Abstract / Summary
Background: Quantifying behavioral drivers of protective action during infectious disease outbreaks remains challenging. App-based experimental epidemic games (epigames) provide a framework for studying these decisions in naturalistic settings, but correspondence between in-game measures and real-life beliefs or behaviors requires evaluation. We examined whether an activity-based opportunity cost influenced voluntary quarantine decisions within an epigame and whether real-life health beliefs transferred into the game and predicted observed choices. Methods: We conducted a two-week randomized controlled trial from May 4 to May 17, 2026, at VinUniversity (VinUni) in Hanoi, Vietnam. Participants using the Epigames app installed in their smartphone were randomized to a low-barrier group, earning 1 point per qualifying contact with other participant when remaining active, or a high-barrier group, earning 2 points per contact. Of 439 enrolled participants, 283 were successfully randomized to one of the two groups, made at least one valid daily quarantine decision, and their data was used in the analysis. Real-life (S1) and in-game (S2) beliefs measured susceptibility, severity, quarantine self-efficacy, and perceived benefits. Belief correspondence was assessed using Holm-adjusted Spearman correlations and prospective cumulative-logit models. Quarantine choices were analyzed using participant-day binomial generalized estimating equations (GEE) and participant-level quasi-binomial models. Results: Participants made 1,823 valid daily decisions and chose quarantine on 458 participant-days (25.1%). Quarantine rates were 30.1% in the low-barrier group and 20.2% in the high-barrier group. The high barrier was associated with 41% lower population-averaged odds of quarantine (GEE odds ratio [OR] 0.59, 95% confidence interval [CI] 0.40-0.86, = 0.0059); the quasibinomial estimate was identical (OR 0.59, 95% CI 0.40-0.86, = 0.0055). Among 251 participants with matched S1-S2 data, all four corresponding beliefs were positively associated (Spearman's = 0.259-0.418; all Holm-adjusted < 0.001). Prospective ordinal models confirmed positive matched-domain associations (ORs 1.39-2.18 per one-point S1 increase). Beliefs showed little robust association with quarantine behavior, and neither S1 nor S2 beliefs jointly modified the randomized effect. Self-efficacy, network degree, and the preregistered gender main effect were also unsupported. Conclusion: A higher activity-based opportunity cost reduced voluntary quarantine within the VinUni epigame, while participants carried relative differences in stated health beliefs from real-life to in-game framing. These beliefs did not reliably predict observed quarantine choices within the game framing. Epigames can support controlled study of incentives and belief correspondence in naturalistic settings such as college campuses, but behavioral validity or real-world generalizability requires further work.