% [12]. Similarly, a study conducted in 2025 revealed that structured educational approaches, such as curriculum integration, led to knowledge gains of over 40% in school-based settings [13]. These suggest that focused pedagogical tools are highly effective in correcting common misconceptions such as the belief that these diseases are caused by dirty drinking water rather than skin contact with cercariae-infested water or soil [14].

A critical achievement of this study was the successful translation of knowledge regarding causes and mode of transmission of the common NTDs into knowledge on prevention practices. This is similar to a recent study conducted in Nigeria that reported that targeted health education evidently increased favorable practices from 27.9% to 99.5% among primary school children, supporting the idea that children are highly receptive to behavioral change when information is presented clearly [12]. In comparison with the prevention practices towards SCH and STH, it was revealed that while knowledge on prevention practices increased for both (SCH and STH), the mean increase for knowledge on STH prevention practices was higher than that of SCH prevention practices. This disparity may be attributed to the nature of the preventive behaviors. STH prevention practices (such as handwashing and wearing shoes) often overlaps with general hygiene practices taught in schools, whereas SCH prevention (avoiding infested water) requires more specific, often localized behavioral shifts. This observation is consistent with research conducted in Ethiopia, which reported that pupils often have a higher baseline familiarity with dirty hands and dirty food (STH) compared to the more complex aquatic life cycle of Schistosomiasis [15]. The significant cumulative increase in knowledge on prevention practices scores underscores the school as a vital platform for NTD control. Similar outcomes were observed in a study conducted in China, where long-term school-based health education was associated with a 51% increase in disease-related knowledge and a subsequent 6% reduction in infection prevalence [16].

Furthermore, innovative pedagogical tools like edutainment and infographics have been shown to enhance this assimilation [17], suggesting that the methods used in this study were likely engaging and contextually appropriate for the pupils. As highlighted in a systematic review; while knowledge increases are common, the physical environment such as lack of latrines or clean water often acts as a barrier to practicing what has been learned [18]. Interestingly, this study showed a more pronounced improvement in knowledge on SCH mode of transmission compared to knowledge on STH mode of transmission. This disparity might be due to a lower baseline knowledge of urogenital schistosomiasis symptoms (like hematuria), which are often more distinct than the more generalized symptoms of STH [19]. Related findings were reported in Ethiopia, where community awareness of SCH was significantly lower at baseline than STH, leading to higher relative gains after a standard educational session [20].

The big contrast between the Treatment and Control suggests that the Game-based WASH intervention was highly effective. In health education research, a simple testing effect often explains minor gains in Control groups, but the massive t-values in the Treatment group point to the intervention as the key driver of change [21]. The significant disparity in knowledge gains between the two groups underscores the effectiveness of Game-based WASH intervention over the traditional WASH sensitization. While the Control group showed some minor improvements likely due to the “testing effect” or general community awareness during the study period, the greatness of change in the Treatment group was consistently high. These findings align with health education theories that suggest that targeted, culturally appropriate interventions are necessary to overcome specific knowledge barriers regarding NTDs like SCH and STH [21].

The specific success in improving knowledge on transmission of SCH is vital, as knowledge specifically on transmission is the strongest predictor of individual behavioral changes [22]. However, the relatively lower improvement in knowledge on the transmission of STH across both groups suggests that soil-based transmission pathways may be more difficult for pupils to conceptualize than water-based SCH transmission. Therefore, the study suggests that future interventions should consider more practical demonstrations, such as the use of visual aids showing the microscopic nature of helminth eggs in soil, to bridge this specific gap [22].

The independent samples t-test results confirmed that the Game-based WASH intervention demonstrated a higher statistically significant greater improvement in the pupils’ knowledge on prevention practices compared to the control group. While the control group showed no change in the knowledge on prevention practices for SCH and STH, the treatment group showed clear, positive gains. The difference was particularly observed for knowledge on STH prevention practices; which suggests that the Game-based WASH intervention successfully introduced new, specific health concepts that pupils were not exposed to. The most significant result was the comparison of overall knowledge on prevention practices; although the control group recorded some improvement, the treatment group recorded higher improvement. The result indicates that while general hygiene awareness might rise due to external factors, the Game-based WASH intervention provided a much more robust and comprehensive boost to the pupils’ understanding of how to control WASH-related NTDs. The high significance level for overall knowledge on prevention practices underscores the efficacy of the intervention. In areas like Bunyala Sub-county, where environmental risks for NTDs are high, a significant increase in the level of knowledge is required to translate knowledge on prevention practices into actual behavioral change [23].

Based on the analysis (Paired t-test and independent sample t-test) conducted, the study concluded that the Game-based WASH intervention was a highly effective intervention for increasing health literacy regarding WASH-related NTDs (Schistosomiasis and Soil-Transmitted Helminths).

To ensure the sustainability and broader impact of the Game-based WASH intervention, it is recommended that the Ministry of Education and the Ministry of Health to collaborate and integrate these NTDs modules into the national school curriculum. Establishment of School Health Clubs is encouraged to foster peer to peer advocacy, empowering pupils to act as health ambassadors who disseminate prevention strategies within their families and the broader community to ensure a lasting public health shift.