Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13029 Effectiveness of health promotion utilizing word puzzle games in enhancing older adults' knowledge and attitudes regarding hypertension management Mia Fatma Ekasari,1 Aan Nurhasanah,1 Eros Siti Suryati,1 Puspita Hanggit Lestari,1 Siti Badriah,1 Ahmad Jubaedi2 1Lecturer at Politeknik Kesehatan Kemenkes Jakarta III; 2Faculty of Public Health, Falatehan University, Serang, Indonesia Abstract Hypertension management plays a crucial role in influencing the health outcomes of the elderly with high blood pressure. Various health promotion strategies have been formulated for hypertension management. However, the result has not shown an optimal reduction in the number of hypertension sufferers. An effective health promotion, such as word puzzle games, needs to be developed. Word-based puzzle games can serve as engaging health promotion tools to improve hypertension-related health behaviors among older adults and enhance their cognitive abili- ties. This study aims to assess the effectiveness of a word puzzle game in enhancing the knowledge, attitudes, and practices of elderly individuals regarding hypertension management. A quasi- experimental approach with a pretest-posttest control group design was used. A total of 45 participants, both in intervention and control groups, were recruited through a purposive sampling technique. Data analysis involved descriptive techniques and inferential statistics using t-test models focusing on examining three variables: knowledge, attitudes, and behaviors. The result revealed statistically significant disparities in participants’ knowl- edge (p=0.000), attitudes (p=0.001), and behaviors (p=0.001) between the experimental and control groups after implementing the word puzzle game intervention. Using word puzzle games as health promotion tools successfully enhances older adults’ under- standing, perspectives, and actions regarding hypertension man- agement. These games might be employed to strengthen the abil- ity of older individuals to control their high blood pressure. Introduction An older adult is defined as someone who is 60 years or older1 and is at a higher risk of developing health problems as a result of degenerative processes. The elderly population is more vulnerable to developing complications of various illnesses,2 with high blood pressure being the most common degenerative condition among this group.3 A strong link exists between hypertensive heart dis- ease and Cardiovascular Disease (CVD), with the initial symptom being high blood pressure, leading to numerous health complica- tions if hypertension is left untreated.4 This condition may lead to several chronic diseases, including heart problems and stroke. The prevalence of hypertension in older adults rises in tandem with the global increase of the elderly population. Approximately 1.28 billion people worldwide are estimated to have hypertension.5 In Southeast Asian nations, around 43.2% of older adults suffer from hypertension,6 with 28.1% recorded in Indonesia in 2019. This figure increased to 30.29% in the same year and further rose to 31.7% by 2020.7 Addressing the health issues of the elderly poses considerable obstacles, primarily due to the nature of their ailments, which are often degenerative, long-lasting, and multifaceted, necessitating prolonged care and substantial financial investment.8 Government entities, community organizations, and educational institutions have launched various programs to reduce the occurrence of dis- Correspondence: Mia Fatma Ekasari, Politeknik Kesehatan Kemenkes Jakarta III, DKI Jakarta, Indonesia. E-mail: miafatma74@gmail.com Key words: attitude; behavior; hypertension management; knowledge; older adults. Contributions: MFE, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; AN, conceptualization, investigation, methodology, validation, review & editing; ESS, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; PHL, method- ology, visualization, writing – review & editing; SB, resources, investi- gation, and writing –review & editing; AJ, resources, supervision, and writing –review & editing. Conflict of interest: the authors declare no conflicts of interest. Ethics approval and consent to participate: the research was approved by the Health Research Ethics Commission, Poltekkes Kemenkes Jakarta III, based on ethical certificate No. LB.02.02/KEPK/032/2022. During the research, the researchers focused on the ethical principles of autono- my, beneficence, justice, and non-maleficence. Patient consent for publication: written informed consent was obtained from anonymized patients for publication in this article. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Funding: this research was supported by a research grant from Poltekkes Kemenkes Jakarta III with contract number LB.02.01/1/06941/2021. Acknowledgments: the researchers would like to thank Poltekkes Kemenkes Jakarta III, Poltekkes Kemenkes Tasikmalaya, and Dinas Kesehatan DKI for their support during this research. The researchers also thank the respondents who supported this study. Received: 6 September 2024. Accepted: 5 December 2024. Early access: 20 January 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13029 doi:10.4081/hls.2024.13029 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s1):13029] [page 43] eases stemming from poorly managed hypertension. These initia- tives involve updating health promotion strategies, policies, and protocols aimed at controlling high blood pressure.9 Health educa- tion is a key component of health promotion and disease preven- tion. Hypertension management in Indonesia has been carried out through the POSBINDU PTM (Integrated Non-Communicable Disease Development Post) program with basic health check activ- ities, such as blood pressure checks and providing health education to the elderly.10 People who access POSBINDU showed a good knowledge of hypertension.11,12 Health education for elderly people is needed to maintain and increase knowledge about the risk fac- tors of hypertension.13,14 The activity of health education aims to encourage elderly people to adopt healthy behaviors, especially taking medication,15 and changing their lifestyle to improve their overall health and life satisfaction.16 Health education interventions targeting hypertension patients can enhance older adults’ ability to manage their hypertension con- dition, leading to better blood pressure outcomes.17 As a result, a demand for creative health education methods is needed to tailor elderly with hypertension. Using games as a means of delivering health information to older adults might be an alternative.18 Studies examining gaming interventions for the elderly have shown that games and play-based therapies, particularly in healthcare settings, produce positive outcomes for this age group.19 Extensive research on the use of games for older populations is still needed to develop alternative formats beyond stimulating cognitive function. Despite the implementation of various health promotion inter- ventions using different media, hypertension among the elderly remains a major public health issue. This research utilized a word search puzzle game as an educational intervention to improve older adults’ knowledge, attitudes, and behaviors regarding hyper- tension management. The game was designed not only to provide health education but also to stimulate cognitive function and encourage social interaction among seniors. Word puzzle games have the potential to generate enthusiasm, positive emotions, and engagement while simultaneously enhancing cognitive abilities in older individuals. Moreover, the games offer an engaging tech- nique for acquiring health-related information. This study aimed to assess the effectiveness of this word puzzle game in enhancing older adults’ understanding, attitudes, and practices concerning hypertension management. Materials and Methods Research design A quasi-experimental research design featuring a pretest- posttest method and a control group was utilized in this study. East Jakarta’s Cakung District was selected as a study location targeting a population of elderly living in the DKI Jakarta region. The study participants were pre-elderly and elderly adults who met the fol- lowing selection criteria: i) aged between 45 and 69 years; ii) able to read and write; iii) able to communicate effectively; iv) compe- tent in performing daily activities; v) without visual or auditory impairments; vi) and willing to participate in the study. The study was conducted for a month with four follow-up durations: one every week. Prior to intervention, respondents filled out pre-test questions about the material that would be studied while playing the word puzzle game. The material in the word puz- zle game consisted of four topics: i) definition and effects of high blood pressure; ii) causes of high blood pressure; iii) signs and symptoms of high blood pressure; and (iv) handling high blood pressure. After being explained how to play the game, respondents were asked to complete the word puzzle game for one material/topic each week. After completing all games from each material, respondents were asked to answer a post-test. Study participants The study employed a purposive sampling technique for recruiting participants. Sample size was determined using the Lemeshow formula, with parameters set at α=95%, z=1.96; P=0.71, and d=10% (α is the desired confidence level, Z is the z- score value corresponding to the desired confidence level, P is the proportion of the population estimated to have a particular charac- teristic, and d is the margin of error). The calculated sample of 80 was increased to 90, considering potential attrition. The final par- ticipants were 45 for each group. The study was conducted from March to October 2022. Variables, instruments, and data collection The study examined knowledge, attitudes, and behaviors as research variables. A researcher developed an instrument based on relevant theories, demonstrating satisfactory validity and reliabili- ty, surpassing the r-table value of 0.074 and achieving an alpha value of 0.943. Both groups underwent a pre-test to establish base- line values for assessing the word puzzle game’s impact. The inter- vention group engaged with the word puzzle game, while the con- trol group received a booklet. Post-intervention, both groups com- pleted a post-test. The study compared scores before and after the intervention to evaluate its effectiveness. Word search puzzles are linguistic challenges where words, often centered around a particular theme, are hidden within a matrix of letters. The goal is to discover and identify all the con- cealed words. In this particular game, focused on hypertension, approximately 20-40 terms are embedded in various orientations: left to right, top to bottom, diagonally, and in reverse. A catalog of hidden words is provided, including terminology related to the comprehension of hypertension’s indicators, manifestations, ori- gins, and consequences. As an elderly participant locates a target word, their companion asks about the participant’s understanding of the term and its connection to hypertension. Once the puzzle is completed, the companion provides a summary of the identified words, and the elderly participant is asked to recollect the key points discussed by the companion. Data analysis A research instrument was utilized to gather primary data. The collected information underwent descriptive analysis and inferen- tial statistical evaluation using a t-test. Descriptive analysis focused on variables related to respondent characteristics (age, gender, education, occupation, and ethnic background). To deter- mine differences between the intervention and control groups regarding education, attitude, and behavior variables, a t-test was applied. Ethical clearance The study received authorization from the DKI Jakarta Health Office and successfully passed an ethical review conducted by the Jakarta III Poltekkes Kemenkes Research Ethics Committee, as evidenced by approval No.LB.02.02/KEPK/032/2022. Written informed consent was obtained from all participants in the study. Special issue Pathways of Change [page 44] [Healthcare in Low-resource Settings 2025;13(s1):13029] Results Tables 1 and 2 show the characteristics of participants. Analysis shows that in the intervention group, respondents’ ages ranged from 60 to 71, with an average of 64.69 years. For the con- trol group, the age range was 60 to 76, with a mean of 67.17 years. As illustrated in Table 3, both groups were predominantly com- posed of female participants, individuals with elementary school education, those not currently employed, and people of Javanese ethnicity. The homogeneity test revealed no significant disparities between the intervention and control groups in terms of gender, age, occupation, education, ethnic background, knowledge, atti- tudes, and skills prior to the implementation of the word puzzle game intervention. Comparative analysis of knowledge and attitude scores pre- and post-intervention with word puz- zle game in intervention and control groups The analysis presented in Table 4 shows a statistically signifi- cant disparity in knowledge between the intervention and control groups prior to and following the word puzzle game intervention (p=0.000). For the attitude variable, a statistically significant dif- ference was also observed in the intervention group before and after the word puzzle game intervention (p=0.001). Likewise, the skill variable revealed a statistically significant change in the inter- vention group pre- and post-implementation of the word puzzle game (p=0.001). Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13029] [page 45] Table 3. Distribution of participants' demographic characteristics based on gender, educational attainment, occupational status, and ethnic background. Variable Intervention group Control group Total N % N % N % Gender Male 12 26.7 19 42.2 31 34 Female 33 733 26 57.8 59 66 Education Primary school 33 57.8 28 62.2 61 67 Junior high school 9 20.0 13 28.9 22 24 High school 3 6.7 4 8.9 7 9 Work Civil servant 1 2.2 5 11.1 6 6.7 Private sector employee 4 8.9 5 11.1 9 10 Entrepreneur 3 6.7 2 4.4 5 5.5 Labor 8 17.8 3 6.7 11 12.2 Trade 2 2.2 4 8.9 6 6.7 Not working 27 60 26 57.8 53 58.9 Ethnic origin Javanese 26 57.8 23 51.1 49 54 Betawi 10 22.2 10 22.2 20 22 Sundanese 8 17.8 11 24.4 19 21 Others 1 2.2 1 2.2 2 2 Table 1. Respondents' characteristics based on age. Variable Group N Mean Median SD Min-Max Intervention 45 64.69 63 3.059 60-71 Age of respondents Control 45 67.17 67 4.896 60-76 Table 2. Classification of blood pressure in the elderly intervention group. Blood pressure Intervention group Control group Total Frequency (f) Percentage (%) Frequency (f) Percentage (%) Frequency (f) Percentage (%) Pre-hypertension SBP (mmHg) 120- 139 3 6.7 5 11.1 8 8.9 DBP (mmHg) 80-89 Stage 1 Hypertension 25 55.5 27 60 52 57.8 SBP(mmHg) 140- 159 DBP (mmHg) 90-99 Stage 2 Hypertension 17 37.8 13 28.9 30 33.3 SBP(mmHg) ≥160 DBP (mmHg) ≥100 SBP, systolic blood pressure; DBP, diastolic blood pressure. Variations in knowledge, attitude, and skills scores across groups Table 5 demonstrates a statistically significant difference in respondents’ knowledge (p=0.000), attitude (p=0.054), and skills (p=0.052) between the intervention and control groups following the implementation of the word puzzle game intervention. Discussion The study demonstrates the effectiveness of using word puzzle games as a novel approach to health education for older adults. This method can be particularly useful in enhancing knowledge and attitudes about hypertension management, especially among individuals who may find traditional educational methods less engaging. By using interactive and enjoyable methods like word puzzle games, it is possible to increase engagement and improve health outcomes. To engage participants in locating words within randomly arranged letters, word search puzzle games were employed.18 These puzzles typically feature square or rectangular grids where participants are tasked with identifying words horizon- tally, vertically, or diagonally. The game’s name reflects its nature, as predetermined words are concealed within the letter arrange- ment. Players must complete the puzzle by scanning from left to right (or in reverse) and searching for word beginnings (if provid- ed), uppercase letters, and repeated letters. In cases where no word list is supplied, seniors can find words by reading right to left and top to bottom. This cognitively challenging activity is suitable for older adults, as games provide not only stimulation but also improve focus and memory retention.20 The research revealed that participating in word puzzle games improved elderly individuals’ knowledge, attitudes, and behaviors regarding hypertension management. A significant barrier to self- care among older hypertensive patients is an insufficient under- standing of the condition and its treatment regimen.21 Educational initiatives for elderly individuals with hypertension cover the def- inition, causes, implications, symptoms, treatment options, and management approaches.22,23 Health education enables individuals with hypertension to enhance their understanding, mindset, and ability to manage their diet and self-efficacy.24–26 Numerous studies have shown that health education can positively shape attitudes towards unmanaged hypertension.27,28 Attitudes consist of emotional and behavioral tendencies towards objects or subjects involving psychological values.29 They influence actions, readiness, and the propensity to Special issue Pathways of Change Table 4. Analysis of knowledge, attitude, and skills scores pre- and post-intervention with word puzzle game. Variable Group Mean SD 95% CI T p Knowledge Intervention group Before 8.87 2.029 -1.692-0.441 -3.436 0.001 After 9.93 0.252 Difference -1.067 Control group Before 8.84 1.999 -0.018-0.107 1.431 0.160 After 8.80 2.018 Difference 0.044 Attitude Intervention group Before 26.67 3.456 -3.661-1.095 -3.735 0.001 After 29.04 2.836 Difference -2.378 Control group Before 26.53 3.188 -0236-0.147 0.467 0.643 After 26.58 3354 Difference -0.044 Skills Intervention group Before 28.93 3.499 -5.089-1.759 -9.957 0.000 After 32.36 4.313 Difference -3422 Control group Before 28.89 3.524 -0.064-0.000 0.000 0.1000 After 28.89 3.531 Difference 0.000 Table 5. Evaluation of knowledge, attitude, and skills scores after the word puzzle game intervention. Variable Group N Mean SD 95% CI F p Knowledge Intervention 45 9.93 0.252 0.416-1.629 36.068 0.000 Control 45 8.91 2.032 0.408-1.637 Attitude Intervention 45 29.82 2.452 1.911-4.400 3.808 0.054 Control 45 26.67 3.411 1.909-4.402 Skills Intervention 45 32.36 4.313 1.740-5.016 3.897 0.052 Control 45 28.98 3.461 1.739-5.017 [page 46] [Healthcare in Low-resource Settings 2025;13(s1):13029] behave in specific ways towards particular items. Furthermore, the attitudes of hypertensive patients affect blood pressure manage- ment and compliance with dietary guidelines for hypertension. Patients with hypertension who possess more positive attitudes tend to exhibit better self-care practices.30,31 Research has shown that evidence-based education and sup- port for self-management in hypertensive individuals are linked to favorable health outcomes, such as lower blood pressure, improved knowledge, and enhanced self-management skills.32,33 A retrospective study on hypertensive patients revealed that weight increase, lack of physical activity, and high salt consumption are associated with poor blood pressure control.34 Individuals with hypertension must adhere to a healthy lifestyle that includes phys- ical activities (such as walking, jogging, strength training, and gar- dening), as well as monitoring and reducing salt and sodium intake. This study examined the effectiveness of word puzzle games on elderly people in Cakung District, Indonesia. Therefore, gener- alization of findings to the national context needs to be done with caution. Further research is required with a larger sample size and a wider area scale. To deepen the effectiveness of word puzzle games, combining word puzzle games with other health education interventions, such as diet counseling or physical activity pro- grams, can be done in future studies. This study employed a word puzzle game as an interactive method to deliver health education about hypertension. The find- ings revealed that the intervention group demonstrated improve- ments in knowledge, attitudes, and behaviors compared to the con- trol group. It’s worth noting that word puzzles can also enhance cognitive abilities in elderly individuals.35 Participating in mentally stimulating games can boost older adults’ concentration, cognitive function, and memory.19 Games designed for seniors serve multi- ple purposes beyond memory training and social interaction; they also offer a means to maintain health at home during the pandemic.36 Additionally, prior studies examining the impact of puzzle games on elderly individuals have shown that the process of experiential learning encompasses four cognitive stages: experi- encing, reflecting, connecting, and applying. These stages work together to enhance the cognitive abilities of older adults partici- pating in puzzle-based activities.37 Research has also demonstrated that puzzle therapy can significantly improve cognitive function in the elderly population.38 As a result, puzzle games and similar gaming activities may serve as effective tools for exercising cogni- tive abilities and potentially reducing the risk of dementia in older adults. Conclusions The study revealed improved knowledge, attitudes, and behav- iors in the experimental group that participated in the word game puzzle intervention compared to the control group. The word puz- zle game showed a statistically significant beneficial impact on elderly individuals with hypertension. Utilizing word puzzle games for health education can enhance patients’ understanding of hypertension and improve their ability to manage and monitor blood pressure. 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