Digital Gamification to Enhance Vaccine Knowledge and Uptake: Scoping Review

"Almost all gamified digital tools under study were based on solid theories and proved to be effective in facilitating understanding and appraisal of information about vaccines and behavior change endpoints."

By using game-based mechanisms, gamification stimulates participants' involvement in a quest to facilitate their learning about health. Serious games and mobile or tablet applications with game-based features are increasingly used to not only train health professionals but also deliver prevention and health promotion messages to the general population. Given concerns about declining vaccination rates, gamification might be a useful approach for interventions aiming to increase vaccine acceptance and uptake. The overarching goal of this scoping study was to respond to the need for information on evidence-based interventions that could help design and implement future gamified digital tools to address vaccination hesitancy.

A search for peer-reviewed articles published between July 2009 and August 2019 led to 7 articles meeting inclusion criteria. Game modalities and gamification elements were diverse (e.g., avatars, challenges, informative feedback, points, levels, leaderboards, storytelling), but role play and a reward system were present in all studies. Of the 7 games, 4 were Web-based and 3 were mobile apps; 1 study also used a social networking site. Of the 7 studies, 3 described tools that were co-created by several stakeholders, including health professionals, developers, and end users. All gamified digital tools were promoted and funded through health authorities for public health purposes and universities for educational purposes.

The articles included a mixture of randomised controlled trials (RCTs), quasi-experimental studies, and studies comprising quantitative and qualitative measures. All studies but one explicitly incorporated one or more behavioural theories: self-determination theory, health belief model, self-concept theory, theory of reasoned action and planned behaviour, game theory, social value orientation, nudge theory, and the empowerment model.

To assess the effectiveness of gamified digital tools for vaccination, the researchers took into account 3 types of outcomes: behaviour (e.g., real actions like receiving a vaccination or intent to get vaccinated), cognition (e.g., increased knowledge of the topic or vaccine literacy), and usability/acceptability (e.g., appreciation of the intervention). Furthermore, detailed outcomes of the evaluation of each game were individually reported; in brief:

• Flu Busters! - Sample finding: 92% of those who played the game agreed to be vaccinated, compared to 42% of a group of 12 clinic patients at the same premises who did not play the game.
• I-Vax - Sample finding: Results showed that the reaction to the game varied by personality, but that the game could contribute to a better understanding of vaccination behaviour and vaccine hesitancy.
• FightHPV - Sample finding: After playing the game, concepts about human papillomavirus (HPV) vaccination were better understood, and an increase in HPV knowledge was observed (P=.001).
• Land of Secret Gardens - Sample finding: The game was appreciated as an opportunity to enhance communication about HPV between preteens and parents.
• VAX! - Sample finding: Although results were not statistically significant, data analysis indicated an increase in gain scores for risk perception, self-efficacy, and behavioural intention when participants were able to customise their avatar to look like their ideal or actual self. After playing the game, participants declared their intent to get vaccinated.
• MorbiQuiz - Sample finding: Players reported significantly higher intention to vaccinate (P=.03) and more confidence in the decision (P=.006). Focus group participants stressed that the game invited users to seek information actively, thanks to its gamified approach.
• Stop the Spread - Sample finding: After playing, participants reported that their knowledge about sneezing behaviours and vaccinations increased significantly (P<.05).

Reflecting on the findings, the researchers suggest that effectiveness in terms of behaviour change in the 4 studies that reported data on that type of outcome might be explained by the fact that gamification tends to improve the involvement and motivation of users, who feel more convinced of their decision after playing. Games are thought to provide a medium for increasing self-efficacy and changing behaviour, as they offer the opportunity for a new experience in a safe environment, without real-life consequences to making wrong decisions.

Positive findings on cognition, which were reported by 3 of the studies, corresponded to increased knowledge and literacy about vaccination. These results might be explained by the learning-by-doing approach used in gamified digital tools, where players learn through exploration and experimentation.

Results on usability/acceptability were reported by 3 studies. The researchers suggest that the co-construction process (including different stakeholders) can increase commitment to and acceptability of games. Among successful game features, role play or characterisation, the earning and losing of tokens, and advancing levels were the 3 modalities that were the most used and accepted by users across all studies. For example, following a herd immunity approach, some of the games under study asked users to interact with and confront other imaginary characters to explain the collective dimension and community-level impact of vaccination. Immersive storytelling could also have enhanced engagement and subsequent retention of key messages.

Recommendations for the design of future interventions include, in brief:

• Use a narrative approach with an appropriate storyline to engage, motivate, and empower users throughout the learning process, ensuring that the educational perspective is implicit.
• Create emotional engagement between the player and the environment (e.g., through use of avatars and levels), avoiding creating frustration with levels that are too difficult for the particular audience.
• Strike a balance between simplicity and attractiveness, using concise text and amusing characters and animations.
• Co-construct the game with all concerned stakeholders to ensure that it is appropriate for the intended audience.
• Consider the cost of a gamified digital intervention, which is usually quite high.

The researchers also stress that, given the speed at which technology changes and improves, monitoring new digital tools is essential. Preferred study designs are RCTs or any other experimental design with a control group, combined with longitudinal data collection. If possible, the 3 types of outcomes studied here should be measured. Such evaluations could help build understanding of how gamified digital tools can change vaccination uptake and coverage.

In short, all 7 studies presented positive results in terms of pre-established outcomes (i.e., behaviour, cognition, and usability/acceptability), which for the researchers confirms that gamified digital tools can facilitate communication of vaccination-related messages and contribute to increased vaccination uptake. "Especially during this period of disinformation about vaccination circulating on the internet, gamified digital tools can help provide more accurate information, while being fun and engaging."