Cheer for me: effect of non-player character audience feedback on older adult users of virtual reality exergames.

The presence of an audience and its feedback could affect people's performance and experience during an event, especially related to sports such as tennis or boxing. Similarly, in videogames, players' gameplay could be affected if there is an audience and its feedback in response to players' performance in the environment. The inclusion of an audience with non-player characters (NPC) is common in videogames in general. However, there is a limited exploration of the use of an NPC audience in virtual reality (VR) exergames, especially focusing on elderly players. To fill this gap, this work examines the effect of an NPC audience and its associated feedback (with/without) on elderly users of VR exergames. In a user study, we used 120 NPC in a virtual audience. Results showed that the presence of the NPC audience with responsive feedback led to higher performance (with a higher success rate of performing gesture actions, more successful combinations of actions (or combos for short) performed, and more opponent's combos prevented) and better gameplay experience (with higher levels of competence, autonomy, relatedness, immersion, and intuitive controls) of elderly players. Our results can help frame the design and engineering of VR exergames that are targeted at elderly users to help them have an enhanced gameplay experience and improve their health.

Receiving self-compassion in the virtual world: Testing the potential value of biofeedback.

Self-compassion training has been shown to deliver mental health benefits and preliminary evidence suggests it might also be possible to deliver these benefits effectively via virtual reality (VR) technology. However, which features of the VR training environment influence these training benefits remains poorly understood. This study was designed to provide the first empirical test of the potential value of visual biofeedback during self-compassion training. It was theorised that the provision of biofeedback may increase the benefits of training by increasing mindfulness, a core component of self-compassion. Sixty participants were randomly allocated to one of two experimental conditions, both of which comprised VR-based self-compassion training, but only one of which included visual biofeedback (a red pulsating light representing heart rate). Relative to scores at baseline, participants reported greater self-compassion, and lower self-criticism, anxiety, and stress after VR self-compassion training. However, the provision of biofeedback did not influence the strength of these training effects. These data provide further evidence that VR administered self-compassion training may deliver potentially important mental health benefits, but also meaningfully extends this literature by proving the first evidence that visual biofeedback does not influence the strength of these benefits.

Understanding the Relationship Between User Game Preferences and Depressive Symptoms: A Pilot Study.

Objective: Following the initial measures taken to manage the repercussions of the COVID-19 pandemic, mental health conditions have become a critical concern. Mental health has become a foremost priority not only for health care providers but also for many other organizations, such as educational institutions, companies, and government agencies. A significant proportion of the Australian population having experienced mental disorders highlights the need for effective interventions. Those with pre-existing mental health issues experienced particularly pronounced effects. Among these challenges, advancements in technology offer new possibilities for mental health support. Videogames have shown effectiveness in mitigating symptoms of depression. Previous research has shown that game interface preferences correlate with players' emotional responses. This study aims to use MoodJumper, a game we designed, developed, and evaluated to examine the choice of game preferences in individuals with depressive symptoms. Materials and Methods: A pilot study was carried out after obtaining the Human Ethics committee's approval (n = 20). The participants were asked to fill out a Patient Health Questionnaire-9 (PHQ-9) questionnaire. They then played with the MoodJumper game for 20-30 minutes. Upon completing the game session, they were asked to fill out a questionnaire regarding their experience. Results: The results indicate a nonsignificant correlation between music preference, the direction of movement, and depressive symptoms meaning no significant relationship was found between depressive symptoms and chosen settings. However, a significant negative correlation was found between decision-making ability regarding game preferences and Patient Health Questionnaire-9 scores showing the difficulty of choosing preferred settings when having depressive symptoms. Conclusion: This contribution paves the way for designing and evaluating more impactful game experiences for individuals with mental health challenges.

Extended Reality for Mental Health Evaluation: Scoping Review.

BACKGROUND: Mental health disorders are the leading cause of health-related problems worldwide. It is projected that mental health disorders will be the leading cause of morbidity among adults as the incidence rates of anxiety and depression grow worldwide. Recently, "extended reality" (XR), a general term covering virtual reality (VR), augmented reality (AR), and mixed reality (MR), is paving the way for the delivery of mental health care. OBJECTIVE: We aimed to investigate the adoption and implementation of XR technology used in interventions for mental disorders and to provide statistical analyses of the design, usage, and effectiveness of XR technology for mental health interventions with a worldwide demographic focus. METHODS: In this paper, we conducted a scoping review of the development and application of XR in the area of mental disorders. We performed a database search to identify relevant studies indexed in Google Scholar, PubMed, and the ACM Digital Library. A search period between August 2016 and December 2023 was defined to select papers related to the usage of VR, AR, and MR in a mental health context. The database search was performed with predefined queries, and a total of 831 papers were identified. Ten papers were identified through professional recommendation. Inclusion and exclusion criteria were designed and applied to ensure that only relevant studies were included in the literature review. RESULTS: We identified a total of 85 studies from 27 countries worldwide that used different types of VR, AR, and MR techniques for managing 14 types of mental disorders. By performing data analysis, we found that most of the studies focused on high-income countries, such as the United States (n=14, 16.47%) and Germany (n=12, 14.12%). None of the studies were for African countries. The majority of papers reported that XR techniques lead to a significant reduction in symptoms of anxiety or depression. The majority of studies were published in 2021 (n=26, 30.59%). This could indicate that mental disorder intervention received higher attention when COVID-19 emerged. Most studies (n=65, 76.47%) focused on a population in the age range of 18-65 years, while few studies (n=2, 3.35%) focused on teenagers (ie, subjects in the age range of 10-19 years). In addition, more studies were conducted experimentally (n=67, 78.82%) rather than by using analytical and modeling approaches (n=8, 9.41%). This shows that there is a rapid development of XR technology for mental health care. Furthermore, these studies showed that XR technology can effectively be used for evaluating mental disorders in a similar or better way that conventional approaches. CONCLUSIONS: In this scoping review, we studied the adoption and implementation of XR technology for mental disorder care. Our review shows that XR treatment yields high patient satisfaction, and follow-up assessments show significant improvement with large effect sizes. Moreover, the studies adopted unique designs that were set up to record and analyze the symptoms reported by their participants. This review may aid future research and development of various XR mechanisms for differentiated mental disorder procedures.

Breaking the Isolation: Exploring the Impact of Passthrough in Shared Spaces on Player Performance and Experience in VR Exergames.

VR exergames offer an engaging solution to combat sedentary behavior and promote physical activity. However, challenges emerge when playing these games in shared spaces, particularly due to the presence of bystanders. VR's passthrough functionality enables players to maintain awareness of their surrounding environment while immersed in VR gaming, rendering it a promising solution to improve users' awareness of the environment. This study investigates the passthrough's impact on player performance and experiences in shared spaces, involving an experiment with 24 participants that examines Space (Office vs. Corridor) and Passthrough Function (With vs. Without). Results reveal that Passthrough enhances game performance and environmental awareness while reducing immersion. Players prefer an open area to an enclosed room, whether with or without Passthrough, finding it more socially acceptable. Additionally, Passthrough appears to encourage participation among players with higher self-consciousness, potentially alleviating their concerns about being observed by bystanders. Our findings provide valuable insights for designing VR experiences in shared spaces, underscoring the potential of VR's passthrough to enhance user experiences and promote VR adoption in these environments.

Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study.

BACKGROUND: Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders. OBJECTIVE: This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders. METHODS: Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes. RESULTS: The quantitative data regarding the usability of the system associated with participants' immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant's attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology. CONCLUSIONS: Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities.

Individualized Virtual Reality for Increasing Self-Compassion: Evaluation Study.

BACKGROUND: Depression and anxiety are common and debilitating mental disorders with severe negative repercussions at both individual and societal levels. Although virtual reality (VR) has emerged as a safe and effective tool for the treatment of anxiety disorders, studies of the therapeutic application of VR to treat depression are more limited. OBJECTIVE: The purpose of this study was to test whether a novel type of individualized VR (iVR) can be used to improve self-compassion and decrease depressive symptoms and to evaluate the usability and acceptability of this approach, as rated by participants. The iVR system was designed and developed based on the feedback obtained from a previous study, with improved appearance and feel of the avatar and enhanced graphical quality. METHODS: A total of 36 young adult participants were recruited from a university community social media site. Participants were aware that the study was investigating a treatment for depression but were not recruited based on depression diagnosis. Participants were asked to complete 2 iVR sessions, spaced 2 weeks apart. At baseline and upon completion of each iVR session, participants were asked to complete validated measures of self-compassion and depression. Upon completion of both iVR sessions, additional measures were administered to assess participants' perceptions about the perceived usability and system acceptability of the iVR approach. RESULTS: Self-compassion was assessed at the beginning of session 1 (preintervention baseline) and at the end of session 1 (postintervention assessment). Owing to COVID-19 constraints, 36% (13/36) of the participants were unable to complete the follow-up iVR session. Self-compassion was assessed again for the remaining 64% (23/36) of the participants at the end of session 2 (postintervention assessment). Within-group analyses revealed that self-compassion was significantly increased at the end of both session 1 (P=.01) and session 2 (P=.03) relative to baseline. There was also a nonsignificant trend for depressive symptoms to be low at the end of session 2 relative to baseline. Both quantitative and qualitative participant data supported the iVR approach as being acceptable and usable. CONCLUSIONS: Although these data must be treated as preliminary owing to the small sample size and potential selection bias, the data provide encouraging initial evidence that iVR might be a useful tool to enhance self-compassion and reduce depressive symptoms, highlighting the need for randomized controlled trials in the future.

A Systematic and Comparative Review of Behavior Change Strategies in Stress Management Apps: Opportunities for Improvement.

Stress is one of the significant triggers of several physiological and psychological illnesses. Mobile health apps have been used to deliver various stress management interventions and coping strategies over the years. However, little work exists on persuasive strategies employed in stress management apps to promote behavior change. To address this gap, we review 150 stress management apps on both Google Play and Apple's App Store in three stages. First, we deconstruct and compare the persuasive/behavior change strategies operationalized in the apps using the Persuasive Systems Design (PSD) framework and Cialdini's Principles of Persuasion. Our results show that the most frequently employed strategies are personalization, followed by self-monitoring, and trustworthiness, while social support strategies such as competition, cooperation and social comparison are the least employed. Second, we compare our findings within the stress management domain with those from other mental health domains to uncover further insights. Finally, we reflect on our findings and offer eight design recommendations to improve the effectiveness of stress management apps and foster future research.

The Use of Videogames and Virtual Reality for the Assessment of Anxiety and Depression: A Scoping Review.

This study provides a comprehensive review about the use of videogames and virtual reality (VR) for the assessment of anxiety and depression. This review aimed to answer the research question of the viability of games and VR for the assessment of anxiety and depression. An extensive literature search spanning across several databases published since the year 2000 returned a total of 4566 records. Based on the eligibility criteria, the screening process resulted in the selection of 10 articles for the final review. Equal number of studies utilized games (n = 5) and VR. Three studies made use of machine learning techniques. Only two were found to be clinical studies. An interesting finding was that the studies that focused on anxiety disorders relied mostly on VR, whereas those focused on depression disorders relied mostly on the use of videogames for the assessment. Majority of studies reported encouraging findings that support the use of games or VR for the assessment of anxiety and depression. This study identified potential digital biomarkers or correlates of anxiety and depression that may guide researchers in the design process. It is necessary to highlight that researchers should consider consultation with trained mental health experts, while designing such assessments to ensure safety and privacy. However, due to limited number of articles as well as lack of clinical studies, more clinical evidence is required to strongly support this notion of using videogames or VR as assessment tools for anxiety and depression.

Feasibility of Using Games to Improve Healthy Lifestyle Knowledge in Youth Aged 9-16 Years at Risk for Type 2 Diabetes: Pilot Randomized Controlled Trial.

BACKGROUND: Mobile games can be effective and motivating tools for promoting children's health. OBJECTIVE: We aimed to determine the comparative use of 2 prototype serious games for health and assess their effects on healthy lifestyle knowledge in youth aged 9-16 years at risk for type 2 diabetes (T2D). METHODS: A 3-arm parallel pilot randomized controlled trial was undertaken to determine the feasibility and preliminary effectiveness of 2 serious games. Feasibility aspects included recruitment, participant attitudes toward the games, the amount of time the participants played each game at home, and the effects of the games on healthy lifestyle and T2D knowledge. Participants were allocated to play Diabetic Jumper (n=7), Ari and Friends (n=8), or a control game (n=8). All participants completed healthy lifestyle and T2D knowledge questionnaires at baseline, immediately after game play, and 4 weeks after game play. Game attitudes and preferences were also assessed. The primary outcome was the use of the game (specifically, the number of minutes played over 4 weeks). RESULTS: In terms of feasibility, we were unable to recruit our target of 60 participants. In total, 23 participants were recruited. Participants generally viewed the games positively. There were no statistical differences in healthy lifestyle knowledge or diabetes knowledge over time or across games. Only 1 participant accessed the game for an extended period, playing the game for a total of 33 min over 4 weeks. CONCLUSIONS: It was not feasible to recruit the target sample for this trial. The 2 prototype serious games were unsuccessful at sustaining long-term game play outside a clinic environment. Based on positive participant attitudes toward the games, it is possible to use these games or similar games as short-term stimuli to engage young people with healthy lifestyle and diabetes knowledge in a clinic setting; however, future research is required to explore this area. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12619000380190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377123.

Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review.

BACKGROUND: Mental health conditions pose a major challenge to health care providers and society at large. The World Health Organization predicts that by 2030, mental health conditions will be the leading cause of disease burden worldwide. The current need for mental health care is overwhelming. In New Zealand, 1 in 6 adults has been diagnosed with common mental disorders, such as depression and anxiety disorders, according to a national survey. Cognitive behavioral therapy (CBT) has been shown to effectively help patients overcome a wide variety of mental health conditions. Virtual reality exposure therapy (VRET) might be one of the most exciting technologies emerging in the clinical setting for the treatment of anxiety and depression. OBJECTIVE: This study aims to investigate the virtual reality (VR) technologies currently being used to help support the treatment of depression and anxiety. We also aim to investigate whether and how CBT is included as part of VRET and look at the VR technologies and interventions that have been used in recent studies on depression and anxiety. METHODS: We performed a scoping review. To identify significant studies, we decided to use already aggregated sources from the Google Scholar database. Overall, the goal of our search strategy was to limit the number of initial results related to VR in mental health to only a relevant minimum. RESULTS: Using our defined keywords, Google Scholar identified >17,300 articles. After applying all the inclusion and exclusion criteria, we identified a total of 369 articles for further processing. After manual evaluation, 34 articles were shortlisted; of the 34 articles, 9 (26%) reported the use of CBT with VR. All of the articles were published between 2017 and 2021. Out of the 9 studies, CBT was conducted within a VR environment in 5 (56%) studies, whereas in the remaining 4 (44%) studies, CBT was used as an addition to VRET. All 9 studies reported the use of CBT either in vivo or in a virtual environment to be effective in supporting the treatment of anxiety or depression. CONCLUSIONS: Most studies demonstrated the use of VR to be effective for supporting the treatment of anxiety or depression in a range of settings and recommended its potential as a tool for use in a clinical environment. Even though standalone headsets are much easier to work with and more suitable for home use, the shift from tethered VR headsets to standalone headsets in the mental health environment was not observed. All studies that looked at the use of CBT either in vivo or in a virtual environment found it to be effective in supporting the treatment of anxiety or depression.

Effects of an Immersive Virtual Reality Exergame on University Students' Anxiety, Depression, and Perceived Stress: Pilot Feasibility and Usability Study.

BACKGROUND: In recent years, there has been an increase in the number of students with depression, anxiety, and perceived stress. A solution that has been increasingly used for improving health and well-being is exergaming. The effects and acceptability of exergames have been studied widely but mostly with older adults. The feasibility and usability of exergames among university students, especially those of immersive virtual reality (iVR) exergames, remain unexplored. OBJECTIVE: This study aimed to explore the feasibility of a 6-week iVR exergame-based intervention in reducing anxiety, depression, and perceived stress among university students and to examine the usability and acceptability of such games. METHODS: A total of 31 university students were recruited to participate in a 6-week study in which they needed to play a boxing-style iVR exergame called FitXR (FitXR Limited) twice per week (30 minutes per session). Their anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-II), and perceived stress (Perceived Stress Scale) levels were measured before and after intervention. RESULTS: A total of 15 participants completed the 6-week study. Our results suggested that participants' mean depression scores decreased significantly from 8.33 (SD 5.98) to 5.40 (SD 5.14) after the intervention (P=.01). In addition, most participants (14/15, 93%) believed that the iVR exergame has good usability. Furthermore, most participants (14/15, 93%) were satisfied with the iVR gameplay experience and would play the iVR exergame again in the future. Of the 15 participants, 11 (73%) would recommend the iVR exergame to their friends. CONCLUSIONS: The results gained from this study show that the iVR exergame has good usability, is highly acceptable, and has the potential to reduce depression levels among university students.

Studying the Effect of Display Type and Viewing Perspective on User Experience in Virtual Reality Exergames.

Background: Physical inactivity has been identified as the fourth leading cause of death globally. It is now well established that a sedentary lifestyle is a unique risk factor for several diseases such as type 2 diabetes and cardiovascular disease, which account for about 30% of global mortality. Diabetes is a major preventable cause of costly and debilitating renal failure, heart disease, lower limb amputation, and avoidable blindness. In recent years, the idea of using interactive computing systems that leverage gamification to promote physical activity has been widely researched. Prior studies have shown that exergames, that is those that encourage physical activity, can increase enjoyment and intrinsic motivation compared with conventional exercises; as such, they can be effective in promoting physical and mental health. There has been some research on immersive virtual reality (VR) exergames; however, to the best of our knowledge, it is limited and preliminary. This work aims at filling the gap and investigates the effect of display type (DT) and viewing perspective (VP) on players' exertion, engagement, and overall game experience in immersive VR exergames. Objective: This article aims at examining whether DT and VP can affect gameplay performance, players' exertion, game experience, cybersickness, and electroencephalography (EEG) engagement index when playing a gesture-based (i.e., body motion) exergame. Materials and Methods: Study 1 employed a one-way between-subjects design with 24 participants equally distributed in two groups (immersive VR and 50-inch TV) to perform 12 pre-defined gestures. The main outcome measures were National Aeronautics and Space Administration-Task Load Index (NASA-TLX) workload for each group as well as 7 Likert scale and EEG engagement index for each gesture. Study 2 included 16 participants in playing a game with the gestures selected from study 1. All participants played 4 versions based on combinations of DT (immersive VR and 50-inch TV) and VP (first-person and third-person) to assess exertion (%HRmax, calories consumption, and Borg RPE 6-20), game experience, cybersickness, and EEG engagement index. Results: Study 1 results showed that DT had no effect on the ratings of the gestures, NASA-TLX workload, and EEG engagement index. Study 2 results showed that immersive VR not only resulted in a significantly higher exertion (%HRmax, calories consumption, and Borg RPE) but also helped achieve better positive game experience in challenge, flow, sensory and imaginative immersion, as well as lower negative affect. We also found that nausea and oculomotor were significantly higher in immersive VR. Conclusion: This pilot study demonstrates that youth who played gesture-based exergame in immersive VR had a higher level of exertion (%HRmax, calories consumption, and Borg RPE), although the number of performed gestures were not significantly different. They also felt that immersive VR was much more challenging, immersive (flow, sensory and imaginative immersion), and had a lower negative affect than a 50-inch TV; however, immersive VR was more likely to make youth have higher cybersickness.

Health Benefits of Digital Videogames for the Aging Population: A Systematic Review.

Objective: This article presents the results of a systematic review of the latest, state-of-the-art research on videogames designed for older adults (i.e., those aged 65 or older) and the health benefits derived from playing these games. Findings from each study that met the inclusion criteria were analyzed and summarized into emergent themes to determine the impact of digital games in promoting healthy behaviors and benefits among these older adults. Materials and Methods: Five databases (PubMed, ScienceDirect, IEEE Xplore, ACM Digital Library, and Google Scholar) were searched for studies that evaluated interventions of videogames for older adults aged 65 and older. The initial search yielded 806 articles. After evaluating them against the inclusion criteria, 23 studies remained. Results: Out of the 23 studies we reviewed, 20 reported the significant impact of videogame interventions on the elderly's physical health. In addition, 14 studies reported effects on the elderly's mental health. Exergame is the most popular type of game used in these videogame-based interventions. This review also includes the details of study design (e.g., type of intervention, length, frequency), population sample, and measurements used in the studies. Conclusions: This systematic review demonstrates that videogame-based interventions are helpful in promoting physical health (i.e., balance, mobility, strength, physical fitness, and walking performance/gait parameters) and mental health (i.e., balance confidence, executive functions, reaction time, and processing speed) among older adults. It can also be used by researchers in this field to inform their design decisions. We have listed guidelines that can be used to frame future research in the area and enhance its quality.

MoodJumper: An Exploration of Game Interface Preferences in Users With/Out Mood Disorder.

Mental health conditions pose a major challenge to healthcare providers and society at large. The World Health Organization predicts that by 2030 mental illnesses will be the leading disease burden globally. Mental health services are struggling to meet the needs of users and arguably fail to reach large proportions of those in need. According to New Zealand Mental Health Foundation, one in five will experience a serious mood disorder, including depression, at some time in their life. Games for Health including those supporting mental health have recently gained a lot of attention. However, game interface preferences for users with a history of mental health conditions have not been systematically studied, making it difficult to determine what game features may attract and further engage users affected by mental health conditions. We present MoodJumper, a prototype Android mobile game, which enables players to jump to the top of the level by steering the avatar from platform to platform, gradually gaining height and collecting coins on the way up. We conducted a preliminary study (n = 25), in which participants were able to modify different settings of the game (background color, dark/light, character movement, gender, and music), while their gaming behavior was tracked. The results show that regardless of self-reported history of mood disorder, the majority of participants prefer the dark and colored layout setting and there were no differences in gaming variables including session duration and high scores. This represents a first indication that history of mood disorder does not affect user preferences for game interface settings. It will be important to follow up with data on users currently affected by low mood. Systematic study of game interface preferences in users with mood disorder constitutes a vital step in being able to harness the potential power of games for supporting mental health.

Diabetic Mario: Designing and Evaluating Mobile Games for Diabetes Education.

Traditionally, diabetes education has relied on written materials, with limited resources available for children with diabetes. Mobile games can be effective and motivating tools for the promotion of children's health. In our earlier work, we proposed a novel approach for designing computer games aimed at educating children with diabetes. In this article, we apply our game design to a mobile Android game (Mario Brothers). We also introduce four heuristics that are specifically designed for evaluating the mobile game, by adapting traditional usability heuristics. Results of a pilot study (n = 12) to evaluate gameplay over 1-week showed that the children found the game engaging and improved their knowledge of healthy diet and lifestyle.