This research aims to investigate and explore the effects of gameful experience of Plague Inc. on public knowledge, attitudes, and practices (KAP) regarding COVID-19 through online surveys.

This research used a cross-sectional study design to explore the impact of Taiwanese gameful experiences on KAP regarding COVID-19.

From May 6-28, 2020, we collected data through an online survey, the link to which was published on social networking services (such as Facebook, PTT Bulletin Board System, internet game forums).

The target population was residents of Taiwan, the population of which was 23,591,920 [34] in April 2020. We used the sample size calculator provided by Rao Soft Inc and selected a 95% confidence level, 5% margin of error, and 23,591,920 population size; the calculated recommended sample size was 385.

This study was conducted in line with the Declaration of Helsinki. All participants were anonymous and provided informed consent. They clearly understood the research content in the online questionnaire [35]. The survey information sheet contained an introduction, background, goals, anonymity statement, and questionnaire descriptions. The average survey completion time was 5 minutes.

The online survey consisted of four parts: demographics, KAP of COVID-19, game experience of Plague Inc., and a gameful experience scale.

The first part includes demographic variables such as gender, age range, education, living arrangement, and occupation.

The second part pertains to the revised COVID-19 scale. The scale contains 27 questions on the three dimensions of COVID-19—namely, knowledge, attitudes, and practices. Each dimension has 9 questions, with 0 as the lowest score and 9 as the highest. Respondents are required to select “Yes,” “No,” or “Uncertain” for each question. For each correctly answered question, one point is added to the total score of the dimension that contains the question. Moreover, no point was awarded for questions with an incorrect or “Uncertain” answer.

The original scale was used to discuss the KAP regarding Middle East respiratory syndrome coronavirus (MERS-CoV) during the annual Hajj pilgrimage [36], and it was adjusted and translated to Chinese. In addition, five experts in clinical medical treatment and public health were invited to examine the questionnaire content to ensure the questionnaire’s validity. The questionnaire is shown in Table 1.

The third part is about gameful experience of Plague Inc., including “ever played Plague Inc.,” “time since last played,” and “total playtime ranges.” In this part, screenshots were used to describe the game’s content (Figure 2).

The fourth part is the gameful experience scale consisting of 27 questions, divided into 6 dimensions: enjoyment, absorption, creative thinking, activation, absence of negative affect, and dominance [37]. The scale is a 5-point Likert scale, with options from 1 (strongly disagree) to 5 (strongly agree).

This scale was also used in nursing-related research and was considered to demonstrate excellent reliability and validity. It can be used to evaluate nursing students’ gaming experiences during training [38]. Three practitioners from the gaming industry were invited to give suggestions on modifying the questionnaire after translation.

Plague Inc. is a strategic simulation game that simulates how various pathogens are spread throughout the world. It was released on the App Store and Google Play in 2012. In 2014, Plague Inc: Evolved was launched on Steam, a platform for PC games.

At the beginning of each game, players can repeatedly spread new pathogens to different countries. Using DNA points in the game, players try to achieve the goal of eliminating all of mankind by employing different modes of transmission, symptoms, and abilities, and influencing the infectivity, severity, and lethality of the viruses.

Players may indirectly control the speed at which infectious pathogens spread by selecting different routes of transmission, as shown in Figure 3. In particular, the game simulates how pathogens spread via airplanes and boats, increasing the number of infected countries and individuals.

Players may change the infectivity and lethality of pathogens by selecting different symptoms, as shown in Figure 4. They may keep the death toll from ascending too rapidly by balancing infectivity and lethality, while allowing pathogens to continue spreading through infected individuals.

Plague Inc. simulates countries with different climates and latitudes. In addition, as the game progresses, vaccines will appear to prevent players from winning. Therefore, players have to use their abilities to influence the pathogen’s temperature and drug resistance, as shown in Figure 5.

Based on the normality test, this study used nonparametric statistics, the Mann–Whitney U test, and the Kruskal–Wallis test to verify the KAP of COVID-19 to understand whether the KAP of COVID-19 was affected by gaming experience. In addition, we used the chi-square test to analyze whether there is a significant difference between whether participants have played Plague Inc. and their demographic characteristics and the Spearman rank correlation test to analyze the correlation between gameful experience and COVID-19 KAP.

In this study, the Cronbach α test was used to detect the internal consistency of the KAP of COVID-19 questionnaire and the gameful experience scale. For the KAP of COVID-19 questionnaire, Cronbach α=.82, while Cronbach α=.994 for the gameful experience scale; the results had acceptable internal consistency [39].

This study determined the demographics of members of the public who have played Plague Inc. The results show that the research participants who have played Plague Inc. are mainly males aged 20-39 years. Studies in Spain and Turkey also found that gender indirectly affects game type preferences [40,41]. Research in the United States discovered that although the majority of middle-aged and older adults do not play video games, age does not affect their preference for strategic simulation games [42].

Participants who have played Plague Inc. displayed higher levels of knowledge and attitudes toward COVID-19. Health education implemented through gameful experience has been proven to effectively enhance knowledge of leptospirosis [43]. In addition, integrating gamified media into medical education courses has been shown to effectively improve knowledge and skill performance among nursing students [44-46]. Moreover, designing applications to integrate with gameful experience to explore learning performance in professional nursing education has also been proven to generate a higher level of knowledge when compared to traditional teaching methods [15].

In particular, research participants who had played Plague Inc. one year before the outbreak of the COVID-19 pandemic had higher attitude scores for COVID-19 than those who had not. Designing medical clinical instructional content as a serious game and incorporating gameful experience into training may effectively enhance medical knowledge and confidence among nursing students. Moreover, students may repeatedly practice in the simulated environment, and thereby develop a self-guided learning strategy [47,48]. China’s research on COVID-19–related serious games also confirmed that educational games result in better performance in learning retention than online lectures [49].

Participants who have played Plague Inc. indicated higher creative thinking and dominance during their gameful experience. Their attitudes and practices regarding COVID-19 have a significant positive correlation. In addition, the creative thinking involved in gameful experience is considered to be one of the significant factors that affect learning performance [50]. Gamified learning materials have been proven to stimulate creative thinking in learners and improve their attitudes and soft skills for school subjects [51]. Moreover, simulated situations can also cultivate creative thinking and indirectly improve attitudes toward public health [52,53].

The game environment of Plague Inc. allows players to repeatedly experiment with different pathogens and features. During this process, players gain a better understanding of how to enhance the infectivity and lethality of a pathogen. The challenge experiences and strategies accumulated through playing the game may indirectly improve the players’ corresponding attitudes and practices toward pathogens. Previous research has demonstrated that the reason that effective learning performance is achieved through serious games is due to the concept of experience-based learning. In addition, with game situations designed for players to repeatedly try and challenge, such games may motivate players to reflect on the content and strategize accordingly [54].

This study has several limitations. First, the sample number may be insufficient to represent the general public of Taiwan. Second, as the survey was conducted on social networking websites, the surveys were mainly completed by males aged 20-39 years. This study lacks a broader scope of participants. Third, the research survey was conducted in May 2020; the COVID-19 pandemic was already easing in Taiwan by then. Moreover, the government and medical units had also implemented advocacy and educational messaging through multiple channels. As such, the public had developed a basic understanding of COVID-19. Fourth, as the game investigated in this study is a strategic simulation game, research participants may indirectly represent a specific group. Finally, Plague Inc. was not designed specifically for COVID-19. In addition, the goal of the game is to infect and kill all human beings. A new version of the game, The Cure, was launched on November 11, 2020, which allows players to promote antipandemic prevention and isolation measures by roleplaying as the World Health Organization; however, the public may still be unable to acquire precise knowledge of specific viruses via this game.

This research focuses on the relationship between public KAP regarding COVID-19 and the gameful experience of Plague Inc. However, there may be more factors that affect public KAP regarding COVID-19 other than the gameful experience of Plague Inc. Therefore, further research is required to explore possible interactions with other dimensions [31].

This study has demonstrated that Plague Inc. provides pathogen simulation scenarios that allow players to continuously seek challenges. Members of the public who have played Plague Inc. exhibit higher levels of knowledge and attitudes regarding COVID-19. Moreover, the creative thinking and dominance developed in the gameful experience have been found to be correlated with attitudes and practices regarding COVID-19. Reinforcing creative thinking and dominance through serious games may be a valid approach. However, further verification is required.

Finally, it is imperative to heighten public awareness of the symptoms and transmission routes of COVID-19 amid the unprecedented crisis of the current pandemic. This study suggests that new media, such as games, should be employed to help the public accumulate learning experiences regarding pathogens and further establish public KAP toward pathogens. In this manner, the public may become more heedful of public health issues in the future.