SurviveCovid-19++ : A collaborative healthcare game towards educating people about safety measures and vaccination for Covid-19

The Covid-19 pandemic has largely affected the day-to-day lives of many (Haleem et al., 2020) and also had a huge impact on the economy of several countries (Altig et al., 2020). While the first wave of the pandemic seemed to settle down during the summer of 2020, there started to be a rise in the number of cases across the world due to the second wave of the pandemic in the fall of 2020 (Ioannidis et al., 2021). Newer strains of the virus are being identified in various countries during the second wave, which also resulted in rapid spread and more serious impact on the patients’ health, than the basic strain (Le and Tran, 2021; Seligmann et al., 2020; De Visscher et al., 2021). There is a significant rise in the number of cases, affecting even the younger population, across many countries that witnessing the second wave (Le and Tran, 2021; Seligmann et al., 2020; De Visscher et al., 2021). Around 2.84 million deaths have been reported across the world due to Covid-19, as of 6 April, 2021¹¹1https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19---6-april-2021. On 5 April, 2021, India alone recorded 103K cases²²2https://www.who.int/india/emergencies/coronavirus-disease-(covid-19)/india-situation-report, which is the all time highest number of cases in 24 hours span, since the Covid-19 outbreak in the country, and notable across the world according to WHO report¹.

Vaccines are being developed to control the spread of the virus and are being proactively administered to people across the world. Social welfare campaigns and announcements are being conducted by various governments across the world to improve awareness among the people to get vaccinated. For example, the Government of India has started vaccine communication strategy, that included setting up telephone lines to resolve doubts and misconceptions of the general public towards the vaccine, advertisements in press and national media, and so on³³3https://www.mohfw.gov.in/pdf/Covid19CommunicationStrategy2020.pdf. Such strategies emphasize the need to educate people about the importance of taking the vaccines and its uses.

With around eight strains of the virus identified across the world⁴⁴4https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-surveillance/variant-info.html#Consequence, scientists are working towards developing vaccines to control each of these strains (Forni and Mantovani, 2021; Lurie et al., 2020). The sanitation staff in majority of the countries are carrying out sanitization works in public places to create hygenic conditions, which could reduce the spread of the virus (Khan and Yadav, 2020; Cheng et al., 2020). Doctors, nurses and medical students across the world have been performing their duties impeccably, almost round the clock, to cure the patients effected by Covid-19 (Kumaraiah et al., 2020; Miller et al., 2020; McConnell, 2020; Tan et al., 2020). With safety measures such as usage of masks and limited strength in public gatherings made mandatory in many countries, common people in across the world are also expected to follow the safety precautions and fulfill their duty of controlling the pandemic. Considering these varied duties and responsibilities of people with varied professional backgrounds, collaborative efforts and mutual support among all professions is essential to control the spread of the virus (Chakraborty et al., 2020; Wen et al., 2020). This also emphasizes the need for individuals to understand the importance of each profession to control the pandemic and empathize with each other.

Games support effective learning and contribute to improved retention capacity (Habgood and Ainsworth, 2011; De Freitas, 2018). Several games have been developed to support learning and teaching various aspects, which include programming, mathematics, languages, health care measures, and so on (De Freitas, 2018; Sharifzadeh et al., 2020). It has been observed that games that involve collaborative aspects increase user engagement and consequently support better and motivated learning (Bigdeli and Kaufman, 2017). Collaborative aspects also improve communication in a team and thus support in enhancing the team spirit, while learning new concepts in the domain of interest of the game (Buchinger and da Silva Hounsell, 2018). Such games have been introduced in various fields such as science and medicine and were observed to enhance the learning experience of users (Sung and Hwang, 2013; Hannig et al., 2012).

Though there are many educational and motivational games, there exist very few games to bring awareness about Covid-19 and the safety measures to be followed against Covid-19. SurviveCovid-19 (Venigalla et al., 2020) has been developed to bring awareness on the health measures to be followed to control Covid-19. However, it only supports single player version, and is only from a citizen’s perspective. Considering the importance of collaborative effort required to control the pandemic, the need to educate people about importance and uses of vaccines, and the advantages of collaborative games, a game that supports collaborative, multi-player version could better contribute in educating the users. Also, the existing SurviveCovid-19 game does not include any information about the vaccine or strains of the virus. With vaccination being administered and with growing strains of the virus, educating people about the differences in these strains and the vaccines could be more useful.

Hence, in this paper, we present SurviveCovid-19++, a multi-player, collaborative game, that helps in understanding collaborative effort required by people with different professional backgrounds such as doctors, law enforcers and so on, in controlling the pandemic, while including the aspects of safety measures, administering vaccines and multiple strains of the virus. SurviveCovid-19++ supports four individuals with varied professions - Doctor, Citizen, Sanitation Worker and Law Enforcer. It facilitates doctors to treat people affected with Covid-19 in the game through medicines, law enforcers to break crowds in the city, citizens to pick up groceries and sanitation workers to sanitize the localities and kill the virus. It also encourages players of all professions to use masks and sanitizers to prevent themselves from being effected, while delivering their duties, and also requires all the players to work collectively towards collecting vaccine parts in each stage. We perform a preliminary evaluation on the influence of SurviveCovid-19++ on players’ understanding of individual and collaborative efforts, and safety measures towards controlling the spread of Covid-19 based on factors determining pedagogical value. We also evaluate the player experience and usability through a quantitative user survey, based on and MEEGA+ evaluation model.

Considering the playfulness and motivation inducing factor of games, they have been adapted in the healthcare domain to treat patients, to educate individuals about healthcare practices and motivate them to follow these practices, and also to train healthcare students (Habgood and Ainsworth, 2011; Costa et al., 2015; Graafland and Schijven, 2018).

Several guidelines for development of serious games for education have been introduced in the literature (De Croon et al., 2018; Buchinger and da Silva Hounsell, 2018; Wendel et al., 2013). Croon et al. have performed a systematic literature review of design guidelines of serious games and collated a list of guidelines based on this review to assist developers of serious games for healthcare (De Croon et al., 2018). These guidelines include selection of gamification mechanics and tailoring the game based on target audience personalities. These guidelines also further incorporate the motivational and self-determination aspects (De Croon et al., 2018). Wendel et al. have proposed design guidelines for collaborative educational games, irrespective of education domain (Wendel et al., 2013). These guidelines include common goals, communication, heterogenous resources and so on (Wendel et al., 2013). A set of 9 design guidelines for collaborative games in healthcare domain have been proposed by Buchinger et al. based on a systematic literature review of guidelines for collaborative educational games (Buchinger and da Silva Hounsell, 2018). Features such as intra player interaction, synchronization, rewards and challenge are some of the nine guidelines presented by Buchinger et al (Buchinger and da Silva Hounsell, 2018). Sherlock Dengue 8, a healthcare educational game that aims to teach youngsters about dengue fever, designed based on these guidelines, was observed to help in promoting knowledge acquisition and also increase confidence among the users to control the disease (Buchinger and da Silva Hounsell, 2018).

SurviveCovid-19++ is a multiplayer collaborative game that can be played by a maximum of four players and a minimum of one player. It starts with the storyline of a group of friends in four different professions - Citizen, Doctor, Sanitation Worker, and Law Enforcer, in a city, working towards controlling the spread of Covid-19 in the city and treating the affected individuals. It has defined roles (in-game profession-based) for each avatar and the players can select the avatar of their choice, without repetition in the team. Each avatar is assigned specific tasks, along with collaborative tasks that are to be accomplished to clear each stage of the game. The Citizen is required to collect groceries throughout the game. The Doctor is required to collect medicine and treat Covid-19 infected patients with these medicines collected. The Sanitation worker needs to collect sanitizer/disinfectant refills throughout the game and use them to disinfect infected locations. The Law Enforcer is required to break crowds in the city. All the players are required to collect required number of vaccines apart from their personal goals in the game, while using masks and sanitizers to protect themselves from getting infected by the virus, in the game, to clear each stage. If an avatar gets infected by the virus, the health of the avatar gets reduced and the player’s movement in the game is slowed down. The more the player gets infected, slower the movement of the player. A snapshot of the game comprising four players is presented in Fig. 1. An arrow is assosciated with each player to show the direction of finding vaccine parts, as shown in Fig. 1[G].

SurviveCovid-19++ has been designed by including the design guidelines for collaborative games, presented in (Wendel et al., 2013) and (Buchinger and da Silva Hounsell, 2018). An adaptive set of guidelines, inclusive of all the relevant features from the above mentioned guidelines considered in the design of SurviveCovid-19++. These guidelines and the corresponding adaptation in the game are listed below:

Intra-player Interaction (Buchinger and da Silva Hounsell, 2018)/Communication (Wendel et al., 2013) - All the players in a specific room are provided with a chat application (as shown in Fig. 1[J]) that supports interactions among the players in each team.

Synchronization (Buchinger and da Silva Hounsell, 2018) - To support quicker gameplay and to encourage interactions among players, SurviveCovid-19++ adapts a synchronous gameplay, which allows all the players to simultaneously perform their actions corresponding to their in-game roles (indicated in Fig. 4[D]).

Roles (Buchinger and da Silva Hounsell, 2018) - As bringing out collaboration is an important aim of SurviveCovid-19++, different roles are assigned to each player in the game (indicated in Fig. 4[C]).

Resources (Buchinger and da Silva Hounsell, 2018) - All the players are assigned certain tasks of collecting and using multiple resources, which correspond to various aspects in dealing with Covid-19, in the game. For example, common citizen in the game has to collect groceries, sanitation worker s have to collect disinfectant refills (indicated in Fig. 1[F]), while all the players are required to collect health vitamins (indicated in Fig. 1[E]) to increase their health score (presented as shown in Fig. 1[C]), and vaccine parts in each stage, to clear the stage and use these vaccines in the next stages. Also, masks and sanitizers are to be collected when required in the game, to stay safe from the virus.

Score (Buchinger and da Silva Hounsell, 2018) / Scoreboard (Wendel et al., 2013) - Each player in the game is given a score based on the number of objects and refills collected (as indicated in Fig. 1[I] and Fig. 1[A] respectively) and the team is also collectively given a score based on the vaccines collected (as indicated in Fig. 1[H]).

Challenge (Buchinger and da Silva Hounsell, 2018) - The virus strain gets stronger in each stage, thus requiring players to collect more number of vaccines. This feature increases the difficulty level of the game, keeps the players informed about the possibility of virus strain growing stronger and the requirement of players to stay alerted by following safety precautions against the virus all the time, while satisfying their roles in the community.

Rewards (Buchinger and da Silva Hounsell, 2018) - The players are also rewarded based on the number of masks and sanitizers collected in the game, thus encouraging them to use masks and sanitizers often, along with collecting various objects to clear the level.

Operationalization (Buchinger and da Silva Hounsell, 2018) - SurviveCovid-19++ does not require use of any special devices, and thus does not result in game spread difficulties. SurviveCovid-19++ also supports players to take up any of the four roles, thus facilitating unhindered game play, even if there are less than four players.

Common goal/Success (Wendel et al., 2013) - All the players in the game clear each stage together and win or lose the game, through collective effort. Individual players are not facilitated to move to next stages alone, thus enforcing collaboration among the players.

Heterogeneous Resources (Wendel et al., 2013) - Each avatar in the game has varied abilities and responsibilities. For example, law enforcer has the capability to break crowds while the doctor does not have. Such features could thus preserve the heterogeneous resources nature of the game.

Refillable personal resources (Wendel et al., 2013) - SurviveCovid-19++ provides users with meter for health (as indicated in Fig. 1[B]), masks and sanitizers. These meters can be refilled when the players visit a doctor, collect masks and sanitizers respectively. These features could thus create a tension in the game among the players and supports collaborative game play.

Collectable and tradeable resources (Wendel et al., 2013) - SurviveCovid-19++ facilitates players to collect resources specific to their roles and these resources can be traded off when the players wish to swap their roles, to clear a stage. Players can click on ‘Esc’ key to interchange their roles by trading some of their points.

Collaborative tasks (Wendel et al., 2013) - Each player in the game is assigned a specific task, based on the role/avatar taken up by the player. To clear each stage, all the avatars are required to work together and fulfill their roles.

Ingame help system (Wendel et al., 2013) - Instructions and directions are presented at multiple locations through out the game to help players navigate and play the game. This in-game feature has been designed as text on the various objects in the game, so that it does not interrupt the game.

Trading System (Wendel et al., 2013) - SurviveCovid-19++ allows players to discuss among themselves if they wish to swap roles to attain collective success. This swapping process requires the players to agree to trade some of their collectibles or points, thus encouraging them to take decisions that could affect the team’s win or loss.

SurviveCovid-19++ is a desktop based educational game, designed based on specific rules corresponding to players’ actions. It thus, does not include any artificial intelligence agent in the current version. Hence, the features Artificial Intelligence, that corresponds to inclusion of AI, as specified in (Buchinger and da Silva Hounsell, 2018) has not been considered in the design of SurviveCovid-19++.

SurviveCovid-19++ has thus been designed keeping all the relevant guidelines in view to facilitate in educating individuals about safety measures, vaccination and roles of different professions in the context of Covid-19. The current versions consists of four stages, as shown in Fig. 2 with increasing difficulty as the stages progress.

The development of SurviveCovid-19++ has been done using the Unity 3D Game Development Framework⁵⁵5https://unity.com/. There are two major components to the game, Server component and the Client component as seen in Fig. 3. Development of the server component has been done with the help of Photon Networking Package provided by Unity. It is directly installed into the Unity Editor for usage. This component is responsible for all the necessary multiplayer capabilities required for the game such as the synchronization of the game state and multiplayer room creation features. Combining the Photon Networking package with C# scripting language allowed us to implement in-game chat functionality for the players. Using a Network Manager script on client side we facilitate the connection of multiple Clients to the Server component over the internet.

The Client component consists of all the graphical and mechanical aspects of the game. The graphical assets used in the game have been developed using the Blender 3D modelling software and Unity Standard assets pack. We proceeded to translate the safety guidelines for preventing the spread of Covid-19 virus, into specific game mechanics. For example, the completion of the game is made to be dependent upon the completion of individual goals specific to the different avatars along with a primary goal of collecting vaccine parts. If any individual player is not able to continue due to reduced health, the game is over for all the players. These mechanisms helped us in enforcing collaboration amongst different players. All the mechanisms were implemented using the C# programming environment provided by the Unity editor. All the quantitative elements necessary for keeping track of the game such as score, percentage completion of the goals, and health remaining are displayed to the user using UI elements. Finally, using the windows build settings from Unity, we build the exe file for the game as shown in Fig. 3.

Consider Moksha and her three friends from school, came across an article about collaborative efforts by people against Covid-19. However, they were not able to understand the significance of it to fight against Covid-19. Together they considered playing SurviveCovid-19++ game to gain deeper understanding about different collaborative efforts taken by people to tackle the Covid-19 virus. They download the game on their individual desktops and start the game. The players are now prompted to choose a display name. Moksha creates a room as shown in Fig. 4[A] and the rest of the members join using the same room name as depicted in Fig. 4[B]. The players are then shown a player selection screen with 4 different avatars and their respective tasks as shown in Fig. 4[C]. The players decide amongst themselves and choose their respective avatars, and start the game as shown in Fig. 4[D].

Moksha selects the Doctor whose role is to heal infected people to avoid the spread of Covid-19. Similarly her friend Veda opts for the sanitation worker whose role is to keep the surroundings safe by destroying viruses. Rishi picks the role of the Citizen who collects the essentials in the form of groceries. Bharath picks the role of Law Enforcer who makes sure that there are no large gatherings in order to prevent the virus outbreak.

Both doctor and sanitation worker avatars have limited shots of vaccine and sanitizer respectively, which can be refilled by picking up appropriate pickups spread throughout the game as displayed in Fig. 5[B] and Fig. 5[C]. By using masks and sanitizers the citizen could navigate the map along with other avatars, while collecting essentials, as shown in Fig. 5[A]. Law enforcer could break crowds as shown in Fig. 5[D], which allows the player to quickly clear out large spaces. Doctor treats the infected people in the city as shown in Fig. 5[E] and the sanitation worker uses disinfectant to clean the city and kill the virus as shown in Fig. 5[F].

The four players are quickly overwhelmed by the waves of virus themed monsters which follow them and infect them upon contact, as depicted in Fig. 6 [A]. As they proceed through the stages, they encounter different varieties of viruses depicting different strains of Covid-19 as shown in Fig. 6[B]. The four friends use the in-game chat functionality to interact with each other and come up with different strategies to finish the game. Collecting Mask and Sanitization pickups, as indicated by Figure6[E], provided the players with temporary protection from the virus as depicted in Fig. 6[F]. Fig. 6[C] depicts player visiting healthcare camps across the map to heal themselves when required, and getting healed. By collecting the primary vaccine parts, depicted in Fig. 6[D], and completing individual goals the players proceed through the multiple stages together and are able to finish the game, all the while carefully following safe guidelines such as social distancing and usage of masks and sanitizers. Upon successful completion of the game the friends realize that SurviveCovid-19++ depicts how it would be very difficult to survive without all of the different avatars working together and fulfilling their roles to fight Covid-19.

Among the 28 volunteers who participated in the user survey, 24 of them were male and four of them were female. Most of the participants are undergraduate students and have agreed that they play games frequently. Based on the answers given by the participants for the Questionnaire 1 before playing the game, we observe that about six of the participants did not correctly interpret the role of citizens and law enforcers in controlling the pandemic. Three of the participants wrongly interpreted the role of sanitation workers and about 60% (17 out of 28) of the participants have misinterpreted the need for collaborative efforts towards controlling the pandemic. When all the participants answered Questionnaire 1 after playing the game, we observed change in their interpretation. All the participants described the roles of individuals with different professions correctly to a reasonable extent and also recognized the need for collaborative efforts to control the pandemic. This implies that SurviveCovid-19++ has contributed to better understanding of the players in the context of Covid-19.

The mean and standard deviation for each question in Questionnaire 2 are presented in Table 2. The mean value greater than 3.46 for all the questions in Questionnaire 2 indicates that users had a reasonably positive experience with the game. All the ten questions corresponding to pedagogy-related factors (LO and ABC) have mean greater than or equal to 3.92, indicating that SurviveCovid-19++ could successfully teach need for collaborative efforts and role of each individual in the community, and could successfully influence the players to follow safety measures towards controlling Covid-19.

The mean and standard deviation values of all the thirteen quality factors have been plotted in Fig. 7. Mean value greater than 3.46 for all of the quality factors, with low standard deviation, indicates that majority of the players agreed that SurviveCovid-19++ is useful, interesting and usable.

We calculate the quality score of SurviveCovid-19++ based on MEEGA+ model by considering the mean values for factors under the dimensions - player experience and usability. Corresponding Cronbach Alpha values presented in MEEGA+ for each dimension are applied to the means of player experience and usability factors, and the resultant value is normalized by multiplying it by 10. This resulted in a quality score of 71.90. According to the MEEGA+ evaluation model, games with quality score greater than 65 are considered to be of excellent quality, and that less than 42.5 are considered to be poor quality. The game has a quality score of 71.90, indicating inclusion of the game in excellent category. This result indicates that such games are challenging for learners, without monotonous activities and clear rules to play the game.

SurviveCovid-19++ enforces players to collaboratively work towards controlling Covid-19, by following the safety measures, collecting vaccine parts and other individual collectibles. Thus, it could educate players about importance of safety measures and vaccination, and role of individuals in different professions towards controlling the spread of the virus. This game can be played by wider range of audience, without any constraint on educational background, except for basic understanding of English language. The only hardware constraint is that it can be played only on desktops with internet connection.

The current multiplayer version accommodates only four players per room, analogous to the four avatars being considered in the game and has only four stages. More number of players and stages can be accommodated, with minimal technical modifications in the game. The current version requires the game application to be downloaded on the players’ local machine. It does not support playing the game on a browser. However, it can be extended as a browser-based game with minimal efforts. SurviveCovid-19++ currently supports only desktops/laptops and is not compatible with mobile devices. Also, apart from the instructions presented in the chat box, SurviveCovid-19++ does not support any other in-game AI/non-AI based assistant or in-game dialogues, to guide the players. However, this being a collaborative game that supports chat application, players could communicate with each other and play the role of AI assistant by conveying human suggestions and instructions.

As we focused on influencing behaviour of the players towards following safety measures for Covid-19, and collaborating towards controlling the spread of the pandemic, we performed an in-depth evaluation with 28 players and closely observed their behavioural changes when they encounter various scenarios in the game, and assessed their experience with the game. However, we plan to extend the evaluation with a larger number of players.

In this paper, we presented SurviveCovid-19++, a multiplayer, collaborative desktop game, aimed to facilitate learning about vaccines, safety measures to be followed, roles played by different professions (doctor, citizen, law enforcer and sanitation worker) and need for collaborative effort to control the spread of Covid-19. It has been designed based on the design principles specified for collaborative games and for games in the healthcare context to ensure better reachability and value of the game. SurviveCovid-19++ has been evaluated to assess player experience, usability and its pedagogical value, through a user survey based on an adapted MEEGA+ questionnaire, with seven teams of four players each. The evaluation comprised of a pre and post test qualitative questionnaire to assess change in perception of the users and a likert-scale based quantitative questionnaire to assess player experience, usability and influence of the game on players. The results of the evaluation were positive, with observed attitudinal changes and learning outcomes among all the participants, and all the participants willing to recommend SurviveCovid-19++ to their colleagues.

SurviveCovid-19++ currently supports only four avatars, corresponding to four different professions. More number of avatars could be added in the game, to support wide range of professions in-game, in the future versions. The current multi-player version only supports up to four players, which could further be extended in the future. As a part of future work, we also plan to facilitate users to create and customize their own avatars. Also, SurviveCovid-19++ currently supports only four stages. We plan to increase the number of stages by adapting a procedural approach to generate stages, and increase difficulty in each stage. Moreover, the current version of the game is supported only on desktop, which can be extended to support mobile devices as well.