Co-Designing a Mobile-Based Game to Improve Misinformation Resistance and Vaccine Knowledge in Uganda, Kenya, and Rwanda

"...a template for developing locally relevant interventions to counter future infodemics..."

Vaccine misinformation can have a serious negative impact on vaccination uptake. Misinformation disproportionately affects marginalised populations within low- and middle-income countries (LMICs), which often have lower trust in and exposure to official health information sources. This paper has 3 objectives, which are: (i) to provide background on evidence-based theories and strategies to combat misinformation; (ii) to describe Cranky Uncle, an evidence-based online game designed to combat science denialism; and (iii) to document the development of the vaccination-related Cranky Uncle version and its co-design process for the East African setting.

The paper begins with an outline of various evidence-based theories and strategies to combat misinformation, including:

• Inoculation theory: Similar to biological vaccination, inoculation theory posits that exposure to a weakened form of misinformation can develop cognitive immunity, reducing the likelihood of being misled. Two common inoculation approaches are: (i) fact-based inoculations, which expose how the misinformation is wrong through factual explanations; and (ii) logic-based inoculations, which are more generalisable because they explain the misleading rhetorical techniques or logical fallacies used in misinformation.
• The FLICC taxonomy: This acronym represents five categories of misleading rhetorical techniques: Fake experts (F), Logical fallacies (L), Impossible expectations (I), Cherry picking (C), and Conspiracy theories (C). Applying the FLICC framework to vaccine-related misinformation enables the identification of the key misleading techniques used to confuse the public about vaccination.
• Parallel argumentation: This pedagogical approach involves transplanting the false logic from misinformation into a parallel or analogous concrete, everyday example. A logic-based approach like this one may demonstrate how an argument is false without lengthy explanations of complex information.
• Humour: Humour can take many forms, such as wordplay, anthropomorphism, and satire. The use of humourous parallel arguments to explain the logical fallacies in misinformation has been found to be effective in neutralising misinformation about vaccines. More generally, humour has been shown to be effective for communicating information about health, science, and social issues to the general public.
• Games: A subset of digital serious games has the particular educational goal of building players' resilience against misinformation. In active inoculation games, players learn the techniques of science denial by interactively learning to use the misleading techniques themselves in an ironic fashion. Games can combine the interactive inoculation approach with other gameplay elements, such as being made to repeatedly practice identifying misinformation.

In December 2020, the digital game Cranky Uncle was released on iPhone, Android, and browser. The game combined previous research on logic-based inoculation, critical thinking, humour-based corrections, and active inoculation and gamification to psychologically inoculate players against science denialism, particularly surrounding climate change. In 2022, a new collaboration between UNICEF, the Sabin Vaccine Institute (Sabin), and Irimi Company enabled the development of the Cranky Uncle Vaccine. This version focused on reducing the influence of vaccine misinformation and, as a secondary goal, fostering trust in vaccines at both the individual- and community-level. To enable global roll-out of this intervention, this collaboration aims to create and launch regionalised versions of the game featuring appropriately localised content adapted through co-design workshops with local implementation partners and UNICEF Country Offices. To inform the design of the first regional version for East Africa, a co-design process was conducted, with workshops run in: Kampala, Uganda; Kitale, Kenya; and Kigali, Rwanda.

The paper describes the full co-design methodology. In brief, during four 3-hour focus groups per country setting, workshop participants offered feedback on cartoon character design, gameplay experience, and the game's content. During these sessions, participants spent up to 45-minutes playing a prototype of the Cranky Uncle Vaccine game, completing a pre- and post-gameplay survey to assess the game's effectiveness in increasing misinformation resiliency.

Specific steps were taken to engage participants in helping to make the game more culturally relevant and avoid unintended consequences in East African countries. For example, alongside the co-facilitator, participants read the scripts line-by-line, pausing to discuss any needed simplification, further explanation, or cultural translation of words, phrases, or examples in the game (e.g., conspiracy theories) that might potentially cause confusion to users. They then offered suggested revisions to the script. Participants made other recommendations, such as the introduction of additional characters (e.g., a pregnant woman, a child, a person with disabilities) in order to better reflect the diversity of their societies. Young people, in particular, had many ideas on how to make the game more entertaining, such as giving players audio notification or a visual reward for leveling up.

Concurrent with the co-design workshops, stakeholder meetings were conducted in Uganda, Kenya, and Rwanda to lay the groundwork for a nationwide promotional plan to disseminate the game in each country once validated through pilot studies. "If the co-designed game is found effective through a subsequent pilot study validation, this methodology provides a blueprint for further adaptation of the Cranky Uncle Vaccine to other regions, as well as replication of locally relevant intervention development to counter future infodemics." Stakeholders are also exploring how Cranky Uncle Vaccine could be integrated within broader, existing immunisation, communication, or education programmes or services, such as educational curriculum within schools or health promotion outreach activities.

In conclusion: "The development of the Cranky Uncle Vaccine combined science, technology, psychology, education, and the arts, then iterated the content directly with community members, through the co-design process. This resulted in a game that is more locally relevant and resonant, with the goal of maximizing its effectiveness in increasing vaccine acceptance and resistance to misinformation."