Transforming Primary Health Education through Digital Game-Based Learning: Cross-National Behavioral Evidence from the iLearn4Health Platform

Background and Objectives: This study examines the distinction between gamification and Digital Game-Based Learning (DGBL) in health education, introducing the iLearn4Health platform designed to enhance health literacy among primary school students aged 6-12. The research investigates how DGBL's integration of educational content into gameplay mechanics affects user engagement and learning outcomes compared to superficial gami-fication approaches. Materials and Methods: Developed through international collaboration across five European countries, the iLearn4Health platform features six health-focused modules with age-appropriate content and multilingual support. The study analyzed platform usage data from 337 teachers across 24 schools, tracking engagement metrics, including complete steps, progress ratios, and time spent. Multiple statistical approach-es—descriptive analysis, correlation analysis, ANOVA, regression modeling, and cluster analysis—were employed to identify engagement patterns and their predictors. Results: Analysis revealed a distinctive bimodal distribution of user progress, with 52.8% showing low engagement (progress ratio 0.0-0.2) and 35.3% demonstrating high engagement (pro-gress ratio 0.8-1.0). A strong positive correlation (r=.95, p< .001) between time spent and steps completed indicated that sustained engagement predicted educational progression. Multiple regression analysis identified initial engagement as the strongest predictor of overall progress (β=0.479, p< .001), followed by country effects (Romania vs. Cyprus, β=0.183, p=.001) and age (β=0.108, p=.049). Cluster analysis revealed three distinct user profiles: high engagers (35.3%, n=119), early dropouts (52.8%, n=178), and selective en-gagers (11.9%, n=40). Cross-country analysis showed significant variations in platform engagement, with Romania demonstrating 53% higher average progress ratios than Cy-prus (0.460 vs. 0.301, p< .01). Conclusions: The iLearn4Health platform reflects the effec-tiveness of DGBL—distinct from gamification—for health education in primary schools. The platform supports knowledge acquisition and behavioral change by integrating health concepts directly into age-appropriate game environments rather than merely adding game elements to existing content. Identifying initial engagement as the strongest predictor of overall progress highlights the critical importance of early user experience in determining educational outcomes. The platform's comprehensive approach to DGBL in primary health education establishes a framework for creating effective digital interven-tions that recognize the unique developmental needs of primary school children while adapting to diverse educational contexts.