Pilot Testing a French and Kinyarwandan Game to Improve Vaccine Attitudes and Misinformation Resilience in Rwanda
Main Article Content
Abstract
Vaccine misinformation causes negative impacts such as decreased vaccine acceptance and reduced intent to get vaccinated. The association between susceptibility to vaccine misinformation and vaccine hesitancy underscores the need for interventions that increase public resilience against misinformation. One promising intervention is psychological inoculation, where recipients receive a “weakened form” of misinformation to build immunity to real-world misinformation. Misinformation is delivered in weakened form by exposing its misleading techniques. Cranky Uncle Vaccine is an interactive, digital game that applies inoculation theory, explaining facts about vaccines as well as the misleading techniques used to cast doubt on the facts. We document a pilot study testing the effectiveness of an East African version of Cranky Uncle Vaccine conducted in Rwanda. Two translations of the game were made available with participants choosing either a Kinyarwandan-speaking (n = 535) or French-speaking (n = 499) version. Among Kinyarwandan-speaking players, the average age was 27.8 years with more males (52.7%) than females (46.9%). Among French-speaking players, the average age was 29.9 years with more males (55.3%) than females (44.7%). Among both languages, participants were highly educated (median education level “Some/all university”). Before and after playing the game, participants filled out surveys measuring vaccine attitudes and discernment between facts and fallacies. French-speaking participants showed significant improvement in general vaccine attitude and vaccine importance but while the change in intent to get vaccinated was positive, it was not statistically significant. Kinyarwandan-speaking players showed significant improvement in general vaccine attitude, vaccine importance, and intent to get vaccinated. The game was most effective among players who expressed vaccine hesitancy in the pre-game survey with 55% of hesitant French-speaking participants and 71% of Kinyarwandan-speaking participants switching to being likely to get vaccinated. These results show that a digital game employing an inoculation approach is effective in building public resilience against vaccine misinformation and boosting vaccine acceptance, particularly among those expressing vaccine hesitancy.
Keywords:
vaccination; Rwanda; misinformation; inoculation; games
Article Details
How to Cite
COOK, John et al.
Pilot Testing a French and Kinyarwandan Game to Improve Vaccine Attitudes and Misinformation Resilience in Rwanda.
Medical Research Archives, [S.l.], v. 13, n. 3, mar. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6421>. Date accessed: 06 apr. 2025.
doi: https://doi.org/10.18103/mra.v3i3.6421.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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24. Cook J, Lewandowsky S, Ecker UKH. Neutralizing misinformation through inoculation: Exposing misleading argumentation techniques reduces their influence. PLoS One. 2017;12(5):e0 175799. doi:10.1371/journal.pone.0175799
25. Morris DS, Morris JS, Francia PL. A fake news inoculation? Fact checkers, partisan identification, and the power of misinformation. Politics, Groups, and Identities. 2020;8(5):19.
26. Schmid P, Betsch C. Effective strategies for rebutting science denialism in public discussions. Nat Hum Behav. Sep 2019;3(9):931-939. doi:10.1038/s41562-019-0632-4
27. Basol M, Roozenbeek J, Berriche M, Uenal F, McClanahan WP, Linden SVD. Towards psychological herd immunity: Cross-cultural evidence for two prebunking interventions against COVID-19 misinformation. Big Data & Society. 2021;8(1)
28. Bonetto E, Troïan J, Varet F, Lo Monaco G, Girandola F. Priming resistance to persuasion decreases adherence to conspiracy theories. Social Influence. 2018;13(3):12.
29. McCright AM, Charters M, Dentzman K, Dietz T. Examining the Effectiveness of Climate Change Frames in the Face of a Climate Change Denial Counter-Frame. Top Cogn Sci. Jan 2016;8(1):76-97. doi:10.1111/tops.12171
30. van der Linden S, Leiserowitz A, Rosenthal S, Maibach E. Inoculating the Public against Misinformation about Climate Change. Glob Chall. Feb 27 2017;1(2):1600008. doi:10.1002/gch2.2016 00008
31. Vraga EK, Kim SC, Cook J, Bode L. Testing the effectiveness of correction placement and type on Instagram. The International Journal of Press/ Politics. 2020;25(4):20.
32. Modirrousta-Galian A, Higham PA. Gamified inoculation interventions do not improve discrimination between true and fake news: Reanalyzing existing research with receiver operating characteristic analysis. J Exp Psychol Gen. Sep 2023;152(9):2411-2437. doi:10.1037/xge0001395
33. Guess AM, Lerner M, Lyons B, et al. A digital media literacy intervention increases discernment between mainstream and false news in the United States and India. Proc Natl Acad Sci U S A. Jul 7 2020;117(27):15536-15545. doi:10.1073/pnas.192 0498117
34. Pennycook G, Rand DG. The Psychology of Fake News. Trends Cogn Sci. May 2021;25(5):388-402. doi:10.1016/j.tics.2021.02.007
35. Cook J. Deconstructing climate science denial. In: Holmes D, Richardson LM, eds. Edward Elgar Research Handbook in Communicating Climate Change Edward Elgar.; 2020:62–78.
36. Piltch-Loeb R, Su M, Hughes B, et al. Testing the Efficacy of Attitudinal Inoculation Videos to Enhance COVID-19 Vaccine Acceptance: Quasi-Experimental Intervention Trial. JMIR Public Health Surveill. Jun 20 2022;8(6):e34615. doi:10.2196/34615
37. Roozenbeek J, van der Linden S. Fake news game confers psychological resistance against online misinformation. Palgrave Communications. 2019;5(1):1-10.
38. Cook J, Ellerton P, Kinkead D. Deconstructing climate misinformation to identify reasoning errors. Environmental Research Letters. 2018;13(2)
39. Kim SC, Vraga EK, Cook J. An Eye Tracking Approach to Understanding Misinformation and Correction Strategies on Social Media: The Mediating Role of Attention and Credibility to Reduce HPV Vaccine Misperceptions. Health Commun. Nov 2021;36(13):1687-1696. doi:10.1080/10410236.20 20.1787933
40. Cook J, Ecker UK, Trecek-King M, et al. The cranky uncle game—combining humor and gamification to build student resilience against climate misinformation. Environmental Education Research. 2023;29(4):607-623.
41. Hopkins KL, Lepage C, Cook W, et al. Co-Designing a Mobile-Based Game to Improve Misinformation Resistance and Vaccine Knowledge in Uganda, Kenya, and Rwanda. J Health Commun. Oct 31 2023;28(sup2):49-60. doi:10.1080/108107 30.2023.2231377
42. Cook J, Njomo D, Aura C, et al. Improving Vaccine Attitudes and Misinformation Resistance through Gamification: An Experimental Intervention in Kenya and Uganda. 2024;
43. Cook J, Lepage C, Hopkins KL, et al. Co-designing and pilot testing a digital game to improve vaccine attitudes and misinformation resistance in Ghana. Hum Vaccin Immunother. Dec 31 2024;20(1):2407204. doi:10.1080/21645515.20 24.2407204
44. Ellingson MK, Omer SB, Sevdalis N, Thomson A. Validation of the Vaccination Trust Indicator (VTI) in a multi-country survey of adult vaccination attitudes. PLOS Glob Public Health. 2023;3(4):e0001820. doi:10.1371/journal.pgph.00 01820
45. Wood ML. Rethinking the inoculation analogy: Effects on subjects with differing preexisting attitudes. Human communication research. 2007;33(3):357-378.
46. Compton J. Prophylactic versus therapeutic inoculation treatments for resistance to influence. Communication Theory. 2020;30(3):330-343.
47. Ivanov B, Miller CH, Compton J, et al. Effects of postinoculation talk on resistance to influence. Journal of Communication. 2012;62(4): 701-718.
48. Ivanov B, Sims JD, Compton J, et al. The general content of postinoculation talk: Recalled issue-specific conversations following inoculation treatments. Western Journal of Communication. 2015;79(2):218-238.
49. Randall S, Leask J, Robinson P, et al. Underpinning of the sharing knowledge about immunisation (SKAI) communication approach: A qualitative study using recorded observations. Patient Educ Couns. Jun 2020;103(6):1118-1124. doi:10.1016/j.pec.2019.12.014
50. Parker KA, Ivanov B, Compton J. Inoculation's efficacy with young adults' risky behaviors: can inoculation confer cross-protection over related but untreated issues? Health Commun. 2012;27 (3):223-33. doi:10.1080/10410236.2011.575541
51. Blair RA, Gottlieb J, Nyhan B, Paler L, Argote P, Stainfield CJ. Interventions to counter misinformation: Lessons from the Global North and applications to the Global South. Curr Opin Psychol. Feb 2024;55:101732. doi:10.1016/j.copsyc.2023.1 01732
52. Swim JK, Fraser J, Geiger N. Teaching the choir to sing: Use of social science information to promote public discourse on climate change. Journal of Land Use & Environmental Law. 2014:91-117.
2. Singh K, Lima G, Cha M, et al. Misinformation, believability, and vaccine acceptance over 40 countries: Takeaways from the initial phase of the COVID-19 infodemic. PLoS One. 2022;17(2):e026 3381. doi:10.1371/journal.pone.0263381
3. Loomba S, de Figueiredo A, Piatek SJ, de Graaf K, Larson HJ. Measuring the impact of COVID-19 vaccine misinformation on vaccination intent in the UK and USA. Nat Hum Behav. Mar 2021;5(3):337-348. doi:10.1038/s41562-021-010 56-1
4. Pickles K, Cvejic E, Nickel B, et al. COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey. J Med Internet Res. Jan 7 2021;23(1):e23805. doi:10.2196/23805
5. Dash S, Parray AA, De Freitas L, et al. Combating the COVID-19 infodemic: a three-level approach for low and middle-income countries. BMJ Glob Health. Jan 2021;6(1) doi:10.1136/bmjgh-2020-004671
6. McIntyre KSC, M.; Semujju, B.; Ireri, K.; Munyarukumbuzi, E. Misinformation literacy of COVID-19 digital news in Kenya, Rwanda and Uganda. African Journalism Studies. 2023;33(2):17.
7. Ewongwo A, Sahor AF, Ngwa W, Nwachukwu C. A guide to global access to HPV vaccination to all women in low- and middle-income countries; a minireview of innovation and equity. Front Oncol. 2024;14:1380663. doi:10.3389/fonc.2024.1380663
8. Binagwaho A, Wagner CM, Gatera M, Karema C, Nutt CT, Ngabo F. Achieving high coverage in Rwanda's national human papillomavirus vaccination programme. Bull World Health Organ. Aug 1 2012;90(8):623-8. doi:10.2471/BLT.11.09 7253
9. Gatera M, Bhatt S, Ngabo F, et al. Successive introduction of four new vaccines in Rwanda: High coverage and rapid scale up of Rwanda's expanded immunization program from 2009 to 2013. Vaccine. Jun 17 2016;34(29):3420-6. doi:10.1016/j.vaccine.2015.11.076
10. Mbonigaba E, Yu F, Renosa MDC, et al. Knowledge and trust of mothers regarding childhood vaccination in Rwanda. BMC Public Health. Apr 17 2024;24(1):1067. doi:10.1186/s12889-024-18547-1
11. Bao J, McAlister H, Robson J, et al. Near universal childhood vaccination rates in Rwanda: how was this achieved and can it be duplicated? The Lancet Global Health. 2018;6
12. Ndishimye PM, G. S.; Hewins, B.; Ostadgavahi, A. T.; Kumar, A.; Sharma, M.; Kelvin, D. COVID-19 vaccination coverage and linkages with public willingness to receive vaccination prior to vaccine roll-out: Evidence from Rwanda. medRxiv. 2023;2023-03
13. Vosoughi S, Roy D, Aral S. The spread of true and false news online. Science. Mar 9 2018;359 (6380):1146-1151. doi:10.1126/science.aap9559
14. Chan MS, Jones CR, Hall Jamieson K, Albarracin D. Debunking: A Meta-Analysis of the Psychological Efficacy of Messages Countering Misinformation. Psychol Sci. Nov 2017;28(11):1531-1546. doi:10.1177/0956797617714579
15. Ecker UK, Lewandowsky S, Cook J, et al. The psychological drivers of misinformation belief and its resistance to correction. Nature Reviews Psychology. 2022;1(1):16.
16. Pennycook G, Cannon TD, Rand DG. Prior exposure increases perceived accuracy of fake news. J Exp Psychol Gen. Dec 2018;147(12):1865-1880. doi:10.1037/xge0000465
17. MacFarlane D, Tay LQ, Hurlstone MJ, Ecker UKH. Refuting Spurious COVID-19 Treatment Claims Reduces Demand and Misinformation Sharing. J Appl Res Mem Cogn. Jun 2021;10(2):248-258. doi:10.1016/j.jarmac.2020.12.005
18. Roozenbeek J, Traberg CS, van der Linden S. Technique-based inoculation against real-world misinformation. R Soc Open Sci. May 2022;9 (5):211719. doi:10.1098/rsos.211719
19. McGuire WJ, Papageorgis D. Effectiveness of forewarning in developing resistance to persuasion. Public opinion quarterly. 1962;26(1):11.
20. Lewandowsky S, van Der Linden S. Countering misinformation and fake news through inoculation and prebunking. European review of social psychology. 2021;32(2):36.
21. Banas JA, Miller G. Inducing resistance to conspiracy theory propaganda: Testing inoculation and metainoculation strategies. Human communication research. 2013;39(2):23.
22. Compton J. Threat and/in inoculation theory. International Journal of Communication. 2021;15:13.
23. Compton J, Jackson B, Dimmock JA. Persuading Others to Avoid Persuasion: Inoculation Theory and Resistant Health Attitudes. Front Psychol. 2016;7:122. doi:10.3389/fpsyg.2016.00122
24. Cook J, Lewandowsky S, Ecker UKH. Neutralizing misinformation through inoculation: Exposing misleading argumentation techniques reduces their influence. PLoS One. 2017;12(5):e0 175799. doi:10.1371/journal.pone.0175799
25. Morris DS, Morris JS, Francia PL. A fake news inoculation? Fact checkers, partisan identification, and the power of misinformation. Politics, Groups, and Identities. 2020;8(5):19.
26. Schmid P, Betsch C. Effective strategies for rebutting science denialism in public discussions. Nat Hum Behav. Sep 2019;3(9):931-939. doi:10.1038/s41562-019-0632-4
27. Basol M, Roozenbeek J, Berriche M, Uenal F, McClanahan WP, Linden SVD. Towards psychological herd immunity: Cross-cultural evidence for two prebunking interventions against COVID-19 misinformation. Big Data & Society. 2021;8(1)
28. Bonetto E, Troïan J, Varet F, Lo Monaco G, Girandola F. Priming resistance to persuasion decreases adherence to conspiracy theories. Social Influence. 2018;13(3):12.
29. McCright AM, Charters M, Dentzman K, Dietz T. Examining the Effectiveness of Climate Change Frames in the Face of a Climate Change Denial Counter-Frame. Top Cogn Sci. Jan 2016;8(1):76-97. doi:10.1111/tops.12171
30. van der Linden S, Leiserowitz A, Rosenthal S, Maibach E. Inoculating the Public against Misinformation about Climate Change. Glob Chall. Feb 27 2017;1(2):1600008. doi:10.1002/gch2.2016 00008
31. Vraga EK, Kim SC, Cook J, Bode L. Testing the effectiveness of correction placement and type on Instagram. The International Journal of Press/ Politics. 2020;25(4):20.
32. Modirrousta-Galian A, Higham PA. Gamified inoculation interventions do not improve discrimination between true and fake news: Reanalyzing existing research with receiver operating characteristic analysis. J Exp Psychol Gen. Sep 2023;152(9):2411-2437. doi:10.1037/xge0001395
33. Guess AM, Lerner M, Lyons B, et al. A digital media literacy intervention increases discernment between mainstream and false news in the United States and India. Proc Natl Acad Sci U S A. Jul 7 2020;117(27):15536-15545. doi:10.1073/pnas.192 0498117
34. Pennycook G, Rand DG. The Psychology of Fake News. Trends Cogn Sci. May 2021;25(5):388-402. doi:10.1016/j.tics.2021.02.007
35. Cook J. Deconstructing climate science denial. In: Holmes D, Richardson LM, eds. Edward Elgar Research Handbook in Communicating Climate Change Edward Elgar.; 2020:62–78.
36. Piltch-Loeb R, Su M, Hughes B, et al. Testing the Efficacy of Attitudinal Inoculation Videos to Enhance COVID-19 Vaccine Acceptance: Quasi-Experimental Intervention Trial. JMIR Public Health Surveill. Jun 20 2022;8(6):e34615. doi:10.2196/34615
37. Roozenbeek J, van der Linden S. Fake news game confers psychological resistance against online misinformation. Palgrave Communications. 2019;5(1):1-10.
38. Cook J, Ellerton P, Kinkead D. Deconstructing climate misinformation to identify reasoning errors. Environmental Research Letters. 2018;13(2)
39. Kim SC, Vraga EK, Cook J. An Eye Tracking Approach to Understanding Misinformation and Correction Strategies on Social Media: The Mediating Role of Attention and Credibility to Reduce HPV Vaccine Misperceptions. Health Commun. Nov 2021;36(13):1687-1696. doi:10.1080/10410236.20 20.1787933
40. Cook J, Ecker UK, Trecek-King M, et al. The cranky uncle game—combining humor and gamification to build student resilience against climate misinformation. Environmental Education Research. 2023;29(4):607-623.
41. Hopkins KL, Lepage C, Cook W, et al. Co-Designing a Mobile-Based Game to Improve Misinformation Resistance and Vaccine Knowledge in Uganda, Kenya, and Rwanda. J Health Commun. Oct 31 2023;28(sup2):49-60. doi:10.1080/108107 30.2023.2231377
42. Cook J, Njomo D, Aura C, et al. Improving Vaccine Attitudes and Misinformation Resistance through Gamification: An Experimental Intervention in Kenya and Uganda. 2024;
43. Cook J, Lepage C, Hopkins KL, et al. Co-designing and pilot testing a digital game to improve vaccine attitudes and misinformation resistance in Ghana. Hum Vaccin Immunother. Dec 31 2024;20(1):2407204. doi:10.1080/21645515.20 24.2407204
44. Ellingson MK, Omer SB, Sevdalis N, Thomson A. Validation of the Vaccination Trust Indicator (VTI) in a multi-country survey of adult vaccination attitudes. PLOS Glob Public Health. 2023;3(4):e0001820. doi:10.1371/journal.pgph.00 01820
45. Wood ML. Rethinking the inoculation analogy: Effects on subjects with differing preexisting attitudes. Human communication research. 2007;33(3):357-378.
46. Compton J. Prophylactic versus therapeutic inoculation treatments for resistance to influence. Communication Theory. 2020;30(3):330-343.
47. Ivanov B, Miller CH, Compton J, et al. Effects of postinoculation talk on resistance to influence. Journal of Communication. 2012;62(4): 701-718.
48. Ivanov B, Sims JD, Compton J, et al. The general content of postinoculation talk: Recalled issue-specific conversations following inoculation treatments. Western Journal of Communication. 2015;79(2):218-238.
49. Randall S, Leask J, Robinson P, et al. Underpinning of the sharing knowledge about immunisation (SKAI) communication approach: A qualitative study using recorded observations. Patient Educ Couns. Jun 2020;103(6):1118-1124. doi:10.1016/j.pec.2019.12.014
50. Parker KA, Ivanov B, Compton J. Inoculation's efficacy with young adults' risky behaviors: can inoculation confer cross-protection over related but untreated issues? Health Commun. 2012;27 (3):223-33. doi:10.1080/10410236.2011.575541
51. Blair RA, Gottlieb J, Nyhan B, Paler L, Argote P, Stainfield CJ. Interventions to counter misinformation: Lessons from the Global North and applications to the Global South. Curr Opin Psychol. Feb 2024;55:101732. doi:10.1016/j.copsyc.2023.1 01732
52. Swim JK, Fraser J, Geiger N. Teaching the choir to sing: Use of social science information to promote public discourse on climate change. Journal of Land Use & Environmental Law. 2014:91-117.