This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.
Vaccine hesitancy is one of the many factors impeding efforts to control the COVID-19 pandemic. Exacerbated by the COVID-19 infodemic, misinformation has undermined public trust in vaccination, led to greater polarization, and resulted in a high social cost where close social relationships have experienced conflict or disagreements about the public health response.
The purpose of this paper is to describe the theory behind the development of a digital behavioral science intervention—
Recruitment will commence in early 2023 and will cease once 450 participants complete the study (225 per group). The primary outcome is improvement in open conversation skills. Secondary outcomes are self-efficacy and behavioral intentions to have an open conversation with a vaccine-hesitant individual. Exploratory analyses will examine the effect of the game on implementation intentions as well as potential covariates or subgroup differences based on sociodemographic information or previous experiences with COVID-19 vaccination conversations.
The outcome of the project is to promote more open conversations regarding COVID-19 vaccination. We hope that our approach will encourage more governments and public health experts to engage in their mission to reach their citizens directly with digital health solutions and to consider such interventions as an important tool in infodemic management.
PRR1-10.2196/40753
Vaccine hesitancy is one of the many factors impeding public health efforts to control the COVID-19 pandemic [
The aim of this paper is to describe the theory behind the development of a new digital behavioral science intervention—
In 2019, the WHO identified vaccine hesitancy as one of the 10 threats to public health [
The social costs of vaccine hesitancy have also been fueled by the COVID-19 infodemic, in which an overabundance of information has made it more difficult for the public to differentiate between correct and misinformation. When the public’s questions and concerns are left unanswered, information voids occur, which can lead to widespread false and misleading information. For instance, searches involving antivaccination rhetoric increased during the COVID-19 pandemic as people sought information about vaccine safety [
For instance, 56% of participants in a nationwide UK-based study reported having arguments, feeling angry, or falling out with others because of discussions surrounding COVID-19 [
We sought to develop an evidence-based behavioral science intervention that could address diverse drivers of vaccine hesitancy while also supporting individuals in managing the psychological burden of the COVID-19 pandemic. Vaccine hesitancy is context specific and falls along a dynamic continuum, with motivation toward vaccination existing on a spectrum of those who are fully, partially, or not yet vaccinated [
Reviews of a broad range of intervention approaches for addressing vaccine hesitancy report a lack of evidence or mixed findings on the effectiveness of many interventions [
In addition, personalized communication can increase COVID-19 vaccine uptake, and these interventions are most effective when tailored to and delivered by a trusted peer or community member [
Thus, the target group for the intervention is the close ties of vaccine-hesitant individuals who are vaccinated or are supportive of COVID-19 vaccination. For the purposes of this study, we refer to these individuals as
Accordingly, the goal of
Theory of change for The Good Talk! intervention. CP: conversation partner; TG: target group.
We applied the theoretical framework of boosting to guide the development of our intervention. Boosting is an evidence-based behavioral science approach that focuses on building people’s skills and competences rather than targeting a specific behavior [
The focus of boosting approaches on fostering competences aligns with the objectives and key drivers of the intervention target behavior. Competence in interpersonal communication skills is associated with positive conversational outcomes, such as personal conversational satisfaction and more positive evaluations from conversation partners [
Developing open conversation skills can also build confidence and self-efficacy in conversations [
Thus, our objective was to review the literature on open conversation skills to identify a set of simple strategies that could be integrated into a short behavioral intervention in the form of boosts. We aimed to design an intervention that would help individuals learn the effectiveness of these strategies on conversational outcomes through guidance and feedback, thus fostering participants’ self-efficacy in applying these strategies to initiate open conversations. In the following section, we will provide an overview of the evidence basis for the open conversation skills. The
We conducted a narrative review of a broad range of literature on communication approaches to identify evidence-based open conversation skills that can be designed as boosts within the intervention. To align with the goals, we searched for communication literature that focused on developing or fostering supportive relationships, promoting self-efficacy and empowerment, or on psychological or therapeutic approaches developed to support behavior change. Specifically, we explored literature on the topics presented in
Communication theories or frameworks to support behavior change (eg, motivational interviewing [
Core communication skills for fostering ongoing, supportive relationships (eg, building trust, empathy, and autonomy) [
Literature on specific topics related to persuasive communication and listening skills [
Psychological strategies on how to handle negative reactions or outcomes (eg, mindfulness and intellectual humility) [
Conversation guidelines or recommendations for health risk communications (eg, crisis communication) or on how to communicate about vaccinations [
From this literature, we identified 8 general open conversation skills that we categorized into 4 main communication objectives: to build trust and respect, be supportive, be receptive and demonstrate empathy, and practice acceptance. These objectives can be represented as a mnemonic for
The first objective focuses on building trust and rapport with the conversation partner to develop or maintain a supportive relationship or establish a partnership. The first of the 3 open conversation skills,
Offering support during a conversational exchange can facilitate relationship building and serves to foster self-efficacy in the conversation partner. The first conversation skill is to
Two open conversation skills relate to the objective to open up. First,
The final objective involves preparing the individual for a case in which their conversation will not necessarily lead to a positive outcome or observable behavior change [
We sought to deliver the intervention through a medium that had a strong evidence basis for promoting behavior change, was realistic and had strong ecological validity in terms of interpersonal communications during the COVID-19 pandemic, would motivate people to engage with the intervention, and could reach broad and diverse audiences. Gamified behavioral interventions have been found to promote positive behavior change across a variety of health-related areas, including asthma control, medication adherence, and diet [
Serious games are games that do not have “entertainment, enjoyment or fun as their primary purpose” [
Serious web-based games have the potential to reach a broad and diverse audience, can be accessed worldwide on mobile and desktop devices, and can be shared with others via web-based media. Edutainment mobile games aimed at educating remote or low-resource communities on issues such as agriculture and farming practices, health, livelihoods, and financial literacy have been disseminated in over 20 countries, with COVID-19–focused games reaching >2.7 million people across 11 countries in 2020 [
In the previous sections, we have detailed the theoretical development of
The efficacy of the intervention game will be evaluated in a preregistered randomized controlled trial. Specifically, we aim to answer the following research question: “How well does
Our primary hypothesis is as follows:
We also hypothesize the following:
Participants will be recruited to play the game via video or push notifications promoting
Previous studies evaluating the effect of similar serious games on the development of competences report small-to-medium effect sizes averaging around f=0.18 [
The intervention game was developed in collaboration with the game design company “Tiltstudio,” that has experience designing serious games including “Bad News,” “Go Viral,” and “Harmony Square,” targeting misinformation, COVID-19 misinformation, and political misinformation tactics, respectively. The game was designed to simulate messenger-type conversations between participants and close contacts in their social network. Messenger-type technologies are dyadic, informationally rich, synchronous, and mimic interpersonal communication and are therefore better suited for establishing a sense of connection and generating empathy [
The game consists of 5 chapters in which the participants have conversations with characters representing their close contacts. In the first chapter, participants are introduced to the objective of the game, that is, to have as many people attend an event that they are organizing and to earn points for the good talk skills. The participant is asked to select an avatar to represent themselves and can choose between 1 of 4 social events they would like to organize (eg, birthday party, dinner, dance party, or housewarming).
The remaining 4 chapters see the participants encounter characters within their close ties who are motivated by reactance (negative affective reaction when one feels personal freedoms are being threatened), skepticism (doubting knowledge or claims), and inertia (opposing change or action) when discussing COVID-19 measures for the social event. As the conversation develops, the player must select from ≥2 conversational responses that affect the participant’s pathway toward the game objective and the points they earn on a Good Talk Meter. The Good Talk Meter increases with response choices that represent good open conversation skills and decreases for those that represent bad open conversation skills. In each chapter, participants are guided by a
Brief overview of the goal and open conversation skills for each chapter.
Chapter | Goal |
Introduction | The participant is introduced to the objective of the game and asked to select an avatar and an event they would like to plan. An overview of |
Gain trust | The participant converses with someone who is worried about their kids not being vaccinated and whose kids are skeptical about the government’s use of COVID-19 antigen tests. The participant is encouraged to gain the trust of the conversation partner and, in turn, to encourage their partner to use open conversation skills to gain the trust of their children by expressing their concerns, finding mutual value, and supporting their kid’s autonomy. |
Offer support | In this chapter, the conversation partner mistrusts the seriousness of the pandemic, is skeptical about the evidence, and does not see a personal need to get vaccinated. The participant is encouraged to ask for the perspective of their conversation partner rather than argue, with the goal to understand their views and to continue the conversation. By acknowledging their partner’s perspective and concerns, the participant is encouraged to find some common ground so that both feel comfortable attending the event. |
Open up | The conversation partner is vaccinated but does not see a need to get the booster vaccination after reading some misinformation on the web and is reluctant to change their mind. The partner is overwhelmed by information and the impact of restrictions. By asking open questions, not being dismissive of their partner’s feelings or concerns, and accepting their points while being respectful of divergent views, the goal is to help the partner overcome their inertia. |
Don’t be sad if it doesn’t work out | In the final chapter, the participant encounters a conversation partner who is against vaccination, who mistrusts the government, and who continues to share fake news and misinformation rather than engage in an open conversation. Rather than argue, the participant is guided to not react negatively and to accept that the conversation will be unlikely to lead to a positive outcome. |
Example of The Good Talk! game interface on a web browser.
Participants who enter the game website and agree to participate in the research study will be randomized to the experimental or control group (between subjects) and complete both a pre- and postgame survey (within subjects). The experimental group will play
Participants will be asked whether they have had or are currently supportive of people getting the COVID-19 vaccination, whether they currently know someone who is hesitant toward getting the COVID-19 vaccination (and if so, their relationship with this individual), and whether they have previously tried to have a conversation about COVID-19 vaccination with a vaccine-hesitant individual.
Participants will rate how confident they are to be able to start a conversation about COVID-19 vaccination with a vaccine-hesitant individual on a 7-point scale ranging from “not at all confident” to “very confident.” The self-efficacy item will be asked in the pre- and poststudy surveys.
Participants will be asked to indicate how likely it is that they will start an open conversation about COVID-19 vaccination with a vaccine-hesitant individual in the next 4 weeks on a 7-point scale ranging from “I will definitely not start a conversation” to “I will definitely start a conversation.” Consistent with recommendations for assessing intentions, the measure uses a likelihood scale and defines a timeframe for the behavior [
Following the behavioral intention item in the poststudy survey, participants will be asked to plan their intention. Implementation intentions refer to intentions to enact a preplanned behavior and can mentally simulate the process of implementing a goal, aiding goal striving [
Participants will be provided with conversation snippets presented as messenger app messages and asked to rate each statement according to how good or bad they think the response is when having an open conversation on a 5-point scale ranging from “very bad” to “very good.” Participants will rate 8 conversation snippets in the prestudy survey and a different set of 8 conversation snippets in the poststudy survey. Using parallel versions of pre- and postintervention tests in the evaluation of serious games reduces practice effects [
Examples of good and bad open conversation skills included in the pre- and poststudy measure.
Objective and skill | Good response | Bad response | |
|
|||
|
Find mutual value |
I am worried about the safety of the vaccine for my family. What if it made them sick?a Response: I’m concerned about my family’s health too and also feel responsible if something bad was to happen to them. |
Hey, so I’m unvaccinated but I’m still gonna go over to my friend’s house who is really strict about people being vaccinated. Response: Hmn, that’s not something I would do. I would respect other’s decisions. |
|
Respect autonomy |
I can’t believe the government is suggesting that everyone should get vaccinated. This is my health, my decision. Response: The choice is yours and only you can make it. What would help you make your decision? |
These COVID regulations are ridiculous, next thing you know I’ll have to wear a hazmat suit to go shopping.a Response: You should respect other people’s health and follow the regulations. |
|
Don’t lecture or persuade (don’t be an expert) |
How can they even be sure the vaccine is safe if they made it so fast? It was rushed, who knows what steps they missed!a Response: I think it might have something to do with reducing all the red tape that helped speed things up but I’m not sure. Let’s look into it together! |
I am concerned about the side-effects of the vaccine. I heard that they can get pretty bad. Response: Have you looked at the data? I have, and the side-effects are minor. You should look into what can happen if you don’t get the vaccine. |
|
|||
|
Ask for perspective |
My friend has a party but she says I need to be vaccinated to go, not sure how I feel about it? Response: What makes you unsure? |
I don’t believe getting a booster vaccine is really necessary.a Response: It’s interesting how you justify putting other people at risk. |
|
Affirm feelings or perspective; acknowledge past efforts or successes |
I’m unsure about whether to take the vaccine, it seems dangerous.a Response: It is good that you are critical and don’t rush into things when you are unsure. Remember when you had to switch to that new medication and felt better when you looked into it more? |
Our neighbours were strict with the social distancing thing and one of them got it anyway. And they are both vaccinated! So I just don’t see the point. Response: That’s not how to think about it. Just because they got it doesn’t mean it’s not worth you making any effort. |
|
|||
|
Ask open questions |
For now, I don’t want to get the vaccine. Just because everyone else has decided to get it, doesn’t mean that I have to as well. Response: If you were to consider getting the vaccine, what would change your mind? |
How would a mask even help against a virus?a Response: Did you look at the evidence? |
|
Be resilient if the other is right |
First we were told not to bother with masks, and then we were told to wear masks everywhere! These backflips don’t help.a Response: That’s true, the changing recommendations about wearing masks did not help. It goes to show how uncertain things were at the beginning. |
I’m waiting, that’s all. It takes time to make sure that the vaccine is safe for everyone. Response: Yeah I’ve heard that point before but let’s focus on why it is important that all healthy people should get vaccinated. |
|
|||
|
Accept negative outcomes (the conversation may not work out) |
It’s clear that you and I are not on the same page about this. I have my reasons, you have yours. Response: That’s OK, thanks for helping me understand your reasons. It seems like it doesn’t work out, so let’s leave it there and maybe we can speak again next week? |
Look I just don’t think we are ever going to agree on this.a Response: You don’t appreciate my views! But give me one more try and I bet I can change your mind on this one. |
aItems included in the prestudy survey.
Participants will be asked to provide their age (in years) and indicate their gender, current level of English fluency, country of residence, and highest level of education obtained.
Participants will first answer the questions regarding their support for COVID-19 vaccination and their past experience speaking with vaccine-hesitant individuals. Participants will then complete a pretest survey containing the 8 open communication skills items and the self-efficacy and behavioral intention items. The experimental group will then play
Following the game, participants will respond to a posttest survey containing the open communication skills, self-efficacy, and behavioral intention questions. Participants will also complete the implementation intention questions and a short demographic survey. At completion of the study, participants will be thanked for their time and invited to share the study with their friends. Participants in the control group will be given the option to play
Flow diagram representing the study design and procedure. WHO: World Health Organization.
Ethics approval for the study has been submitted and is awaiting approval from the WHO Ethics Review Committee (application ID: CERC.0177).
Recruitment and data collection are estimated to commence in early 2023. The efficacy of the study will be analyzed using an analysis of covariance with posttest open conversation skills as the dependent variable, controlling for pretest scores. Partially completed surveys will be included in statistical analysis whenever possible. As a sensitivity check, analyses will be repeated by excluding participants who complete the study less than 2 SDs below the median completion time as a data quality check.
The primary outcome is open conversation skills. The secondary outcomes are self-efficacy and behavioral intention items. Exploratory analyses will examine the effect of the game on implementation intentions as well as potential covariates or subgroup differences based on sociodemographic information or previous experiences with COVID-19 vaccination conversations.
We hypothesize that
Nevertheless, there are potential limitations to the insights that can be drawn from this study. First, as participants will access the study via a public link that is associated with the promotion of the game, it is not possible to blind participants completely from their assigned experimental condition. Although participants will be blinded to their assigned conditions at the initial pretest survey stage, it is not possible to avoid dropouts or potential self-selection to their assigned condition. To limit this effect, all participants will be told that both games are very important for the research and that everyone will get the opportunity to play
We envisage that the positive results of the study can lead to concrete practical applications, for instance, as a valuable resource for health care professionals whose patients request advice on how to have vaccination conversations with those close to them. Furthermore, health care systems can refer to
Overview of open conversation boosts and supporting literature.
World Health Organization
The authors acknowledge Tiltstudio, who was the vendor and recipient of funding to develop the game, and Lisa Menning for the helpful suggestions and comments on earlier versions of the manuscript. WHO does not endorse the brand or products of any technology platform mentioned in this paper, and any mentions are simply for clarification purposes. JAE, BY, SP, SB, DM, TN, and TDP are staff of the World Health Organization, and these authors alone are responsible for the views expressed in this publication, and they do not represent the views of their organizations.
None declared.