Background: Virtual reality (VR) active gaming is growing in popularity but little is known about physical activity during gameplay. Two popular VR games are Gorilla Tag and Beat Saber. Little is known about physical activity during these games in youth. Objective: The purpose of this study was to investigate the enjoyment, intensity, and amount of physical activity while playing Gorilla Tag and Beat Saber in early adolescent youth. Methods: Sixteen participants, 13 males and 3 females with an average age of 10.7±0.34 years played two VR games (Gorilla Tag and Beat Saber) in a single session. Both games followed the same procedure: a max of 10-minute familiarization period, 5 minutes of rest, 15 minutes of gameplay, and 10 minutes of rest. Participants wore a heart rate monitor to track heart rate reserve (% HRR) and accelerometers on the wrist and waist to monitor time in sedentary activity, light physical activity , and moderate to vigorous physical activity of the arm and whole-body. The Physical Activity Enjoyment Scale-child version (PACES) and ratings of perceived exertion were completed after each game. Dependent t-tests compared measures between games. Results: The results revealed that average and maximum %HRR were significantly higher during Gorilla Tag than Beat Saber, with heart rate-based physical activity intensity reaching light for Beat Saber and moderate for Gorilla Tag. Arm moderate to vigorous physical activity and whole-body moderate to vigorous physical activity and light physical activity were greater during Gorilla Tag than Beat Saber. Arm and whole-body sedentary time were significantly lower during Gorilla Tag than Beat Saber. Gorilla Tag and Beat Saber were rated as highly enjoyable. There were no differences between games for maximum (p=.352) or average (p=.362) ratings of perceived exertion. Both games were rated as light intensity for average ratings of perceived exertion (GT: 4.3±1.9; BS: 4.7±2.3) and moderate intensity for maximum ratings of perceived exertion (GT: 5.4±1.9; BS: 5.8±2.4). Conclusions: These results suggest that Beat Saber produced light intensity physical activity and Gorilla Tag produced light to moderate-intensity physical activity in early adolescent youth, with both games rated as highly enjoyable.

Background: In collaboration with clinical domain experts, we developed a prototype of immersive virtual reality (VR) cognitive remediation for major depressive disorder (bWell-D). In the development of a new digital intervention, there is a need to determine the effective components and clinical relevance using systematic methodologies. From an implementation perspective, the effectiveness of digital intervention delivery is challenged by low uptake and high noncompliance rates. Gamification may play a role in addressing this as it can boost adherence. However, careful consideration is required in its application to promote user motivation intrinsically. Objective: We aimed to address these challenges through an iterative process for development that involves co-design for developing content as well as in the application of gamification while also taking into consideration behavior change theories. This effort followed the methodological framework guidelines outlined by an international working group for development of VR therapies. Methods: In previously reported work, we collected qualitative data from patients and care providers to understand end-user perceptions on the use of VR technologies for cognitive remediation, reveal insights on the drivers for behavior change, and obtain suggestions for changes specific to the VR program. In this study, we translated these findings into concrete representative software functionalities or features and evaluated them against behavioral theories to characterize gamification elements in terms of factors that drive behavior change and intrinsic engagement, which is of particular importance in the context of cognitive remediation. The implemented changes were formally evaluated through user trials. Results: The results indicated that feedback from end users centered on using gamification to add artificial challenges, personalization and customization options, and artificial assistance while focusing on capability as the behavior change driver. It was also found that, in terms of promoting intrinsic engagement, the need to meet competence was most frequently raised. In user trials, bWell-D was well tolerated, and preliminary results suggested an increase in user experience ratings with high engagement reported throughout a 4-week training program. Conclusions: In this paper, we present a process for the application of gamification that includes characterizing what was applied in a standardized way and identifying the underlying mechanisms that are targeted. Typical gamification elements such as points and scoring and rewards and prizes target motivation in an extrinsic fashion. In this work, it was found that modifications suggested by end users resulted in the inclusion of gamification elements less commonly observed and that tend to focus more on individual ability. It was found that the incorporation of end-user feedback can lead to the application of gamification in broader ways, with the identification of elements that are potentially better suited for mental health domains.

Background: The exponential growth of new technologies has meant that the educational field has had to update itself. From the educational point of view, there are some studies that have promoted the implementation of new technologies. These facts have raised the need to implement augmented reality in the university environment, especially among students of health sciences. The use of augmented reality can mean a new approach to teaching by teachers and better learning by students. Objective: To compare the degree of usability of the two augmented reality applications and to analyse the academic performance of the control group and the experimental group at the Universities of Cadiz and Malaga. The existence of significant differences and relationships between the two variables were observed. Methods: This is a quasi-experimental design with post-test as the only evaluation measure that has followed the SPIRIT statement and the ethical and legal aspects of the Principles of the Declaration of Helsinki. An intervention was carried out using two augmented reality applications in the subject of General Procedures in Physiotherapy II at the Universities of Malaga and Cadiz. Results: A total of 199 participants took part in the study. Demographic variables, ratings and usability were analysed, as well as the statistical analysis of the study with the presentation of the results and their interpretation. Significant differences (p<0.001) were found in the ratings at both universities. In addition, significant differences (p<0.001) were found between the experimental group and the control group. Regarding the degree of usability in the univariate analysis, no significant differences were found (p=0.049). A multiple regression analysis of the rating and usability was performed. Rating was found significant differences, with a beta of 1.4 (p<0.001) and usability was also significant (p=0.029) in favour of Aumentaty group. Conclusions: Significant differences were observed in those who used augmented reality compared to the control group being higher in the University of Malaga. There are no correlations between the variables of usability and qualifications. Clinical Trial: NTC05798468

Background: Physical activity (PA) is vital for physical and mental health, but many college students fail to meet recommended levels. AI-powered gamification interventions through mobile application (app) have the potential to improve PA levels among Chinese college students. Objective: To assess the feasibility and usability of an AI-powered gamification intervention. Methods: A quasi-experimental study spanning two months was conducted on a sample of college students aged 18 to 25 from 18 universities in Beijing. PA data were recorded using the ShouTi Fitness app, and participant engagement was evaluated through surveys. User satisfaction was gauged via the System Usability Scale (SUS), while the intervention's feasibility was assessed through Spearman rank correlation analysis, Mann-Whitney tests, and additional descriptive analyses. Results: As of July 2023, we enrolled 456 college students. In total, 18,073 PA sessions were recorded, with men completing 8,068 sessions and women 10,055 sessions. The average PA intensity was 7 METs per session. Most participants preferred afternoon sessions and favored short-duration sessions, with men averaging 66 seconds per session and women 42 seconds. The SUS score for the intervention based on app is 65.2. Users responded positively to the integration of AI and gamification elements, including personalized recommendations, action recognition, smart grouping, dynamic management, collaborative, and competition. Specifically, 341 users (75%) found the AI features very interesting, 365 (80%) were motivated by the gamification elements, 364 (80%) reported that the intervention supported their fitness goals, and 365 (80%) considered the intervention reliable. A significant positive correlation was observed between the duration of individual PA and intervention duration for men (rho = 0.510, P < .001), although the correlation was weaker for women (rho = 0.258, P = .046). However, the frequency of PA declined after 35 days. Conclusions: This study provides pioneering evidence of the feasibility and usability of the AI-powered gamification intervention. While adherence was successfully demonstrated, further studies or interventions are needed to directly assess the impact on PA levels and focus on optimizing long-term adherence strategies and evaluating health outcomes.

Background: Retention capacities depend on the learning context. The optimal interval between two learning sessions to maintain the learner’s knowledge is often a subject of discussion, as well as the methodology used. Screen-based simulation could represent an easy alternative for re-training in neonatal resuscitation. Objective: The aim of the study was to evaluate the benefits of a 3-month recall in high-fidelity simulation or screen-based simulation, 6 months after an initial neonatal resuscitation training in simulation among anesthesia and intensive care residents. Methods: All anesthesia and intensive care residents who participated were volunteers and they were trained in the same session (theoretical course and a high-fidelity simulation). Then, attendees were randomized in three groups: a first group with no 3-month recall, a second one with a high-fidelity simulation recall (HF), and a last group with a screen-based simulation recall (SG). In order to reassess the skills of each participant, a high-fidelity simulation has been performed at 6 months. The evaluation included expert assessment of technical skills using the NRPE score, and non-technical skills assessed by the ANTS score as primary outcomes and some knowledge quiz, self-assessment of confidence as secondary outcomes. We compared the results between groups and intragroup progressions. Results: Twenty-eight participants were included in the study. No differences were observed between groups at the 6-month evaluation. However, we observed a significant improvement in theoretical knowledge and self-confidence among students over time. Concerning non-technical skills evaluated by the ANTS score, there was a significant improvement between the initial training and the session at 6 months in both groups that had a recall session (16 vs 12.8, p=.012 in HF group, 16 vs 13.9, p=.05 in SG group, 14.7 vs 15.1, p=.498 in control group). Regarding technical skills assessed by the NRPE score, there was a non-significant trend toward improvement in the two groups with recall, while a regression was observed in the control group. The increase of students' self-confidence was significant for each group, but it remained higher in the two groups that had a 3-month recall. Conclusions: Initial training for anesthesia and intensive care residents in neonatal resuscitation leads to improved knowledge and self-confidence that persists at 6 months. A 3-month recall, whether through high-fidelity simulation or screen-based simulation, is showing better results on non-technical (such as situation management and team communication) and technical skills. Screen-based simulation, while saving time and resources, seems to be an effective educational method for recall after initial training. The study’ outcomes are justifying the need of further studies, with larger attendance, to confirm the promising results of the serious games role in the educational programs for students. Clinical Trial: CERAR (Ethics Committee for Research in Anesthesia Resuscitation) IRB 00010254-2021-048;

Background: Proper donning and doffing of personal protection equipment (PPE) and hand hygiene in the correct spatial context of a health facility is important for the prevention and control of nosocomial infections. On-site training is difficult due to the potential infectious risks and shortages of PPE, whereas video-based training lacks immersion which is vital for the familiarization of the environment. Virtual reality (VR) training can support repeated practice of PPE donning and doffing in an immersive environment that simulates a realistic configuration of a health facility. Objective: The aim is to develop and evaluate a VR simulation focusing on the correct event order of PPE donning and doffing, i.e., the item and hand hygiene order in the donning and doffing process but not the detailed steps of how to don/doff an item, in an immersive environment that replicates the spatial zoning of a hospital. The VR method should be generic and support customizable sequencing of PPE donning and doffing. Methods: An immersive VR PPE training tool was developed by computer scientists and medical experts. The effectiveness of the immersive VR method versus video-based learning was tested in a pilot study as a randomized controlled trial (N=32: VR group N=16, video-based training N=16) using questionnaires on spatial-aware event order memorization questions, usability, and task workload. Trajectories of participants in the immersive environment were also recorded for behavior analysis and potential improvements of the real environment of the health facility. Results: Comparable sequence memorization scores (VR: \mu=\ 79.38,\ \sigma=12.90 vs. Video: \mu=74.38,\ \sigma=17.88,\ p=0.372) as well as NASA-TLX scores (VR: \mu=42.9,\ \sigma=13.01 vs. Video: \mu=51.50,\ \sigma=20.44,\ p=0.168) were observed. The VR group had an above average usability in the System Usability Scale (\mu=\ 74.78\ >\ 70.0) and was significantly better (VR: \mu=74.78,\ \sigma=13.58 vs. Video: \mu=57.73,\ \sigma=21.13,\ p=0.009) than the video group. The analysis and visualization of trajectories revealed a positive correlation between the length of trajectories and the completion time, but neither correlated to the accuracy of the memorization task. Further user feedback indicated a preference for the VR method over the video-based method. Limitations of and suggestions for improvements in the study were also identified. Conclusions: A new immersive VR PPE training method was developed and evaluated against the video-based training. Results of the pilot study indicate that the VR method provides comparable training quality to the video-based training with better usability. In addition, the immersive experience of realistic settings and the flexibility of training configurations make the VR method a promising alternative to video instructions.

Background: Pediatric patients undergoing surgery frequently experience significant anxiety, which can result in adverse effects such as prolonged sedation and behavioral changes associated with pharmacological interventions like oral midazolam. Video games offer a nonpharmacological distraction method that shows promise in alleviating procedural anxiety without significant side effects. However, the effectiveness of video games compared to midazolam in managing perioperative anxiety remains uncertain. Objective: This study aimed to evaluate the effectiveness of video game interventions in reducing perioperative anxiety in pediatric patients undergoing general anesthesia. Methods: We conducted a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by reference screening. Primary outcomes included anxiety levels assessed during parent separation and mask induction procedures, while secondary outcomes encompassed emergence delirium (ED), postoperative behavior, and length of stay in the Post-Anesthesia Care Unit (PACU). The risk of bias was assessed using the Risk of Bias 2 (ROB 2) scale. Data were synthesized descriptively and through meta-analysis, with the certainty of the evidence evaluated using GRADE criteria. Results: Six randomized controlled trials involving 612 participants were included in the analysis. Children who participated in video game interventions reported significantly lower anxiety levels during parent separation (standardized mean difference [SMD] −0.31, 95% CI −0.50 to −0.12; P = .001), with high certainty, and during mask induction (SMD −0.29, 95% CI −0.52 to −0.05; P = .02), with moderate certainty, compared to those receiving oral midazolam. Additionally, significant differences in postoperative behavior changes in children were observed compared to oral midazolam (SMD −0.35, 95% CI −0.62 to −0.09; P = .008). Children in the video game intervention groups also had a shorter length of stay in the PACU (MD −19.43 minutes, 95% CI −31.71 to -7.16; P = .002). However, no significant differences were found in ED (MD −2.01, 95% CI −4.62 to 0.59; P = .13). Conclusions: Video game interventions were more effective than midazolam in reducing perioperative anxiety among pediatric patients, improving postoperative behavior, and shortening length of stay in the PACU. However, video games alone did not outperform midazolam in managing ED. Further high-quality research is needed for more conclusive results. Clinical Trial: PROSPERO CRD42023486085; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=486085

Background: Cognitive bias modification (CBM) programs have shown promise in treating psychiatric conditions, but they can be perceived as boring and repetitive. Incorporating gamified designs and adaptive algorithms in CBM training may address this issue and enhance engagement and effectiveness. Objective: To gather preliminary data and assess the preliminary efficacy of an adaptive approach bias modification (A-ApBM) paradigm in reducing cue-induced craving in individuals with methamphetamine use history. Methods: A randomized controlled trial with three arms was conducted. Individuals aged 18-60 with methamphetamine dependence and at least one year of methamphetamine use were recruited from 12 community-based rehabilitation centers in Sichuan, China. Individuals with inability to fluently operate a smartphone and/or the presence of mental health conditions other than methamphetamine use disorder (MUD) were excluded. A-ApBM group engaged in ApBM training using a smartphone application for four weeks. A-ApBM used an adaptive algorithm to dynamically adjust the difficulty level based on individual performance. Cue-induced craving scores and relapse were assessed using a visual analog scale at baseline, post-intervention, and at week-16 follow-up. Results: A total of 136 participants were recruited and randomized: 48 were randomized to the A-ApBM group, 48 were randomized to the S-ApBM group, and 40 were randomized to the no-intervention control group. The A-ApBM group showed a significant reduction in cue-induced craving scores at post-intervention compared to baseline (Cohen’s d =0.34, p<0.01, 95% CI =[0.03,0.54]). The reduction remained significant at the week-16 follow-up (Cohen’s d =0.40, p=0.01, 95% CI =[0.18,0.57]). No significant changes were observed in the S-ApBM and control groups. Conclusions: The adaptive ApBM paradigm with gamified designs and dynamic difficulty adjustments may be an effective intervention for reducing cue-induced craving in individuals with methamphetamine use history. This approach improves engagement and personalization, potentially enhancing the effectiveness of CBM programs. Further research is needed to validate these findings and explore the application of adaptive ApBM in other psychiatric conditions Clinical Trial: Registered at clinicaltrials.gov (ID NCT05794438).

Background: Virtual reality (VR) is helpful for the management of stress and anxiety. However, current interventions have limitations related to location (ie, therapist’s office or hospitals) and content (ie, virtual experiences only for relaxation). Objective: This randomized pilot trial aims to investigate the efficacy and acceptability of a brief remote VR-based training for supporting stress and anxiety management in a sample of Italian health care workers. Methods: A total of 29 doctors and nurses (n=21; 72% female; mean age 35.6, SD 10.3 years) were recruited and randomized to a VR intervention group or a control group in a passive control condition. Participants assigned to the VR intervention group received remote VR-based training consisting of 3 sessions at home delivered in 1 week using the VR psychoeducational experience “MIND-VR” and the 360° relaxing video “The Secret Garden.” The primary outcome measures were stress, anxiety, depression, and the knowledge of stress and anxiety assessed at baseline and posttreatment. We also evaluated the immediate effect of the remote VR-based training sessions on the perceived state of anxiety and negative and positive emotions. The secondary outcome measure was the usability at home of the VR system and content. Results: The VR intervention significantly reduced stress levels as assessed by the Perceived Stress Scale (6.46, 95% CI 2.77 to 10.5; P=.046) and increased the knowledge of stress and anxiety, as evaluated by the ad hoc questionnaire adopted (–2.09, 95% CI –3.86 to –0.529; P=.046). However, the home-based VR training did not yield similar reductions in stress, anxiety, and depression levels as assessed by the Depression, Anxiety, and Stress Scale-21 items or in trait anxiety as evaluated through the State-Trait Anxiety Inventory Form Y-1. After the home training sessions with VR, there was a significant decrease in anxiety, anger, and sadness and an increase in happiness levels. Analyses of the questionnaires on usability indicated that the health care workers found using the VR system at home easy and without adverse effects related to cybersickness. Of 33 participants, 29 (88%) adhered to the protocol. Conclusions: The results of this randomized pilot study suggest that a week-long home VR intervention, created with content created specifically for this purpose and available free of charge, can help individuals manage stress and anxiety, encouraging further research investigating the potential of remote VR interventions to support mental health. Trial Registration: ClinicalTrials.gov NCT04611399; https://tinyurl.com/scxunprd

Background: Digital serious games (DSGs), designed for purposes beyond entertainment and consumed via electronic devices, have garnered attention for their potential to enhance learning and promote behavior change. Their effectiveness depends on the quality of their design. Frameworks for DSG design can guide the creation of engaging games tailored to objectives such as education, health, and social impact. Objective: This study aims to review, analyze, and synthesize the literature on digital entertainment game design frameworks and DSG design frameworks (DSGDFWs). The focus is on conceptual frameworks offering high-level guidance for the game creation process rather than component-specific tools. We explore how these frameworks can be applied to create impactful serious games in fields such as health care and education. Key goals include identifying design principles, commonalities, dependencies, gaps, and opportunities in the literature. Suggestions for future research include empathic design thinking, artificial intelligence integration, and iterative improvements. The findings culminate in a synthesized 4-phase design process, offering generic guidelines for designers and developers to create effective serious games that benefit society. Methods: A 2-phase methodology was used: a scoping literature review and cluster analysis. A targeted search across 7 databases (ACM, Scopus, Springer, IEEE, Elsevier, JMIR Publications, and SAGE) was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Studies included academic or industry papers evaluating digital game design frameworks. Cluster analysis was applied to categorize the data, revealing trends and correlations among frameworks. Results: Of 987 papers initially identified, 25 (2.5%) met the inclusion criteria, with an additional 22 identified through snowballing, resulting in 47 papers. These papers presented 47 frameworks, including 16 (34%) digital entertainment game design frameworks and 31 (66%) DSGDFWs. Thematic analysis grouped frameworks into categories, identifying patterns and relationships between design elements. Commonalities, dependencies, and gaps were analyzed, highlighting opportunities for empathic design thinking and artificial intelligence applications. Key considerations in DSG design were identified and presented in a 4-phase design baseline with the outcome of a list of design guidelines that might, according to the literature, be applied to an end-to-end process of designing and building future innovative solutions. Conclusions: The main benefits of using DSGDFWs seem to be related to enhancing the effectiveness of serious games in achieving their intended objectives, such as learning, behavior change, and social impact. Limitations primarily seem to be related to constraints associated with the specific contexts in which the serious games are developed and used. Approaches in the future should be aimed at refining and adapting existing frameworks to different contexts and purposes, as well as exploring new frameworks that incorporate emerging technologies and design principles.