ON INFORMATICS

— Vaccination is one preventive measure to prevent oneself from getting any diseases. Vaccinations work by training our immune system to produce antibodies and weaken the targeted disease. Unfortunately, the number of unvaccinated children has increased because some parents reject or doubt the effectiveness of vaccines. This skepticism could result in a resurgence of vaccine-preventable diseases. Additionally, some contribute to vaccine refusal due to other reasons like vaccine misinformation, religious convictions, and insufficient knowledge. The game aims to develop knowledge and awareness to enhance vaccine behavior and acceptance among individuals. eGameFlow model were used as the methodology for game development. This model was chosen as it focuses on the educational game environment, which addresses learning components in the game. There are eight criteria to be considered to evaluate enjoyment using this model. To measure the users’ enjoyment, a set of questionnaires adopted from the eGameFlow model has been used for the evaluation. It is created explicitly to measure learners’ enjoyment of e-Learning games. This game gathers positive feedback from 30 respondents and shows promising results to achieve the objective. All eGameFlow criteria were positive towards enjoyment, with knowledge improvement being the highest contributor. The overall average of the evaluation was at an agreeable level, with a score of 81%, considered as achieving the goal. For future enhancement in increasing player’s enjoyment and game effectiveness, the game can be created in 3D environment to provide deep immersion and autonomy to the player.


I. INTRODUCTION
According to the World Health Organization (WHO), vaccination is a simple and safe way to protect any living creature from harmful diseases. Vaccines act by weakening, and they will train our immune system to create antibodies. Although the vaccine effectively fights diseases, some people refuse to get vaccinated. For example, a study performed by Khoo et al. [1] discovered that the number of vaccine refusals among Malaysian parents had risen sharply. Parents who are skeptical of vaccination may cause their children to refuse vaccines, resulting in a doubled number of unvaccinated children. This, in turn, could result in a resurgence of vaccinepreventable illnesses like measles, mumps, rubella, and varicella.
Vaccine hesitancy presents a global health obstacle in managing the severity of pandemics as well as infectious diseases. It was named one of the WHO's top ten global dangers to general health, as cited by Asres and Umeta [2].
The frequency of vaccine hesitancy increases the vulnerability of highly susceptible groups, such as the elderly or those with pre-existing medical conditions, as observed during the COVID-19 outbreak [3] Resistance to vaccination and related issues are becoming more prevalent due to various factors. One significant reason for vaccine refusal may be religious beliefs [4], such as in the case of Muslims who are becoming more aware of vaccine components derived from animals. Another reason for vaccine anxiety is safety concerns [5], [6]. Parents are reluctant to vaccinate their infants because of concerns over vaccinations containing ritually unclean ingredients. Besides, the presence of wrong and irrelevant sources of information related to vaccines has also led to misinformation and misbelief about vaccination. This occurs because most young parents depend on the information they acquire from the internet, particularly social media platforms like Facebook and Twitter, as their primary source of information.
In a similar vein, the internet has also promoted the use of online games as a learning tool in recent years. Many prior studies have successfully proved that enjoyment is a factor that can affect a game's success and the learning of its players. In achieving this, the current study deployed the eGameFlow model throughout the design and development process. Vaccine information is based on official and credible sources such as the World Health Organization (WHO) and the Ministry of Health Malaysia (MOH). This project was carried out to create awareness and knowledge among the public on the importance of vaccination.
A total of 30 respondents ranging from 18 -38 years old were recruited for this study. They completed a session of playing this educational game. After the gaming session, the user's enjoyment was evaluated using the eGameFlow questionnaire. The findings from this evaluation discovered that the knowledge improvement factor recorded the highest score with an average mean of 4.25. From this result, we conclude that this educational game had successfully achieved its goal: to help the public improve their knowledge about vaccines while having fun playing the game. Hence, it would also decrease the vaccine hesitancy rate. However, the number of respondents is considered small. Due to some limitations, we only collected data from 30 respondents. Future improvement of the game version with other models is also expected.

A. Literature Review
Vaccination has been a popular topic among the public since the emergence of COVID-19. Vaccination is proven to be effective in controlling the disease's spread. According to La Torre et al. [7], achieving high vaccination coverage is the primary method for avoiding vaccine-preventable infectious diseases. Vaccination generates people with hope for survival, and different diseases have different vaccination strategies. There is potential for dengue surveillance to be enhanced through the use of Dengue Serology Rapid Diagnostic Tests (RDTs). These RDTs rely on biosensors that can detect both recent and past dengue infections. By using such tests, it is possible to conduct seroepidemiological surveys and improve dengue vaccination strategies [8]. Healthcare professionals and specialists acknowledge that vaccines are generally effective but also recognize that mild reactions can occur occasionally. However, because of these mild reactions, some individuals use this as an opportunity to claim that vaccinations are dangerous and create uncertainty in the community [9]. Consequently, some people begin to question the safety and necessity of vaccines. A common scenario is when they try to delay, and some resist the vaccination. In addition, the emergence of the anti-vaccination movements has caused a commotion and made things worse as they spread false information, especially the claim that vaccines contain hazardous ingredients. Lack of right vaccine information will cause a negative influence on the community since the anti-vaccination movements will easily dupe individuals.
Malaysia is a developing, middle-income, multi-cultural, and Muslim-majority country with an outstanding public healthcare system. Major vaccinations are free to all Malaysians, and the coverage for Bacillus Calmette-Guérin (BCG) and Diphtheria, Tetanus, Pertussis (DTP) vaccines was as high as 97-99 percent in 2014. This includes the COVID-19 vaccination, which is offered for free regardless of citizenship [10]. In Malaysia, vaccinations are given to children as soon as they are born. This is because young children have limited disease resistance and can get serious illnesses if they become infected with bacteria and are unvaccinated. Even so, some groups still reject vaccines and disagree with the vaccination program. According to data from the Malaysian Ministry of Health (MOH), the number of parents who refused vaccines increased from 470 in 2013 to 1,541 in 2015 [11]. A News report by Ridauddin Daun in 2021, as cited by Jafar et al. [3], further supports this statement by claiming that national COVID-19 Immunisation Programme (PICK) registration (in Malaysia remains below the desired level.
As reported by Singh et al. [12], low education level, especially among middle and older mothers, has contributed to the failure to adhere to the vaccination schedule. They are reported to have doubts about the vaccine, especially the status of the vaccine's contents. Their study also discovered a significant relationship between mothers' educational level knowledge and their attitude toward child vaccination. In general, people with a higher level of education are more aware of the necessity of childhood immunization, and they are a key population in preventing the spread of vaccinepreventable diseases [12]- [15].
A game not only offers an innovative approach to delivering information but also serves as an engaging and enjoyable tool that encourages audience participation [16], [17]. In addition, educational games can make the learning process more engaging, inspiring, and effective by improving knowledge retention, enhancing attention, fostering peer communication, and promoting social skills [18]. The foundation of the eGameFlow originated from the Gameflow model. The GameFlow model has been used to measure player enjoyment, which is relevant to all games. The model provides eight criteria that must be considered to assess the enjoyment level. These criteria are (1) concentration, (2) clear goals, (3) feedback, (4) challenge, (5) control, (6) immersion, (7) player skills, and (8) social interaction [19]. Meanwhile, the flow itself brings its meaning. According to Chen, Wu, and Dennison [20], flow is described as the experience gained when participating in the activity by following the activity's flow. Based on their research, it was found that most of the elements used in flow are (1) a challenging activity requiring skill, (2) a merging of action and awareness, (3) a task with clear goals, (4) a task that provides direct, immediate feedback, (5) concentration on the task at hand, (6) a sense of control, (7) a loss of self-consciousness, and (8) an altered sense of time. It can be concluded that each of the elements is related to each other in measuring the individual's enjoyment.
The eGameFlow model is one of the adjustment models derived from the GameFlow model. It is created explicitly for measuring learners' enjoyment of e-Learning games. Some of the criteria are similar to the GameFlow model, with an additional criterion of Knowledge Improvement. This criterion is replacing the player skill criterion used in the GameFlow Model [21]. Concentration refers to a player's capacity to concentrate on the game task at hand, which can be attained when the game task has clear objectives and offers timely feedback.
The key factor in an educational game is enhancing knowledge, and the game should capture the player's focus on the learning activities while also providing a sense of control over the game and engaging them in the gaming environment to aid the player in learning. Moreover, goal clarity, feedback, and social interaction in the game may interact to affect learning outcomes [22]. Immersion is considered a critical element in game-based learning, which promotes learner engagement. Table 1 shows the definition of the criteria in the eGameFlow model. Considering the nature of this game, which does not include any social interaction, all eGameFlow elements were applied to it (except social interaction).

B. Related Studies
This study involved 1024 respondents from Sabah (East Malaysia) to identify the factors influencing vaccine hesitancy among their community. The authors focused their study on Sabah since its population contributed to the low number of PICK registrations in Malaysia. The participants were recruited randomly, and a 5-points Likert scale questionnaire on Google Forms was distributed.
From this study, it was found that the factors varied according to regions in Sabah. To those who lived in rural areas, the issues of authority, mainstream media, and social media influenced their decision to vaccinate [27]. Residents in rural areas tend to believe in vaccine conspiracy. One of the factors was the education level of rural communities which is commonly lower than urban communities. People or communities with lower education levels are more prone to fall for fake rumors, false news, or negative influence [28].
ARTé: Mecenas is an educational tool supporting student art history learning. This study adopted the eGameFlow scale to analyze students' knowledge and understanding of learning. There were 127 undergraduate students involved in the study. ARTé: Mecenas allowed users to experience the 15th and 16th century Italian Renaissance virtually.
They included 24 items from 6 factors in the eGameFlow scale and extra 16 items for the player's overall learning experience from the gameplay. The six factors included are Concentration, Goal Clarity, Challenge, Autonomy, Immersion, and Knowledge Improvement. This study found that Knowledge Improvement was the most significant factor in an educational game. To accomplish this factor, designers should design a game that is able to catch the player's attention to the learning task provided, as well as engage players in the gaming as much as they can to make sure there will be a great improvement while playing the game [23]. This study concluded that eGameFlow is meaningful in educational games which can help in learning.

C. Methodology
The components of the eGameFlow model are utilised in this game development to enhance the player's enjoyment during gameplay. Each criterion is displayed and highlighted in Table 1. A total of 7 criteria are included in the interface design. Those criteria are concentration, goal clarity, feedback, challenge, autonomy, immersion, and knowledge improvement. The criteria included in the interface design are presented in Fig. 2, Fig 3, Fig. 4a, Fig. 4b, Fig. 5, Fig. 6, Fig.  7, and Fig. 8, respectively. The game has a health navigator, as shown in Fig. 2, and the player needs to focus and concentrate on surviving until he finishes the game. The player has to make sure not to collide with the enemy to maintain their health, which acts as their life. Fig. 3 shows the game goal provided at the beginning of the game to ensure players understand their tasks before playing this game. According to Fig. 4a and Fig. 4b, this educational game gives the player feedback on whether they successfully completed the mission. In a game, feedback is essential so players are continuously informed of their progress. Viruses will act as enemies to the player. Fig. 5 shows an example of a challenge. The challenge in this game is when the virus moves faster each time the player collects an item, and the virus may chase the player. The player has control over the main character and the game's flow as shown in Fig. 6. They can pause or quit the game whenever they want to. A setting button is provided to allow players to customize the game to their preferences. Since it is a 2D game, a simple immersion element, as displayed in Fig. 7 is included. This educational game provides sound effects and background music throughout the game. Each time the player collects an item, a sound effect will appear. This also happens when the player collides with an enemy. A sound effect will appear to give a feeling of "Oh, no! I bumped into an enemy." This educational game also provides vaccine information after the user accomplishes a certain task. Some of the information provided includes the side effects after vaccination and different contents for different vaccines, as shown in Fig. 8. Fig. 8 Knowledge Improvement element 1) Evaluation Procedure: This game can be accessed using a personal computer (PC) or laptop because it is webbased. The participants were briefly explained the procedure in the questionnaire. An instruction and link for the game were also provided. Each participant took approximately 5-9 minutes to test the game. Once the participants had completed the game, they had to answer a questionnaire distributed through Google Forms. The questionnaire was modified into a simple language and written bilingually (in Malay and English) that could be easily understood. A total of 30 participants ranging from 18 to 38 years old were involved in this evaluation. This age range is considered appropriate for assessing the vaccine game because it is based on basic vaccination knowledge. Since this is a web-based game, this age group was best suited because they are the most active users on social media. This conclusion is supported by a study conducted by Hua et al. [29] which looked at social media users. 69.0% of their total respondents were between the ages of 21 and 30. By playing this game, young adults would learn better about the need for immunization.

2) Instrument:
In this study, we adopted the game eGameFlow scale to measure the player's level of enjoyment while playing a knowledge game. Seven eGameFlow criteria were included in this evaluation: concentration, difficulty, goal clarity, feedback, autonomy, immersion, and knowledge improvement. Social interaction was excluded due to the nature of this game. Table 2 represents the seven main scales for eGameFlow and 28 sub-scales included for the overall evaluation.

Scale
Code Sub-scale Concentration C1 The game grabs my attention.

C2
The game provides content that stimulates my attention.

C3
I can remain concentrated throughout the game. C4 Most of the gaming activities are related to the learning task. Goal Clarity GC1 Overall game goals were presented in the beginning of the game. GC2 Overall game goals were presented clearly. GC3 Intermediate goals were presented in the beginning of each scene. GC4 Intermediate goals were presented clearly.  Table 3 shows the respondents' demographic information based on the online survey findings. The survey received responses from an equal number of men and women. The study was primarily conducted by employed individuals, followed by unemployed and students not currently seeking employment. This corresponds to the result of the respondents' age where most of them were between 22 -25 years old (16.7%), 26 -29 years old (16.7%), and 30 -34 years old (33.3%). Only a number of students participated in the study (16.7%), and they were considered to come from the age group of 18 -2 years old (33.5%). This survey was participated by young adults, who were the target users for this educational game.

A. Demographic Summary
Most respondents (50.0%) played online games for more than 10 hours per week, and none did play online games at all in a week. 83.3% of the respondents stated that they played online games to fulfill their leisure time, while 66.7% played online games for fun and 50% to learn something. This shows that online games can be helpful tools for giving information and knowledge. Half of the respondents claimed that they were less experienced gamers (50.0%), followed by novice gamers (33.3%), and moderately experienced gamers (16.7%). No gaming skill is required to play this educational game since it is a simple 2D game only.

B. Enjoyment Evaluation Summary
The mean value for each of the sub-factors from this game's evaluation is shown in Table 4. For each dimension, the overall mean was calculated, which shows the degree of agreement on a particular subscale. The total mean of the Knowledge Improvement Dimension is 4.25, with the highest average value. This demonstrates that the game has successfully increased the player's knowledge. We believe that a game incorporating knowledge will give the player a big advantage. Challenge represents the second-highest score, with a mean value of 4.21. This shows that the game is challenging for the player. One of the most crucial factors in a game that motivates players throughout the game is the challenge. Among the elements, autonomy has the lowest average, with a mean of 3.62. From our point of view, this is due to the nature of this game, which is a simple 2D game. It is a very straightforward game, and the player has less control over the game. The percentage from the overall average of the evaluation is at an agreeable level of 81% which is considered as achieving the goal.

IV. CONCLUSION
From the results discussed, this educational game successfully provided an enjoyable experience in gaining knowledge about vaccines. This game could benefit anyone, especially young adults, to enhance their knowledge of vaccines. An advantage of using the eGameFlow model is the fact that it focuses on the educational game environment, which actively addresses learning components in the game. For future enhancements, we suggest this game be developed in 3D to provide deep immersion and autonomy to the player. A time limitation may also be provided to give players more challenge and time pressure. A study by Cox et al. [30] shows that time pressure significantly impacts the players' immersion.