Abstract Type 2 diabetes mellitus (T2DM) is a major chronic disease that requires continuous self-management to prevent long-term complications. This study aimed to evaluate the effectiveness of the Sweet Escape Game in promoting complication-prevention behaviors among patients with T2DM in Pathum Thani, a central province of Thailand. A quasi-experimental two-group pretest–posttest design was conducted with 64 participants, including 32 in the intervention group and 32 in the comparison group. Participants in the intervention group received the eight-week Sweet Escape Game program, which was developed based on the Health Belief Model, whereas those in the comparison group received usual diabetes education. Data were collected using structured interview questionnaires assessing dietary behavior, physical activity, and medication-use behavior. Blood glucose levels were measured before and after the intervention. Data were analyzed using descriptive statistics, paired and independent samples t-tests, and analysis of covariance. Following the intervention, participants who received the Sweet Escape Game demonstrated significantly greater improvements in dietary behavior, physical activity, and medication-use behavior than those receiving usual diabetes education (P < 0.05). However, no significant between-group difference was observed in blood glucose level after the eight-week intervention. These findings suggest that the Sweet Escape Game is an effective theory-based, game-based health education intervention for strengthening diabetes complication-prevention behaviors in community settings. Integrating this intervention into routine diabetes self-management education programs in primary healthcare settings may enhance patient engagement and promote sustainable self-management behaviors.

Keywords: Type 2 diabetes mellitus, Game-based intervention, Diabetes self-management, Complication prevention, Health behavior

Citation:  Ainthapho, P., Punchard, T., Chanthamuang, W., Maraikaew, A., Taengsuk, K., Kamnueng, T., Arsa, R., Jumneansuk, A., and Dechboon, P. 2026. Effectiveness of the Sweet Escape Game in promoting complication-prevention behaviors among patients with type 2 diabetes mellitus in Pathum Thani, a central province of Thailand: A quasi-experimental study. Natural and Life Sciences Communications. 25(4): e2026097.

Graphical Abstract:

INTRODUCTION

Diabetes mellitus is a major chronic non-communicable disease and remains one of the most significant public health challenges worldwide. According to the International Diabetes Federation (IDF), approximately 537 million adults aged 20–79 years were living with diabetes in 2021, and this number is projected to rise to 643 million by 2030 and 783 million by 2045. Diabetes also contributes substantially to premature mortality, with an estimated 6.7 million diabetes-related deaths reported globally in 2021, equivalent to approximately one death every five seconds (International Diabetes Federation, 2021; Sun et al., 2022). In Thailand, diabetes has become an increasingly serious public health concern, with type 2 diabetes mellitus accounting for the majority of cases. The increasing number of patients, newly diagnosed cases, diabetes-related deaths, and healthcare expenditures reflects the substantial burden of diabetes on individuals, families, communities, and the healthcare system (Ministry of Public Health, 2023; Department of Disease Control, 2024).

Type 2 diabetes mellitus is the most common form of diabetes and is strongly associated with insulin resistance, impaired insulin secretion, and modifiable lifestyle-related risk factors. Although diabetes is generally a lifelong condition, its progression and complications can be prevented or delayed through effective glycemic control and appropriate self-management behaviors. Poorly controlled blood glucose levels can lead to serious microvascular and macrovascular complications, including cardiovascular disease, stroke, diabetic neuropathy, diabetic foot ulcers, lower-limb amputation, diabetic retinopathy, visual impairment, diabetic nephropathy, kidney failure, disability, and premature death (Rask-Madsen and King, 2013; Ceriello and Prattichizzo, 2021). These complications substantially affect patients’ functional ability, quality of life, and long-term independence.

Preventing diabetes-related complications requires continuous self-care and sustained health behavior modification. Key preventive behaviors include healthy dietary practices, regular physical activity, appropriate medication use, blood glucose monitoring, foot care, regular medical follow-up, and early recognition of warning signs (Sen and Chakraborty, 2015; American Diabetes Association Professional Practice Committee, 2024; World Health Organization, 2024). In Thailand, the Ministry of Public Health has implemented several strategies to prevent and control non-communicable diseases, including clinical practice guidelines, self-assessment systems for healthcare facilities, diabetes education activities, and diabetes schools aimed at strengthening patients’ self-management capacity (Ministry of Public Health, 2023). These initiatives emphasize lifestyle modification and active patient participation in preventing diabetes complications.

Despite these ongoing efforts, many patients with type 2 diabetes continue to have poor glycemic control and remain at risk of preventable complications. This suggests that conventional diabetes education may not be sufficient to produce sustainable behavioral change among all patients. Traditional approaches, such as lectures, advice, or printed materials, can improve knowledge but may inadequately address patients perceived susceptibility, perceived severity, perceived benefits, perceived barriers, motivation, and self-efficacy (Leaupon, 2024; Reinders et al., 2024). Previous evidence also indicates that dietary behavior, medication adherence, and physical activity are important predictors of diabetes complication prevention (Colberg et al., 2016; Evert et al., 2019; Powers et al., 2020; Davies et al., 2022). Therefore, more engaging, interactive, and behaviorally oriented interventions are needed to strengthen diabetes self-management practices.

The Health Belief Model provides a relevant theoretical framework for designing interventions to promote complication-prevention behaviors among patients with diabetes (Du et al., 2024; Darvishi et al., 2025; Park et al., 2025). This framework is particularly applicable to diabetes care because many patients may not experience obvious symptoms in the early stages of the disease and may therefore underestimate their susceptibility to long-term complications. According to the model, individuals are more likely to engage in preventive behaviors when they perceive themselves to be at risk, recognize the seriousness of the condition, believe in the benefits of recommended actions, perceive fewer barriers, receive appropriate cues to action, and have sufficient self-efficacy to perform the behaviors (Rosenstock, 1974; Janz and Becker, 1984). Applying this model to diabetes care may help patients better understand their personal risk and strengthen their motivation to adopt healthier behaviors.

Diabetes Self-Management Education and Support (DSMES) has become a cornerstone of comprehensive diabetes care and is strongly recommended by the American Diabetes Association (ADA), the Association of Diabetes Care and Education Specialists (ADCES), and the International Diabetes Federation. DSMES is defined as an ongoing process that facilitates the knowledge, skills, and abilities necessary for effective diabetes self-management. The primary goals of DSMES are to support informed decision-making, promote self-care behaviors, enhance problem-solving skills, strengthen self-efficacy, and improve clinical outcomes while maintaining quality of life (Powers et al., 2020; American Diabetes Association Professional Practice Committee, 2024).

Although DSMES has demonstrated effectiveness in improving diabetes self-management behaviors, maintaining long-term patient engagement remains challenging, particularly among older adults and community-dwelling populations. Conventional DSMES programs frequently rely on lectures, printed educational materials, and one-way communication, which may limit participant motivation and sustained behavioral change. Consequently, innovative educational approaches such as gamification and game-based learning have increasingly been incorporated into DSMES to improve participant engagement, reinforce behavioral skills, and facilitate experiential learning (Brady et al., 2023; Ossenbrink et al., 2023; Kerr et al., 2024).

Game-based health education has emerged as a promising strategy for promoting active learning and behavior change (Brady et al., 2023; Supramaniam et al., 2024). Unlike lecture-based education, game-based interventions provide interactive learning environments in which participants engage with realistic scenarios, make decisions, receive immediate feedback, and learn from the consequences of their choices. For patients with type 2 diabetes, such activities may help translate abstract health information into practical self-care decisions, including choosing appropriate foods, taking medications correctly, engaging in physical activity, caring for the feet, and seeking timely healthcare services (Shiau et al., 2021; Brady et al., 2023; Terathongkum and Kittipimpanon, 2023). These features may enhance awareness, motivation, self-efficacy, and sustained engagement in complication-prevention behaviors.

Although game-based health education has increasingly been applied in chronic disease management, empirical evidence regarding its effectiveness in promoting diabetes complication-prevention behaviors among adults with type 2 diabetes in Thai community settings remains limited. Existing diabetes education interventions have often focused on improving knowledge or general self-care behaviors, whereas fewer studies have specifically targeted complication-prevention behaviors using a theory-based, interactive game approach (Paknapa et al., 2025). Further research is therefore needed to examine whether a culturally appropriate game-based intervention can improve key preventive behaviors among patients with type 2 diabetes in real-world community healthcare settings.

In this study, the Sweet Escape Game was developed as a game-based health education program to promote complication-prevention behaviors among patients with type 2 diabetes mellitus. The program was designed based on the Health Belief Model and integrates simulated activities related to diabetes complications and self-care decision-making. Through these activities, participants are encouraged to recognize their susceptibility to complications, understand the severity of diabetes-related outcomes, identify the benefits of appropriate self-care behaviors, overcome perceived barriers, and develop confidence in maintaining healthy behaviors. The program focuses particularly on key behavioral domains related to complication prevention, including dietary behavior, medication-use behavior, and physical activity behavior.

Pathum Thani Province, a rapidly urbanizing province in central Thailand, was selected as the study setting because it represents an area experiencing substantial demographic and lifestyle transitions associated with increasing non-communicable disease burden. The province has approximately 1.20 million residents and a population density of 787.45 persons/km², reflecting rapid urban expansion and population growth (Pathum Thani Provincial Health Office, 2025). Provincial health reports indicate that endocrine, nutritional, and metabolic diseases are among the three leading causes of outpatient morbidity, while diabetes mellitus is one of the five most common non-communicable diseases requiring hospital admission, with an admission rate of 72.75 per 100,000 population. In addition, Health Data Center (HDC) data show that more than 108,000 patients with diabetes were registered in Pathum Thani in 2024, accounting for approximately (10.8%) of the provincial population, indicating a substantial disease burden and reinforcing the need for effective community-based diabetes management (Health Data Center, Ministry of Public Health, 2024).

Beyond the epidemiological burden, rapid urbanization in Pathum Thani has been accompanied by lifestyle changes characterized by sedentary behavior, unhealthy dietary patterns, and increasing obesity, all of which contribute to poor glycemic control and an elevated risk of diabetes-related complications (Ministry of Public Health, Thailand, and World Health Organization, 2026). Although routine diabetes education is available through primary healthcare services, conventional educational approaches may not adequately sustain long-term behavioral change. Therefore, innovative interventions that actively engage patients and strengthen self-management behaviors are needed to complement existing diabetes care.

This need is consistent with Thailand's current policy direction for diabetes care, which emphasizes comprehensive Diabetes Self-Management Education and Support (DSMES), intensive lifestyle modification, patient empowerment, continuity of care, and community participation. Consequently, evaluating the effectiveness of the Sweet Escape Game in Pathum Thani is particularly relevant because it provides evidence for an innovative, theory-based, community-centered educational strategy that may strengthen diabetes complication-prevention behaviors while supporting the implementation of national diabetes management policies.

MATERIALS AND METHODS

Study design

This study employed a quasi-experimental, two-group pretest–posttest design involving an intervention group and a comparison group. The study aimed to evaluate the effectiveness of the Sweet Escape Game in promoting complication-prevention behaviors among patients with type 2 diabetes mellitus in Pathum Thani Province, Thailand.

Population and sample

The target population comprised 108,333 registered patients with physician-diagnosed type 2 diabetes mellitus in Pathum Thani Province, according to the Health Data Center (HDC), Ministry of Public Health, Thailand (2024). The required sample size was calculated using G*Power version 3.1.9.7 (Faul et al., 2009) based on the primary comparison between the intervention and comparison groups. ANCOVA was subsequently employed to adjust for baseline covariates and improve the precision of the estimated intervention effect. The calculation assumed a significance level (α) of 0.05, statistical power (1−β) of 0.95, and a large standardized effect size (Cohen's d = 0.80), resulting in a minimum sample size of 64 participants (32 participants per group). A statistical power of 0.95 was selected to reduce the probability of Type II error and increase the likelihood of detecting a true intervention effect. The effect size was determined according to Cohen's recommendations for behavioral intervention research and was supported by findings from previous quasi-experimental studies evaluating diabetes self-management interventions (Cohen, 1988; Faul et al., 2009; Rungnoei et al., 2026). A large effect size was considered appropriate because the Sweet Escape Game is a multi-component behavioral intervention incorporating gamification, simulation, peer interaction, and continuous digital support, which was expected to produce a clinically meaningful improvement in diabetes self-management behaviors. This assumption was also supported by previous quasi-experimental diabetes self-management intervention studies reporting moderate to large behavioral effects.

Eligible participants were identified from the diabetes registry of the participating primary healthcare facilities in Khlong Luang District, Pathum Thani Province. Participants were eligible if they: (1) were aged 20 years or older; (2) had physician-confirmed type 2 diabetes mellitus (ICD-10 code E11), as documented in their medical records; (3) were residents of Pathum Thani Province and registered for diabetes care at the participating primary healthcare facilities; (4) had no unstable medical conditions or severe illnesses that could interfere with participation in the intervention activities; (5) owned a smartphone with access to the LINE application; (6) were able to communicate, read, and write in Thai; and (7) voluntarily provided written informed consent before enrollment.

Participants were excluded if they had a diagnosed mental disorder, cognitive impairment, or learning disability that could affect their ability to participate in the intervention or complete the study questionnaires. Participants who discontinued the intervention, were lost to follow-up, or were unable to complete the post-intervention assessment were excluded from the final analysis. The same eligibility criteria were applied to both the intervention and comparison groups.

Sampling procedure

A multi-stage random sampling method was used to recruit patients with type 2 diabetes mellitus in Pathum Thani Province, Thailand. In the first stage, one district was selected from Pathum Thani Province using simple random sampling by lottery method; Khlong Luang District was selected. In the second stage, two subdistricts within Khlong Luang District were selected using the same method; Khlong Si Subdistrict and Khlong Sam Subdistrict were selected. In the third stage, one village from each selected subdistrict was randomly selected by lottery method. Village No. 16 in Khlong Si Subdistrict and Village No. 8 in Khlong Sam Subdistrict were selected. In the final stage, Village No. 16 in Khlong Si Subdistrict was assigned to the intervention group, whereas Village No. 8 in Khlong Sam Subdistrict was assigned to the comparison group. The intervention and comparison groups were selected from different villages to minimize contamination between participants during the study period.

Potential participants were identified from the diabetes registry of the participating primary healthcare facilities in Khlong Luang District, Pathum Thani Province. A total of 90 patients with physician-confirmed type 2 diabetes mellitus were approached and assessed for eligibility. Of these, 26 patients were excluded, including 18 who did not meet the inclusion criteria, six who declined to participate, and two who were excluded for other reasons. Consequently, 64 eligible participants provided written informed consent and were enrolled in the study, resulting in a response rate of 88.9% (64/72 eligible patients). The participant recruitment and follow-up process are presented in Figure 1.

To minimize contamination between the intervention and comparison groups, participants were recruited from different villages located in separate subdistricts of Khlong Luang District, Pathum Thani Province. The two study communities were approximately 27 km apart, thereby substantially reducing opportunities for regular interaction and the exchange of intervention-related information between participants. In addition, all intervention activities were conducted exclusively within the intervention community by the research team. Participants were requested not to share educational materials or discuss the intervention content with individuals outside their study group throughout the study period. These procedures were implemented to minimize contamination bias. The intervention and comparison groups were scheduled on different days, and intervention materials were not distributed to the comparison group until the completion of data collection.

Figure 1. CONSORT-style flow diagram of participants progress through the study.

Research instruments

The research instruments used in this study consisted of two main components: (1) data collection instruments and (2) the Sweet Escape Game intervention program.

Data collection instruments

The research instruments consisted of a structured questionnaire and physiological measurements. The questionnaire was developed based on a review of the literature and previously validated instruments related to diabetes self-management and complication-prevention behaviors. The questionnaire comprised four sections.

Section 1: General characteristics consisted of 12 items designed to collect participants' demographic and clinical characteristics, including sex, age, marital status, educational level, occupation, monthly income, duration of type 2 diabetes mellitus, body mass index (BMI), current diabetes treatment, underlying diseases, history of diabetes-related complications, and smoking status. These variables were collected to describe the study population and compare baseline characteristics between the intervention and comparison groups.

Section 2: Dietary behavior assessed dietary behaviors using 15 items adapted from the Healthy Eating Behavior Assessment developed by the Thai Health Promotion Foundation (Thai Health Promotion Foundation, 2022). Each item was rated on a 4-point Likert scale, with response options ranging from 1 (always) to 4 (never). The total score ranged from 15 to 60, with lower scores indicating healthier dietary behaviors and a lower risk of diabetes-related complications. Dietary behavior was interpreted according to the original instrument developed by the Thai Health Promotion Foundation.

Section 3: Physical activity assessed physical activity using three items measuring the frequency, duration, and intensity of physical activity (Department of Health, 2019). A Physical Activity Index (PAI) was calculated using the following formula: Physical Activity Index = Frequency × Duration × Intensity. The total score was interpreted as follows: <15 = Very inappropriate, 15–29 = Inappropriate, 30–44 = Moderately appropriate, 45–59 = Appropriate, and ≥60 = Highly appropriate. Higher scores indicated a higher level of physical activity.

Section 4: Medication-use behavior assessed medication-use behavior using eight items adapted from the Morisky Medication Adherence Scale (MMAS-8) (Morisky et al., 2008), and Lam and Fresco (Lam and Fresco, 2015). The questionnaire evaluated participants' medication-taking behaviors, including adherence to prescribed medication schedules, missed doses, and appropriate medication use. The total score ranged from 0 to 8, with higher scores indicating better medication adherence.

Blood glucose measurement: Fasting blood glucose (FBG) was measured as the physiological outcome of the study. Blood samples were collected after an overnight fast of at least 8 hours by trained healthcare personnel at the participating primary healthcare facilities. Blood glucose levels were measured using a calibrated portable blood glucose meter that was routinely maintained and calibrated according to the manufacturer's recommendations and the quality assurance procedures of the primary healthcare facilities. Fasting blood glucose values were recorded in milligrams per deciliter (mg/dL) and were used to evaluate changes in glycemic control before and after the intervention. The interpretation of blood glucose levels was based on the criteria of the Diabetes Association of Thailand. A blood glucose level of less than 100 mg/dL was interpreted as normal, 100–125 mg/dL as indicating increased risk for diabetes, and 126 mg/dL or higher as indicating diabetes (Diabetes Association of Thailand under the Patronage of Her Royal Highness Princess Maha Chakri Sirindhorn, 2017).

Sweet Escape Game intervention program

The Sweet Escape Game was developed as a community-based behavioral intervention grounded in the Health Belief Model (HBM) and principles of Diabetes Self-Management Education and Support (DSMES). The intervention was designed to promote diabetes complication-prevention behaviors through active learning, experiential learning, gamification, and peer interaction. Rather than relying on traditional lecture-based education, participants actively engaged in game-based activities, simulation scenarios, group discussions, and reflective learning to strengthen knowledge, self-efficacy, decision-making skills, and motivation for sustainable self-management.

The intervention was delivered over eight consecutive weeks, with one session conducted each week. Each session lasted approximately 120 minutes and was facilitated by the principal investigator together with trained healthcare personnel from the participating primary healthcare facilities. The educational activities focused on healthy dietary behaviors, physical activity, medication adherence, blood glucose monitoring, prevention of diabetes-related complications, and problem-solving skills required for daily diabetes self-management. Participants also received continuous support and follow-up through the LINE OpenChat platform between sessions to reinforce learning, encourage behavioral practice, and facilitate communication with the research team. A detailed description of the learning objectives, educational activities, and expected outcomes for each intervention session is presented in Table 1.

Table 1.  Summary of weekly program contents and key learning activities.

The content validity of the research instruments and intervention program was evaluated by a panel of experts in diabetes care, health promotion, and behavioral science. The instruments were revised according to the experts’ recommendations before data collection. The item-objective congruence (IOC) indices for Sections 2, 3, and 4 of the structured interview questionnaires were 0.74, 0.70, and 0.92, respectively. The overall content validity index (CVI) of the questionnaire was 0.83, indicating an acceptable level of content validity. Internal consistency reliability was assessed using Cronbach’s alpha coefficients, which were 0.825, 0.890, and 0.868 for Sections 2, 3, and 4, respectively.

Data analysis

Data were analyzed using descriptive and inferential statistics. Demographic characteristics were summarized using frequency, percentage, mean, and standard deviation. Baseline differences between the intervention and comparison groups were examined using the chi-square test or Fisher’s exact test for categorical variables and the independent samples t-test for continuous variables.

Baseline outcome variables were compared between groups using independent samples t-tests, and within-group changes from pre-intervention to post-intervention were examined using paired samples t-tests. The primary outcomes were dietary behavior risk score, physical activity score, and medication-use score, while blood glucose level was analyzed as a secondary outcome. Because significant baseline differences were found in age and occupation, ANCOVA was used as the primary adjusted analysis to compare post-intervention outcomes between groups. Each model adjusted for the corresponding baseline outcome score, age, and occupation. Statistical significance was set at P < 0.05. The assumptions of ANCOVA were examined before analysis.

Ethical consideration

Ethical approval for this study was obtained from the Human Research Ethics Committee of Valaya Alongkorn Rajabhat University under the Royal Patronage (Approval No. 0044/2568; approved on 15 August 2025). Participant recruitment and data collection were conducted between October and December 2025. Baseline assessments were completed before the intervention, followed by the eight-week Sweet Escape Game program. Post-intervention assessments were conducted immediately after completion of the intervention. Written informed consent was obtained from all participants prior to study enrollment.

RESULTS

Demographic characteristics

A total of 64 patients with type 2 diabetes mellitus participated in the study, including 32 participants in the control group and 32 participants in the experimental group. Most participants in both groups were female and had completed primary school. No statistically significant differences were found between the groups in gender, educational level, monthly income, marital status, or duration of diabetes (P > 0.05).

The mean age was 61.69 ± 8.27 years in the control group and 66.19 ± 5.15 years in the experimental group. A statistically significant difference in age was observed between the groups (P = 0.012). Occupation also differed significantly between groups (P = 0.005), with general laborer being the most common occupation in both groups. Overall, the two groups were comparable in most demographic characteristics; however, significant baseline differences were observed in age and occupation, as shown in Table 2.

Table 2. Demographic variables of the control and the experimental group.

Note: a = Pearson chi-square test; b = Fisher’s exact test; c = Independent t-test; *P < 0.05.

Baseline comparison of outcome variables

Before the intervention, baseline outcome variables were compared between the control and experimental groups to determine whether the two groups were comparable prior to the implementation of the Sweet Escape Game program. As shown in Table 3, there were no statistically significant differences between the control and experimental groups in dietary behavior risk score, physical activity score, medication-use score, or blood glucose level at baseline (P > 0.05 for all variables).

Table 3. Baseline comparison of outcome variables.

Within-group comparison of pre- and post-intervention outcomes

Within-group comparisons of pre- and post-intervention outcomes are presented in Table 4. In the experimental group, statistically significant changes were observed in dietary risk behavior, physical activity, and medication-use scores after participation in the Sweet Escape Game program. The dietary behavior score decreased significantly from 23.97 ± 4.04 at pre-test to 19.50 ± 3.22 at post-test (mean difference = 4.47, t = 4.240, P < 0.001). The physical activity score increased significantly from 37.56 ± 30.75 to 66.09 ± 36.44 (mean difference = -28.53, t = -4.195, P < 0.001). The medication-use score also increased significantly from 5.54 ± 2.27 to 7.02 ± 1.56 (mean difference = -1.48, t = -3.146, P = 0.004). However, no statistically significant change was found in blood glucose level in the experimental group (138.13 ± 47.65 vs. 136.72 ± 44.76 mg/dL, P = 0.860). In the control group, no statistically significant changes were found in dietary behavior risk score, medication-use score, or blood glucose level (P > 0.05). However, the physical activity score increased significantly from 33.18 ± 17.82 at pre-test to 40.06 ± 25.89 at post-test (mean difference = -6.87, t = -2.476, P = 0.019).

Table 4. Within-group comparison of pre- and post-intervention outcomes.

Note: Group 1 = Experimental group; Group 2 = Control group.

Adjusted effects of the sweet escape game on post-intervention outcomes

The adjusted effects of the Sweet Escape Game on post-intervention outcomes are presented in Table 5. After adjusting for the corresponding baseline outcome score, age, and occupation, ANCOVA revealed statistically significant differences between the experimental and control groups in dietary behavior risk score, physical activity score, and medication-use score.

For dietary behavior risk score, the experimental group had a significantly lower adjusted mean score than the control group (20.15 vs. 23.18), indicating more appropriate dietary behavior after the intervention (F = 15.098, P < 0.001, partial η² = 0.218). For physical activity score, the experimental group had a significantly higher adjusted mean score than the control group (64.03 vs. 39.34), indicating greater improvement in physical activity behavior (F = 21.551, P < 0.001, partial η² = 0.285). Similarly, the experimental group had a significantly higher adjusted mean medication-use score than the control group (7.08 vs. 5.33), indicating better medication adherence after the intervention (F = 10.547, P = 0.002, partial η² = 0.163). However, no statistically significant difference in post-intervention blood glucose level was observed between the experimental and control groups after adjustment (F = 0.372, P = 0.545, partial η² = 0.007).

Table 5. Adjusted effects of the Sweet Escape Game on post-intervention outcomes using ANCOVA.

Note: Group 1 = Experimental group; Group 2 = Control group; ANCOVA was adjusted for the corresponding baseline outcome score, age, and occupation. SE = standard error; CI = confidence interval; Partial η² = partial eta-squared.

DISCUSSION

The findings of the present study are consistent with recent diabetes self-management interventions conducted in Thailand. Rungnoei et al. (2026) demonstrated that a structured self-management support program significantly improved self-care behaviors, fasting blood glucose, and HbA1c among adults with uncontrolled type 2 diabetes by emphasizing patient empowerment and continuous behavioral support. Similarly, Prompong and Ruenros (2025) reported significant improvements in self-management behaviors, healthy lifestyle practices, and glycemic control following a structured self-management program delivered in a hospital-based diabetes clinic. These findings reinforce the importance of behavioral interventions in promoting sustainable diabetes self-management among Thai patients.

The significant reduction in dietary behavior risk score among participants in the experimental group indicates more appropriate dietary behavior after participation in the Sweet Escape Game. This improvement may be explained by the interactive nature of the food-related activities, particularly the Life-Changing Plate and Magic Plate activities, which allowed participants to visualize food-related risks and practice decision-making regarding appropriate dietary choices. For patients with type 2 diabetes, dietary control is a central component of self-management and is strongly related to glycemic control and prevention of long-term complications. The game-based approach may have helped translate abstract dietary recommendations into practical, understandable, and contextually relevant choices. This finding is consistent with previous evidence indicating that game-based or gamified interventions can enhance engagement and support diabetes self-management behaviors among adults with type 2 diabetes (Shiau et al., 2021; Brady et al., 2023; Ossenbrink et al., 2023; Kerr et al., 2024).

The experimental group also demonstrated a significant improvement in physical activity score after the intervention. This may be attributable to the Yoga Style activity and movement-based learning strategies, which provided participants with a feasible and accessible form of physical activity. In addition, reminders and encouragement through the LINE OpenChat group may have served as cues to action, reinforcing participants’ motivation to engage in regular physical activity (Yu et al., 2025). Physical activity is an important component of diabetes self-management because it contributes to improved insulin sensitivity, weight control, cardiovascular health, and overall metabolic function. The improvement observed in this study supports the potential value of incorporating enjoyable, low-intensity, and socially supported activities into diabetes education programs, particularly for older adults or community-dwelling patients with type 2 diabetes.

Medication-use score also improved significantly in the experimental group compared with the control group. The Max Medicine activity and medication-trap game may have increased participants’ awareness of common medication-related barriers, such as forgetting doses, incorrect timing, or misunderstanding medication instructions. These activities may also have strengthened participants perceived benefits of appropriate medication use and their confidence in maintaining regular medication-taking behavior. Medication adherence is essential for controlling diabetes and preventing complications, yet it is often influenced by individual beliefs, routine, perceived necessity, and barriers to sustained use (Polonsky and Henry, 2016; Yu et al., 2025). The findings suggest that interactive learning activities may be useful for reinforcing appropriate medication-use behaviors in community-based diabetes care.

The observed improvements in dietary behavior, physical activity, and medication-use behavior may be explained by the theoretical structure of the Sweet Escape Game, which was developed based on the Health Belief Model. The program addressed key constructs of the model, including perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. For example, the Sweet Danger activity was designed to increase awareness of the severity of diabetes-related complications, while the Breaking Barriers for Better Health activity encouraged participants to identify personal barriers and develop strategies to overcome them. The LINE OpenChat group and community role model served as cues to action and sources of social reinforcement (Kim et al., 2025). According to the Health Belief Model, individuals are more likely to engage in preventive behaviors when they perceive themselves to be at risk, recognize the seriousness of the condition, believe in the benefits of action, perceive fewer barriers, and have confidence in their ability to perform the behavior (Rosenstock, 1974; Janz and Becker, 1984). Therefore, the theory-based design of the Sweet Escape Game may have contributed to the behavioral improvements observed in this study.

The findings are also consistent with previous studies and systematic reviews suggesting that game-based and gamified health interventions can promote active learning, motivation, and behavior change in diabetes self-management (Shiau et al., 2021; Brady et al., 2023; Reinders et al., 2024). Game-based interventions may be particularly useful because they provide realistic scenarios, immediate feedback, social interaction, and opportunities for repeated practice. These features may help patients move beyond passive knowledge acquisition toward practical self-care decision-making. However, previous evidence has also shown that the effects of game-based interventions on clinical outcomes, such as blood glucose or HbA1c, are less consistent than their effects on behavioral outcomes (Shiau et al., 2021; Ossenbrink et al., 2023). This pattern is similar to the findings of the present study.

The Sweet Escape Game can be viewed as an innovative community-based Diabetes Self-Management Education and Support (DSMES) strategy because it integrates behavioral theory with active learning, experiential education, and continuous social support. Consistent with the core principles of DSMES, the program emphasized patient empowerment, informed decision-making, self-efficacy, and sustained self-management behaviors through participant-centered learning activities (Powers et al., 2020; Brady et al., 2023; Ossenbrink et al., 2023). Similar findings have been reported in Thailand. Rungnoei et al. (2026) demonstrated that a structured self-management support program significantly improved self-care behaviors, fasting blood glucose, and HbA1c through individualized counseling and continuous behavioral support, whereas Prompong and Ruenros (2025) reported improvements in self-management behaviors and glycemic control following a structured diabetes self-management program. Likewise, Odglun et al. (2023) showed that culturally tailored community-based educational interventions effectively promoted healthy lifestyle behaviors among Thai adults with type 2 diabetes. These findings reinforce the importance of structured behavioral interventions within Thailand's primary healthcare system. However, unlike conventional DSMES programs, which are commonly delivered through counseling or classroom-based education, the Sweet Escape Game integrates the Health Belief Model with gamification, simulation-based learning, role-play, peer interaction, and continuous reinforcement through the LINE OpenChat platform. Participants actively practiced problem-solving and decision-making in simulated situations rather than receiving information passively. These distinctive features may explain the significant improvements observed in dietary behavior, physical activity, and medication-use behavior, suggesting that game-based learning can complement conventional DSMES approaches by increasing participant engagement and facilitating experiential learning within community settings (Odglun et al., 2023; Prompong and Ruenros, 2025; Rungnoei et al., 2026).

Although the Sweet Escape Game significantly improved diabetes complication-prevention behaviors, no statistically significant between-group difference was observed in post-intervention fasting blood glucose levels. This finding is consistent with previous evidence demonstrating that improvements in self-management behaviors generally precede measurable changes in metabolic outcomes (Hood et al., 2015; Colberg et al., 2016; Powers et al., 2020; American Diabetes Association Professional Practice Committee, 2024). Behavioral modification can occur rapidly through enhanced knowledge, motivation, and self-efficacy, whereas improvements in glycemic control often require sustained adherence over several months. Moreover, fasting capillary blood glucose is influenced by recent dietary intake, medication use, physical activity, stress, illness, and timing of measurement, making it less appropriate than HbA1c for evaluating long-term intervention effectiveness (Martos-Cabrera et al., 2020; Ossenbrink et al., 2023; Versluis et al., 2025). Therefore, although no significant short-term improvement in fasting blood glucose was observed, the clinically relevant behavioral improvements identified in this study may contribute to improved long-term glycemic control if maintained over time. Future studies should incorporate HbA1c together with longer follow-up periods to determine whether these behavioral changes translate into sustained metabolic benefits.

From a practical perspective, the present findings support the integration of innovative game-based DSMES approaches into routine diabetes care within Thai primary healthcare settings. The Sweet Escape Game may serve as a complementary educational tool for multidisciplinary diabetes care teams working in primary care units, community hospitals, and diabetes clinics by enhancing patient engagement and reinforcing long-term self-management behaviors. This approach also aligns with Thailand's current policy direction, which emphasizes comprehensive diabetes care, intensive lifestyle modification, continuity of care, and community participation through the Thailand's National Diabetes Remission Programme. Rather than replacing existing diabetes education services, the Sweet Escape Game may complement current DSMES practices by providing an engaging, culturally appropriate, and community-based educational strategy that supports national efforts to reduce diabetes-related complications and strengthen long-term diabetes self-management (Ministry of Public Health, Thailand, and World Health Organization, 2026). The intervention could be implemented by multidisciplinary teams in primary healthcare facilities, particularly village health volunteers, nurses, and public health practitioners responsible for community diabetes management. Given its low-cost design, ease of implementation, and compatibility with routine primary healthcare services, the Sweet Escape Game could be incorporated into community-based DSMES programs delivered by multidisciplinary healthcare teams throughout Thailand.

This study has several strengths. First, the Sweet Escape Game was developed as a theory-based intervention grounded in the Health Belief Model, rather than as a general health education activity. Second, the program combined multiple active learning strategies, including simulation games, movement-based activities, role play, group reflection, digital reminders, and a community role model. Third, the intervention was implemented in a real-world community setting, which increases its practical relevance for primary healthcare services. Finally, ANCOVA was used to adjust for baseline outcome scores and significant baseline differences in age and occupation, thereby improving the rigor of the analysis.

However, several limitations should be acknowledged. First, the quasi-experimental design limits causal inference because participants were not randomly assigned at the individual level. Although statistical adjustment was performed, residual confounding may remain. Second, the study was conducted in two communities within one province, which may limit the generalizability of the findings. Third, the follow-up period was short, and the study may not have been long enough to detect changes in glycemic outcomes. Fourth, behavioral outcomes were assessed using structured interviews and may be subject to self-report bias or social desirability bias. Future studies should consider randomized controlled designs, larger and more diverse samples, longer follow-up periods, and clinical indicators such as HbA1c.

Despite these limitations, the findings have practical implications for diabetes care in community settings. The Sweet Escape Game may be used as a supplementary health education strategy to enhance patient engagement and promote complication-prevention behaviors among patients with type 2 diabetes. Healthcare providers in primary care units, community hospitals, and diabetes clinics may adapt the program to support dietary modification, physical activity, medication adherence, and continuous self-management. Further research is warranted to examine the long-term effectiveness, scalability, and cost-effectiveness of this game-based intervention in broader healthcare contexts.

CONCLUSION

The Sweet Escape Game was associated with significant improvements in dietary behavior, physical activity, and medication-use behavior among patients with type 2 diabetes mellitus. The findings suggest that this Health Belief Model-based, game-based intervention is an effective approach for promoting diabetes complication-prevention behaviors in community settings. Although no significant short-term improvement in fasting blood glucose was observed, the Sweet Escape Game demonstrated meaningful improvements in diabetes complication-prevention behaviors and may serve as a practical community-based Diabetes Self-Management Education and Support (DSMES) strategy for strengthening long-term diabetes self-management in primary healthcare settings. Future studies should evaluate the long-term effectiveness of the intervention using extended follow-up periods, HbA1c, and implementation in different healthcare settings to determine its scalability and generalizability.

ACKNOWLEDGEMENTS

The authors would like to express their sincere gratitude to all patients with type 2 diabetes mellitus who participated in this study. We also thank the healthcare personnel, community health volunteers, and local health authorities in Pathum Thani Province for their valuable support and assistance during participant recruitment and data collection. Their cooperation contributed significantly to the successful completion of this study.

AUTHOR CONTRIBUTIONS

Panchaphon Ainthapho: Conceptualization (Lead), Data Curation (Lead), Validation (Lead), Writing – Original Draft (Equal); Thanaporn Punchard: Data Curation (Lead), Formal Analysis (Equal), Validation (Equal), Writing – Review & Editing (Equal); Wiraya Chanthamuang: Data Curation (Equal), Formal Analysis (Equal); Aphatsara Maraikaew: Data Curation (Equal), Formal Analysis (Equal); Khongkapan Taengsuk: Data Curation (Lead), Formal Analysis (Equal), Writing – Review & Editing (Supporting); Thawichai Kamnueng: Data Curation (Equal), Formal Analysis (Supporting); Rattanaporn Arsa: Conceptualization (Lead), Formal Analysis (Equal), Investigation (Lead), Supervision (Lead), Methodology (Equal), Writing – Original Draft (Lead); Apichet Jumneansuk: Conceptualization (Lead), Formal Analysis (Supporting), Writing – Original Draft (Equal); Phitchasuda Dechboon: Conceptualization (Supporting), Formal Analysis (Lead), Writing – Original Draft (Equal).

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

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