Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review

"Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions."

Vaccine hesitancy is one reason some people are un- or undervaccinated. Along with traditional communication strategies, the use of other strategies to inform and educate about immunisations - for example, with digital gamified tools (e.g., apps) - may help encourage vaccine uptake. Gamification is defined as the use of game design elements (e.g., rewards systems) in nongame contexts. This scoping review describes digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools.

The researchers searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. They also conducted web searches with Google in May 2022 to identify digital gamified tools lacking associated publications. They consulted 12 experts in the field of gamification and health behaviour to identify any papers or tools they might have missed.

The final data set included 28 peer-reviewed papers and 11 digital gamified tools. The studies were conducted in 26 different countries, with sample sizes ranging from 8 to 50,286. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. The 11 digital gamified tools included in the study featured 6 types of gamified elements: reward points, serious games, physical trading cards, certificates, role-playing, and quizzes.

Overall, tools that were evaluated showed that gamification can increase predictors of vaccine uptake, such as knowledge, attitudes, beliefs, behaviours, and vaccination intention:

• Eleven (39%) of the 28 studies evaluated the effects of digital gamified tools on behavioural intentions with regard to vaccines. Ten of these studies, 3 (30%) of medium quality and 7 (70%) of high quality (≥75%), showed increased intentions to vaccinate. When considering only the high-quality (≥80%) studies, digital gamified tools appeared to be consistently associated with increased vaccination intention.
• Of 7 (25%) studies that assessed knowledge, 6 (86%) showed an increase in knowledge about immunisation in general. All these 6 (86%) studies were of high quality (≥80%).
• Digital gamified tools demonstrated positive effects on beliefs toward vaccination. All 3 (11%) of the 28 studies that evaluated the effects of digital gamified tools on beliefs toward vaccination showed positive effects on beliefs toward vaccination.
• With regard to effects on attitudes (for or against vaccination), when considering only the high-quality (≥80%) studies, the researchers observed inconsistent effects.
• Nine (32%) of 28 studies evaluated the effects of digital gamified tools on other outcomes. When considering only the high-quality (≥80%) studies, the researchers observed a variety of positive effects associated with digital gamified tools, including confidence in vaccines, confidence in decisions about vaccines, empathy toward vulnerable people, collective responsibility, psychological empowerment, and vaccination self-efficacy and readiness.

The researchers did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others.

Reflecting on the findings, the researchers stress that "context is key. Although an engaging approach may work for some groups or in some situations, it may be less well accepted among other groups and in other situations. For instance, a casual and approachable style of communication will work for the younger audience to convey vaccine information but might be deemed insufficient to health care professionals in a more formal setting, such as hospitals....Future research in this area should consider possible contextual factors, such as local culture, social and demographic characteristics of users, and different influences on vaccine hesitancy and acceptance in different regions. To help better match games to the context(s) in which they will be played, when developing games, developers and researchers may wish to consider involving potential players from different contexts early and often."

In conclusion, this study "emphasizes the importance of a comprehensive approach that fosters a mutually beneficial relationship between technological innovation, evidence-based strategies, and an intricate understanding of local contexts. This approach has the potential to make gamification a sustainable and adaptable tool in the arsenal of public health interventions, rather than just a passing trend."