Background: Many adolescents in Uganda are affected by common mental disorders, but only a few affordable treatment options are available. Digital mental health interventions offer promising opportunities to reduce these large treatment gaps, but interventions specifically tailored for Ugandan adolescents are limited. Objective: This study aimed to determine the feasibility and acceptability of the Kuamsha program, an intervention delivered through a gamified app with low-intensity telephonic guidance, as a way to promote mental health among adolescents from the general population in Uganda. Methods: A 3-month pre-post single-arm trial was conducted with adolescents aged between 15 and 19 years living in Wakiso District, Central Uganda. The intervention was coproduced with adolescents from the study site to ensure that it was culturally acceptable. The feasibility and acceptability of the intervention were evaluated using an explanatory sequential mixed methods approach. Feasibility was assessed by collecting data on trial retention rates and treatment adherence rates. Acceptability was assessed through a questionnaire and in-depth interviews with participants following the conclusion of the intervention period. As a secondary objective, we explored the changes in participants’ mental health before and after the intervention. Results: A total of 31 adolescents were recruited for the study. Results from the study showed high levels of feasibility and acceptability. Trial retention rates exceeded 90%, and treatment adherence was ≥80%. These results, evaluated against our predefined trial progression criteria, indicate a successful feasibility study, with all criteria exceeding the thresholds necessary to progress to a larger trial. App engagement metrics, such as time spent on the app and modules completed, exceeded existing literature benchmarks, and many adolescents continued to use the app after the intervention. In-depth interviews and questionnaire responses revealed high acceptability levels. Depressive symptoms trended toward reduction (mean difference: 1.41, 95% CI –0.60 to 3.42, Cohen d=0.30), although this was not statistically significant (P=.16). Supporting this trend, we also observed a reduction in the proportion of participants with moderate depressive symptoms from 32% (10/31) to 17% (5/29) after the intervention, but this change was also not significant (P=.10). Conclusions: This study presents evidence to support the Kuamsha program as a feasible and acceptable digital mental health program for adolescents in Uganda. A fully powered randomized controlled trial is needed to assess its effectiveness in improving adolescents’ mental health.

Background: Serious games (SG) have emerged as promising tools for cognitive training and therapeutic interventions, especially for enhancing executive functions. These games have demonstrated the potential to support individuals with diverse health conditions, including neurodevelopmental and cognitive disorders, through engaging and interactive experiences. However, a comprehensive understanding of the effectiveness of SG in enhancing executive functions is needed. Objective: This systematic review aims to assess the impact of serious games on executive functions (EF), focusing on attention, working memory, cognitive flexibility, and inhibitory control. In addition, it explores the integration of SG into educational and therapeutic settings for individuals with cognitive and neurodevelopmental conditions. Only open access articles published from 2019 to the search date were included to capture the most recent advancements in the field. Methods: A comprehensive search was conducted on June 20, 2024, across Scopus, Web of Science, and PubMed databases. Due to limited direct results linking SG and neurodiversity, separate searches were performed to analyze the relationship between SG and EF, as well as SG and neurodiverse populations. Two independent reviewers assessed the quality and risk of bias of the included studies using the Risk of Bias 2 tool for randomized studies and the Risk of Bias in Non-Randomized Studies of Interventions tool for nonrandomized studies. Results: The review identified 16 studies that met the inclusion criteria. Of these, 15 addressed the use of SG for improving EF in neurodiverse populations, such as children with attention-deficit/hyperactivity disorder, autism spectrum disorder, and down syndrome. These studies demonstrated significant improvements in various EF domains, including attention, working memory, and cognitive flexibility. However, there was notable heterogeneity in sample sizes, participant ages, and game types. Three studies specifically focused on individuals with down syndrome, showing promising results in improving cognitive functions. Conclusions: SG hold considerable potential as therapeutic tools for enhancing EF across neurodiverse populations. They have shown positive effects in improving cognitive skills and promoting inclusion in both educational and therapeutic settings. However, further research is required to optimize game design, assess long-term outcomes, and address the variability in study quality. The exclusive inclusion of open access studies may have limited the scope of the review, and future research should incorporate a broader range of studies to provide a more comprehensive understanding of SG’s impact on neurodiversity. Clinical Trial: PROSPERO CRD42024563231; https://tinyurl.com/ycxdymyb

Background: Chronic pain presents a significant treatment challenge, often leading to frustration for both patients and therapists due to the limitations of traditional methods. Research has shown that synchronous visuo-tactile stimulation, as used in the rubber hand experiment, can induce a sense of ownership over a fake body part and reduces pain perception when ownership of the fake body part is reported. The effect of the rubber hand experiment can be extended to the full body, e.g. during the full body illusion, using both visuo-tactile but also cardio-visual signals. Objective: This study first aimed to evaluate the usability and accuracy of a novel, mobile virtual reality (VR) setup that displays participants' heartbeats as a flashing silhouette on a virtual avatar, a technique known as the cardio-visual full body illusion. The second part of the study investigates the effects of synchronous cardio-visual stimulation on pain perception and ownership in 20 healthy subjects as compared to asynchronous stimulation (control condition). Methods: The setup comprises a head-mounted display (HMD) and a heart rate measurement device. A smartphone-based HMD (Samsung Galaxy S8+) was selected for its mobility, and heart rates were measured using smartwatches with photoplethysmography (PPG). The accuracy of two smartwatch positions was compared to a five-point electrocardiogram (ECG) standard regarding their accuracy (number and percent of missed beats).. Each participant underwent two 5-minute sessions of each synchronous and asynchronous cardio-visual stimulation (total of four sessions) followed by pain assessments. Usability, symptoms of cybersickness, and ownership of the virtual body were measured using established questionnaires (System Usability Scale, Simulator Sickness Questionnaire, Ownership Questionnaire). Pain perception was assessed using advanced algometric methods (Algopeg, Somedic algometer). Results: Results demonstrated high usability scores (mean 4.42 out of 5), indicating ease of use and acceptance, with minimal side effects (mean 1.18 of possible 4 points on the Simulator Sickness Questionnaire). The PPG device showed high heart rate measurement precision, which improved with optimized filtering and peak detection algorithms. However compared to previous work, no significant effects on body ownership and pain perception were observed between the synchronous and asynchronous conditions. These findings are discussed in the context of existing literature on VR interventions for chronic pain. Conclusions: In conclusion, while the new VR setup showed high usability and minimal side effects, it did not significantly affect ownership or pain perception. This highlights the need for further research to refine VR-based interventions for chronic pain management, considering factors like visual realism and perspective.

Background: With climate change, the number of natural disasters is increasing globally, and the resulting weather-related events lead to increased loss of life and property. Meanwhile, the significance of disaster education is becoming increasingly important. Despite the events of disaster being hard to predict, people’s responses to such events can be improved by education and training. Gamification, an innovative teaching method, has demonstrated great potential across various fields, including disaster education. Objective: We aimed to investigate the different application types of gamification in disaster education, focusing on nursing staff, medical professionals, university students, and disaster relief workers. Specifically, the goal is to identify the types of gamified teaching used in disaster education. Methods: This scoping review was conducted according to the Joanna Briggs Institute (JBI) methodology. The PCC model was used to frame the inclusion criteria. A systematic search of relevant literature across Cochrane Library, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, China Science and Technology Journal Database(VIPC), and SinoMed. Articles published in Chinese and English were selected for the review. The search was conducted to identify literature published from the establishment of the respective databases to April 21, 2024. Two researchers independently screened the literature according to the inclusion and exclusion criteria and extracted the data. Results: We included a total of 16 studies in this review, originating from eight different countries. These studies involved 1,744 participants: nursing students (n=451), medical students from other majors (n=420), college students (n=287), hospital decision-makers (n=264), hospital medical staff (n=262), and disaster relief workers (n=60). The gamification approaches to teaching and learning encompassed seven categories: Tabletop games, Serious games, Scenario simulation games, Virtual reality and mobile games, Theme games, Board games, and Escape room games. The objectives of the studies were diverse. Three studies conducted randomized controlled trials, with only one performing a comparative analysis between different games. Two studies carried out long-term outcome evaluations. Conclusions: This scoping review explored seven types of games for disaster education and provides evidence for future education and training. Further research is needed to establish a long-term evaluation mechanism and a better game-based teaching program to provide more insights into the future of disaster education.

Background: Osteoarthritis is one of the most common degenerative diseases of the musculoskeletal system and can ultimately lead to the need for surgery, such as total knee or hip arthroplasty. Functional movement deficits can be a prognostic factor for osteoarthritis in the lower extremities. Thus, training physiological movement patterns may help in the treatment of such functional deficits. Motivation to exercise frequently is of utmost importance and can be promoted by using digital real-time feedback. Objective: This qualitative study aims to gather user recommendations for prototype feedback visualizations in a real-time exercise-feedback system called homeSETT for the treatment of functional deficits. The system provides real-time feedback to participants while performing exercises that focus on functional deficits, such as lateral trunk lean, pelvic drop, and valgus thrust. The findings of this study should help to optimize the prototype feedback visualizations. Thus, the main research questions were how patients, physiotherapists, and physicians evaluate the presented, current state of prototype feedback visualizations for selected functional exercises, and what improvements and variations would be recommended. Methods: Testing of the prototype feedback visualizations took place at a movement laboratory using a 3D optoelectronic movement analysis system. Data on usability factors were acquired using the thinking aloud method during and semistructured interviews after prototype testing. Transcribed audio recordings of semistructured interviews as well as scribing logs of the thinking aloud method were examined using qualitative content analysis. Results: Data were analyzed from 9 participants, comprising 2 (22%) patients, 2 (22%) physicians, and 5 (56%) physiotherapists. The mean age of the participants was 45 (SD 9) years and the mean work experience among the participating physiotherapists and physicians was 22 (SD 5) years. Each participant tested 11 different exercise-feedback combinations. Overall, results indicated that participants enjoyed the prototype feedback visualizations and believed that they could be used in therapeutic settings. Participants appreciated the simplicity, clarity, and self-explanatory nature of the feedback visualizations. While most participants quickly familiarized themselves, some struggled to recognize the feedback goals and connect the visualizations to their movements. Recommendations for improvement included optimizing color schemes, sensitivity, and difficulty adjustments. Adding instructional information and game design elements, such as repetition counting and reward systems, was deemed useful. The main study limitations were the small sample size and the use of feedback on performance as the sole feedback modality. Conclusions: The prototype feedback visualizations were positively perceived by the participants and were considered applicable in therapy settings. Insights were gathered on improving the color scheme, sensitivity, and recognizability of the feedback visualizations. The implementation of additional gamification and instructional elements was emphasized. Future work will optimize the prototype feedback visualizations based on study results and evaluate the homeSETT system’s efficacy in eligible patient populations.

Background: Adequate pain relief, early restoration of breathing, and rapid mobilization pose a clinical challenge in patients with blunt chest trauma. Virtual reality (VR) has the potential to achieve these 3 interrelated treatment objectives with enhanced self-efficacy and autonomy of patients and limited support by clinicians. Objective: This study aimed to assess the effectivity of breathing and physical exercises using VR on the pulmonary recovery of patients with blunt chest trauma at the ward. Methods: A pilot randomized controlled trial was performed. The control group received usual physiotherapy consisting of protocolized breathing exercises (8 times daily for 10 minutes) and physical exercises (2 times daily for 10 minutes). The VR group was instructed to perform these exercises using VR. The primary outcome was vital lung capacity at day 5 or earlier at discharge. Secondary outcomes were patient mobility (time standing, lying, and sitting), clinical outcomes (length of hospital stay, pulmonary complications, transfer to intensive care unit, and readmission within 30 days), pain, activities of daily living, patient-reported outcome measures (satisfaction and quality of recovery). Patient experiences and barriers and facilitators toward implementation were assessed through interviews. Results: The study was prematurely ended due to enrollment failure combined with poor protocol adherence to exercises in both groups. A total of 27 patients were included, of which 19 patients completed 3 or more days. Vital lung capacity at 5 days (or last measurement) was equal between groups with 1830 (SD 591) mL and 1857 (SD 435) mL in the control and VR groups, respectively. No marked differences were observed in secondary outcomes. Patient interviews showed positive attitudes toward the use of VR, describing that visualization of the exercises helped patients to perform the exercises correctly and to continue the exercises for a longer duration. Also, patients experienced the immersiveness of VR as an analgesic. However, patients did not experience added value over usual care and reported that better integration in treatment and the hectic hospital environment could improve the use of the VR exercises. Conclusions: The suitability of patients to use virtual reality therapy (VRx) in a hospital (trauma) ward setting is lower than generally expected. Effective application of VRx requires professional guidance and needs thorough alignment with clinical practice. For future research, we recommend to chart adherence to study protocol before designing a VR clinical trial. Patient-reported experiences need to be prioritized in evaluating VR acceptance, usability, and effectiveness. In line, we recommend performing a systematic analysis (eg, using the technology acceptance model) on the acceptance before pilot or main effectiveness studies. Finally, the eligibility of patients and exclusion of patients due to the inability to use VRx should be routinely reported. Trial Registration: ClinicalTrials.gov NCT05194176; https://tinyurl.com/2bzh4tzx

Background: Cochlear implants are implanted hearing devices; instead of amplifying sounds like common hearing aids, this technology delivers preprocessed sound information directly to the hearing (ie, auditory) nerves. After surgery and the first cochlear implant activation, patients must practice interpreting the new auditory sensations, especially for language comprehension. This rehabilitation process is accompanied by hearing therapy through face-to-face training with a therapist, self-directed training, and computer-based auditory training. Objective: In general, self-directed, computer-based auditory training tasks have already shown advantages. However, compliance of cochlear implant recipients is still a major factor, especially for self-directed training at home. Hence, we aimed to explore the combination of 2 techniques to enhance learner motivation in this context: adaptive learning (in the form of an intelligent tutoring system) and game-based learning (in the form of a serious game). Methods: Following the suggestions of the evidence-centered design framework, a domain analysis of hearing therapy was conducted, allowing us to partially describe human hearing skill as a probabilistic competence model (Bayesian network). We developed an algorithm that uses such a model to estimate the current competence level of a patient and create training recommendations. For training, our developed task system was based on 7 language comprehension task types that act as a blueprint for generating tasks of diverse difficulty automatically. To achieve this, 1053 audio assets with meta-information labels were created. We embedded the adaptive task system into a graphic novel–like mobile serious game. German-speaking cochlear implant recipients used the system during a feasibility study for 4 weeks. Results: The 23 adult participants (20 women; 3 men) fulfilled 2259 tasks. In total, 2004 (90.5%) tasks were solved correctly, and 255 (9.5%) tasks were solved incorrectly. A generalized additive model analysis of these tasks indicated that the system adapted to the estimated competency levels of the cochlear implant recipients more quickly in the beginning than at the end. Compared with a uniform distribution of all task types, the recommended task types differed (χ²₆=86.713; P<.001), indicating that the system selected specific task types for each patient. This is underlined by the identified categories for the error proportions of the task types. Conclusions: This contribution demonstrates the feasibility of combining an intelligent tutoring system with a serious game in cochlear implant rehabilitation therapies. The findings presented here could lead to further advances in cochlear implant care and aural rehabilitation in general. Trial Registration: German Clinical Trials Register (DRKS) DRKS00022860; https://drks.de/search/en/trial/DRKS00022860

Background: Young people are particularly at risk of developing mental health problems, a challenge exacerbated by the COVID-19 pandemic. Digital tools such as apps and chatbots show promise in providing accessible, cost-effective, and less stigmatized ways of strengthening their mental health. However, while these interventions offer benefits, they extend mental health measures beyond traditional therapeutic settings and relationships, which raises ethical concerns due to the absence of established guidelines and regulations. This is particularly notable for technologies incorporating serious gaming elements. In addition, adolescents are in a sensitive and at times vulnerable phase, which shows great potential for the effective use of preventive and sensitizing mental health measures. Considering the lack of an integration into existing mental health structures among many young users, ethical considerations become crucial. Objective: This scoping review aims to build a knowledge base on the ethical aspects of developing and implementing gamified digital mental health interventions for young people. Methods: We conducted a search on research articles and conference papers from 2015 to 2023 in English, German, and Spanish. We identified 1815 studies using a unique combination of keywords in the databases Scopus, Web of Science, MEDLINE, and PsycINFO. After removing duplicates (741/1816, 40.8%), we included a total of 38 publications in this review following a double screening process. Results: This review found that ethically relevant aspects were discussed with regard to (1) research ethics, (2) ethical principles (including privacy, accessibility, empowerment and autonomy, cultural and social sensitivity, and co-design), (3) vulnerable groups, and (4) social implications (including implementation using facilitators in specific social contexts, relationship with other therapeutic options, economic aspects, and social embeddedness of technologies). Conclusions: This scoping review identified a prevailing limited interpretation of “ethics” as research ethics across the included publications. It also shows a lack of discussion on the social embeddedness of technologies and that co-design is frequently viewed in instrumental terms and vulnerability is mostly addressed pragmatically. Through providing concrete examples of how mental health researchers and game designers thus far have addressed and mitigated ethical challenges in specific interventions, this review illustrates how ethical issues do or do not prompt diverse reflections, mitigation strategies, and actions. It advocates for ethics to be integrated as an ongoing practice throughout all stages of developing and implementing serious game elements in mental health interventions for young people.

Background: Attention deficit hyperactivity disorder (ADHD). is one of the common neurodevelopmental disorders in children, virtual reality (VR) has been used in the diagnosis and treatment of ADHD. Objective: This paper aims to systematically evaluate the effect of virtual reality VR technology on the attention and motor ability of children with ADHD. Methods: The intervention method of the experimental group was VR technology, while the control group adopted non-VR technology. The population was children with ADHD. The outcome indicators were attention and motor abilities. The experimental design was randomized controlled trial (RCT). Two researchers independently searched PubMed, Cochrane Library, Web of Science (WOS), and EMBASE for randomized controlled trials related to VR technology on ADHD children's attention and motor ability. The retrieval date was from the establishment of each database to January 4, 2023. The PEDro scale was used to evaluate the quality of the included literature. Stata 17.0 was used for effect size combination, forest map-making, subgroup analyses, sensitivity analyses, and publication bias. GRADEpro was used to evaluate the level of evidence quality. Results: A total of 9 literature involving 370 children with ADHD were included. VR technology can improve ADHD children’s attention (Cohen’s d=-0.68, 95% CI (-1.12, -0.24), P=.00) and motor ability (Cohen's d=0.48, 95% CI (0.16,0.80), P=.00). The intervention method and diagnosis type of VR technology had a moderating effect on the intervention effect of children's attention (P<.05). The improvement of children's attention by “immersive” VR technology was statistically significant (Cohen's d=-1.05, 95% CI (-1.76, -0.34), P=.004). The improvement of children's attention by “non-immersive” VR technology was statistically significant (Cohen's d=-0.28, 95% CI (-0.55, -0.01), P=.041). VR technology had improvement effects on both children with “informal diagnosis” (Cohen's d=-1.47, 95% CI (-2.35, -0.59), P=.001) and on children with “formal diagnosis” (Cohen's d=-0.44, 95% CI (-0.85, -0.03), P=.032). Conclusions: VR technology can improve ADHD children's attention and motor ability. The immersive VR technology has the best attention improvement for the informal diagnosed children with ADHD. Clinical Trial: This research program has been registered on the international system evaluation platform Prospero （https://www.crd.york.ac.uk/PROSPERO/）Registration No. (crd42024499199).

Background: Pain is a leading cause of disability around the world and severely impacts quality of life for millions of Americans. Arts engagement using virtual reality and serious games represent promising non-pharmacological self-management treatment approaches to chronic pain. This study is the first randomized controlled trial to explore the impact of a web-based serious game that simulated a visit to an art museum on pain and social disconnection among individuals living with chronic pain and loneliness. Objective: To test the joint and separate effects of exposure to virtual art and attachment figure priming on pain and social disconnection among individuals living with chronic pain and loneliness. Methods: This randomized controlled trial employed a 2 (virtual artwork present, absent) x 2 (secure attachment, avoidant attachment prime) repeated measures factorial web-based experimental design with a hanging control condition. Mediation and moderation analyses examined how feelings about the social world triggered by the artwork and frequency of museum visits impacted the effects of the interventions on pain and social disconnection. Results: The results are based on 309 participants. Mean age 42.78 years old (SD=13.11, Min=18, Max=76) and 60.2% women. Post-test pain was lower than pre-test pain for the artwork present (P=.001) and absent (P=.001) conditions. Similarly, post-test pain was lower than pre-test pain for the secure (P=.001) and avoidant (P=.001) attachment priming conditions. Relative to the control group, artwork present (P=.001) and absent (P=.010) conditions had decreased post-test pain. The secure (P=.001) and avoidant (P=.001) attachment priming conditions also had lower post-test pain scores relative to the control group. Moreover, social disconnection decreased from pre- to post-test for both the artwork present (P=.04) and the secure attachment priming (P=.002) conditions. Relative to the control group, post-test social disconnection was lower for the artwork present (P=.02) and secure attachment priming condition (P=.03). The artwork-secure attachment (P=.001) and artwork-avoidant attachment (P=.006) conditions had lower post-test pain scores compared with the control group. Social disconnection decreased from pre- to post-test for the artwork-secure attachment (P=.010) and no artwork-secure attachment (P=.05) conditions. Post-test social disconnection was lower for the artwork-secure attachment condition compared with the control group (P=.04). Positive feelings about the social world triggered by artwork exposure and frequency of museum visits in the last year played a mediating and moderating role in these effects. Positive feelings about the social world were associated with decreased pain (B=-.53) and social disconnection (B=-.25), and these effects operated on individuals exposed to virtual artwork at low, medium, and high frequency of physical museum visits. Conclusions: Relative to a control group, visiting a virtual art museum reliably decreased pain and social disconnection among individuals living with chronic pain and loneliness. Engaging with virtual artwork that triggers positive feelings about the social world may mitigate the burden of chronic pain. Clinical Trial: Trial Registration: ClinicalTrials.gov NCT05310747 and OSF - https://osf.io/q7un3