ImmunizziAMO: A School-Based Field Trial to Teach New Generations the Importance of Vaccination through Games and to Fight Vaccine Hesitancy in Italy

"Ensuring education and knowledge dissemination about vaccines among the younger generations through school-based programs might be a good strategy to strengthen parental acceptance and shape the future vaccine acceptance behavior of people who will soon become parents and adults..."

In response to a 2017 measles outbreak in Italy, 10 vaccinations become mandatory by law for children between the ages of 0 and 16 years. A heated debate followed in civil society and politics, also triggered by the spreading of fake news about the lack of safety of the vaccines and a hypothetical link between vaccines and autism. As a result, a significant part of the general population started expressing concerns and negative attitudes toward vaccines. The aim of the project described in this article was to transmit knowledge and convey educational messages on the importance of vaccines, through the use of games, in elementary school children, their families, and teachers.

In 2015, the Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy suggested that, to pursue the goal of defeating vaccine hesitancy, the World Health Organization (WHO) should engage allies from civil society at global, regional, and country levels. To that end, children in primary school might be a group to be engaged in changing the culture around vaccines. Vaccinations involve them directly and, by conveying to children the principles of safety and importance of vaccinations, it might be possible to reach parents, relatives, and teachers.

The health promotion intervention called "ImmunizziAMO" is a prevention model set in the primary school, based on active learning achieved through the use of games to support the traditional transmission of knowledge. Card, board, and movement games are a growth tool with an established educational and paedagogical value, and the effectiveness of game theory has been demonstrated by scientific evidence that cognitive and behavioral aspects are reinforced with play.

The field trial was carried out between April 2019 and October 2019 at Podere Rosa and San Cleto schools in the neighbourhood of San Basilio, one of the most deprived areas in the metropolitan area of Rome, Italy. The intervention, which involved 10 classes with 143 children participating, was structured in teaching and gaming sessions, as follows:

• On Day 1, students were given a lesson that explained these topics: what vaccines are for, what they contain, how they act, what infectious diseases they can prevent, and what herd immunity is. This information was conveyed using a video, in the form of a cartoon, as teaching support; it was specifically designed to stimulate children's curiosity and promote the acquisition of facts without generating boredom and moments of distraction. After each 2- to 3-minute scene, the video was interrupted to allow the researchers to intervene, so that they could add explanations and stimulate dialogue in the classroom. After watching the video, the children took part in physical activities such as dodge ball that were contextualised, in that the children who hit the other players represented the microorganism. Unvaccinated children had to avoid the ball, while vaccinated individuals had the prerogative of protecting the susceptible ones. This game was functional in understanding herd immunity.
• On Day 2, small groups of children (6-10 persons each) played board and card games during 60-minute sessions were coordinated by teachers in the classrooms. The winning playing cards depicted children with shields (suggesting the value of vaccination), while the loser cards had figures of microorganisms on them. These card games followed the rules of games belonging to the Italian tradition. For example, a board game called "The Vaccine Goose" evoked the well-known "Game of the Goose". In this revised version, the winning boxes were represented by vaccinated individuals and allowed the gamer to reach the finish line earlier; conversely, cells with pathogen microorganisms decelerated the path of the participant.
• Day 3 took place at Explora - Il Museo Dei Bambini (a children's museum in Rome). Each 15-minute activity consisted of interactive games that strengthened issues already addressed in the previous intervention sessions. The workshops were as follows:
  • "I Defend Myself", a puzzle game explaining how the immune memory generated by the vaccine works;
  • "If I Protect Myself, I Protect You", a game of stamps and inks (to create a poster to take to school) about the concept of herd immunity;
  • "I Wash My Hands", a game on the importance of washing hands that conveyed the concept of contamination through Petri dishes and microscopes; and
  • "I Present to You the Vaccine", a quiz to learn together how to defend ourselves by developing immunity.

  At the end of the game, a certificate was given to everyone.

The intervention was concluded by administering to the children the same questionnaire proposed at the beginning of the trial, to detect any difference between pre- and post-intervention knowledge. In addition, each child was asked to create a drawing with what most impressed him or her about this experience and to express an opinion or a feeling about what he or she learned.

The comparison between the scores at the beginning and end of the intervention showed a significant increase in knowledge about vaccines and immunity. The mean knowledge score arose from 3.52 (standard deviation (SD) = 1.67) to 5.97 (SD = 1.81). "The significant difference in knowledge score recorded before and after the intervention confirms that learning through play can be a way forward to broaden the spectrum of health topics and to educate young people." Specifically, students understood the utility of vaccination as a prevention tool, and they acquired the concept of herd immunity. In their drawings, the children showed appreciation for the game sessions and for the pictures printed on the cards.

Other studies cited here confirm several findings from the field trial:

• Game-based health promotion interventions are effective with young children, as well as adolescents and young adults.
• Game-based health promotion interventions can be tailored to educate players about infectious diseases.
• Positive effects on mental health and social behaviour of children have been documented.
• Long- and short-term interventions may show similar efficacy.

The researchers reflect on the importance of stimulating community engagement as a part of a broader approach to community health issues, writing: It "might be relevant for the effectiveness of these interventions that community leaders (teachers) are engaged alongside health professionals and prevention experts. This 'alliance' can strengthen and facilitate the intervention of researchers and confer accountability from children and their parents."

Those seeking to replicate this intervention in their context may wish to ensure the following communication tools: the administration of little but well-stated information alternating with short recreational moments; the use of popular games, selected to fit the matter and tailored to attract the attention of children; and the intention to stimulate children's curiosity towards subjects that are also often challenging for adults.

In conclusion, this study suggests that the use of games in an elementary school can increase the knowledge related to the topic of vaccination, starting in childhood.