Co-Designing and Pilot Testing a Digital Game to Improve Vaccine Attitudes and Misinformation Resistance in Ghana

"These results demonstrate the effectiveness of a digital game in building public resilience against vaccine misinformation as well as improving vaccine attitudes and intent to get vaccinated."

Misinformation related to vaccines has been shown to potentially negatively impact public perceptions and intentions to vaccinate in many contexts. Psychological inoculation - an intervention that involves warning recipients about the misleading techniques used in misinformation - could preemptively boost public resistance against misinformation. One such intervention, the interactive digital game Cranky Uncle Vaccine, was originally developed and tested in East Africa. This paper documents the subsequent co-design process of Cranky Uncle Vaccine in Ghana, West Africa, and reports results of a pilot study testing the game's effectiveness in improving vaccine attitudes and discernment between vaccine facts and misinformation.

The paper begins by providing an explanation of innoculation theory, which relies on two primary mechanisms: (i) forewarnings or threats of counter-attitudinal attacks to stimulate resistance and (ii) preemptive refutation of these attacks to guide the process of counterarguing and equip individuals with specific content to counter future persuasive challenges. Next is a review of the concept of gamification, which involves incorporation of key elements of games, such as fun, rewards, and competition, into non-game settings to enhance user engagement.

Drawing on these elements is Cranky Uncle Vaccine, a misinformation game focused on the 10 most common fallacies found in vaccine misinformation. Available on smartphones and browsers, the game features, for example, a healthcare worker explaining facts about vaccines and vaccine research (fact-based inoculation) and the cranky uncle character explaining a misinformation technique he uses to cast doubt on vaccine facts. As detailed at Related Summaries, below, the game's content, including the fallacy explanations, game play, and cartoon characters, were refined in a series of co-design workshops held in Uganda, Kenya, and Rwanda. This process resulted in a single version of the game developed for the three East African countries, which was subsequently pilot-tested in Uganda and Kenya.

To refine content for the Ghana version of the game, co-creation workshops were organized in the Volta and the Greater Accra regions with young people, health workers, and health promotion officers from those two regions. During the various sessions, the East African version of the game was presented to the participants through printed out copies, scenario cards, and feedback questionnaires. Feedback from the workshops were collated to inform visual design of the game's characters. For example, the younger characters were dressed in modern clothes and accessories such as headphones and watches.

In order to evaluate how effectively the game could be used to assess vaccine-related behaviours in Ghana, a pilot study was carried out on a sample size of 829 participants, composed of university students and health workers in Ghana. Pilot participants filled out surveys before and after playing the game, measuring vaccine attitudes (pre-game mean (M) = 3.4, post-game M = 3.6), intent to get vaccinated (pre-game M = 3.5, post-game M = 3.6), and discernment between vaccine facts and fallacies (pre-game area under the curve (AUC) = 0.72, post-game AUC = 0.75).

The researchers observed a significant improvement in attitudes toward vaccines, with players demonstrating increased likelihood to get vaccinated after completing the game. Among players who indicated they were unlikely to get vaccinated in the pre-game survey (N = 52, or 6.3% of participants), just over half of these participants (53%) switched to likely to get vaccinated after playing the game. Perceived reliability of vaccine facts remained the same, while perceived reliability of vaccine fallacies significantly decreased, indicating improved ability to spot misleading arguments about vaccines.

Some participants reported a transformative effect on their understanding of vaccines. Participants also reported finding the real-world examples of misinformation instructive, commenting on "how relatable the situations are". One notable piece of feedback on what participants would like changed was a request for audio of characters talking. It would be worth exploring whether this feature could be automated (to avoid having to rely on voice actors for each region that the game is released in).

The content from the Cranky Uncle Vaccine game has been converted to other formats and released in Ghana. A WhatsApp chatbot version of the Cranky Uncle Vaccine game was developed in collaboration with Ghana-based team of global mobile-based intervention company Viamo. For the chatbot game, the content was simplified with the 10 misinformation tricks streamlined down to seven techniques. In addition, an interactive voice response (IVR) version was also developed and translated into five local Ghanaian dialects (Dagabni, Ewe, Ga, Hausa, Twi), with the IVR game being made available on the UNICEF Agoo mobile platform.

"To conclude, this study has added to previous research finding that the Cranky Uncle Vaccine game is effective across multiple African countries in improving vaccine attitudes and intent, as well as increasing players' ability to discern misinformation. Further,...[this] intervention is effective in the Global South, helping to address the issue that over 80% of research into misinformation interventions to date has been conducted in the Global North....Nevertheless, replication of the positive impact of the game across different countries adds to research finding that inoculation is an effective tool against misinformation and digital games offer a scalable means to reach large and diverse populations."