The Effect of Narrative on Physical Activity via Immersion During Active Video Game Play in Children: Mediation Analysis

Assessment of the intensity and attractiveness of physical exercise while playing table tennis in an immersive virtual environment depending on the game mode

BACKGROUND

It appears that active video games (AVGs) and training apps that allow for physical activity (PA) in immersive virtual reality (VR) may be useful for sports, health-enhancing PA, and physical education (PE). Therefore, research is needed to identify their potential.

OBJECTIVE

The study aimed to evaluate the intensity and attractiveness of exercise during table tennis (TT) training in VR in arcade and simulation modes and to assess the potential for using such exercises in health-enhancing PA, sport, and PE.

METHODS

The research used the Racket Fury: Table Tennis VR. Exercise intensity during TT training in VR was evaluated by heart rate (HR) monitoring and rating of perceived exertion (RPE 6-20). The effectiveness of short-term TT training in VR was estimated based on the user's performance in playing against an opponent with artificial intelligence (AI), satisfaction with playing TT was measured using the Physical Activity Enjoyment Scale (PACES), and the potential usefulness of the tested app in PA, sport, and PE was assessed based on a questionnaire for participating PE teachers (30 participants).

RESULTS

PA intensity during TT training in VR expressed as a percentage of maximum heart rate (HRmax) was moderate but was significantly (p < 0.001; d=-0.830) higher in the easier arcade mode (69.50 ± 12.58%HRmax) than in the simulation mode (64.10 ± 9.67%HRmax). Despite the greater fatigue of respondents, user satisfaction was significantly higher in arcade mode. Users' performance when playing with AI was significantly better after 20 min of training in VR than before training. PE teachers recognize the great potential of the app.

CONCLUSIONS

The application tested is characterized by a beneficial PA intensity, with its level depending on the game mode. Facilitating strokes during a game of virtual TT promotes increased intensity of exercise and increased enjoyment of the PA. Short-term TT training in VR improves playing skills in a virtual environment. PE teachers spoke highly of the app and recognized the potential for using VR technology in PA, sports, and school PE.

The effect of animated Sci-Fi characters' racial presentation on narrative engagement, wishful identification, and physical activity intention among children

Characters play an integral role in animated narratives, but their visual racial presentation has received limited attention. A diverse group of U.S. children watched a 15-min physical activity-promoting animated Sci-Fi narrative. They were randomly assigned to one of three conditions, which varied the lead characters' racial presentation: realistic racially unambiguous (Original: White children, Black mother), realistic racially ambiguous (Ambiguous: All with brown skin without specified race/ethnicity), and fantastical racially ambiguous (Fantastical: All with brown skin with fantastical hair-and-eye color schemes). We assessed narrative engagement, wishful identification, and physical activity intention. Controlling for social desirability and multigroup ethnic identity, children who watched Fantastical characters showed significantly higher narrative engagement than those who watched Original characters, but they did not statistically differ from those who watched Ambiguous characters. Structural equation modeling indicated that narrative engagement and wishful identification fully mediated the racial representation effect (Fantastical vs. Original) on physical activity intention.

Virtual Reality-Based Exercise Rehabilitation in Cancer-Related Dysfunctions: Scoping Review

BACKGROUND

Virtual reality-based exercise rehabilitation (VRER) is a promising intervention for patients with cancer-related dysfunctions (CRDs). However, studies focusing on VRER for CRDs are lacking, and the results are inconsistent.

OBJECTIVE

We aimed to review the application of VRER in patients with CRDs.

METHODS

This scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist framework. Publications were included from the time of database establishment to October 14, 2023. The databases were PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv, CNKI, Wanfang Data, VIP, and SinoMed. The population included patients with cancer. A virtual reality (VR) system or device was required to be provided in exercise rehabilitation as an intervention. Eligible studies focused on VRER used for CRDs. Study selection and data extraction were performed by 2 reviewers independently. Extracted data included authors, year, country, study type, groups, sample size, participant age, cancer type, existing or potential CRDs, VR models and devices, intervention programs and durations, effectiveness, compliance, satisfaction, and safety.

RESULTS

We identified 25 articles, and among these, 12 (48%) were randomized clinical trials, 11 (44%) were other experimental studies, and 2 (8%) were observational studies. The total sample size was 1174 (range 6-136). Among the 25 studies, 22 (88%), 2 (8%), and 1 (4%) included nonimmersive VR, immersive VR, and augmented reality, respectively, which are models of VRER. Commercial game programs (17/25, 68%) were the most popular interventions of VRER, and their duration ranged from 3 to 12 weeks. Using these models and devices, VRER was mostly applied in patients with breast cancer (14/25, 56%), leukemia (8/25, 32%), and lung cancer (3/25, 12%). Furthermore, 6 CRDs were intervened by VRER, and among these, postmastectomy syndromes were the most common (10/25, 40%). Overall, 74% (17/23) of studies reported positive results, including significant improvements in limb function, joint range of motion, edema rates, cognition, respiratory disturbance index, apnea, activities of daily living, and quality of life. The compliance rate ranged from 56% to 100%. Overall, 32% (8/25) of studies reported on patient satisfaction, and of these, 88% (7/8) reported satisfaction with VRER. Moreover, 13% (1/8) reported mild sickness as an adverse event.

CONCLUSIONS

We found that around half of the studies reported using VRER in patients with breast cancer and postmastectomy dysfunctions through nonimmersive models and commercial game programs having durations of 3-12 weeks. In addition, most studies showed that VRER was effective owing to virtualization and interaction. Therefore, VRER may be an alternate intervention for patients with CRDs. However, as the conclusions were drawn from data with acknowledged inconsistencies and limited satisfaction reports, studies with larger sample sizes and more outcome indictors are required.

Leveraging Mobile Technology for Public Health Promotion: A Multidisciplinary Perspective

Health behaviors are inextricably linked to health and well-being, yet issues such as physical inactivity and insufficient sleep remain significant global public health problems. Mobile technology-and the unprecedented scope and quantity of data it generates-has a promising but largely untapped potential to promote health behaviors at the individual and population levels. This perspective article provides multidisciplinary recommendations on the design and use of mobile technology, and the concomitant wealth of data, to promote behaviors that support overall health. Using physical activity as anexemplar health behavior, we review emerging strategies for health behavior change interventions. We describe progress on personalizing interventions to an individual and their social, cultural, and built environments, as well as on evaluating relationships between mobile technology data and health to establish evidence-based guidelines. In reviewing these strategies and highlighting directions for future research, we advance the use of theory-based, personalized, and human-centered approaches in promoting health behaviors.

How much did it cost to develop and implement an eHealth intervention for a minority children population that overlapped with the COVID-19 pandemic?

BACKGROUND

eHealth interventions using active video games (AVGs) offer an alternative method to help children exercise, especially during a pandemic where options are limited. There is limited data on costs associated with developing and implementing such interventions.

OBJECTIVES

We quantified the costs of delivering an eHealth RCT intervention among minority children during COVID-19.

METHODS

We categorized the total trial cost into five subcategories: intervention material development, advertising and recruitment, intervention delivery, personnel salaries, and COVID-19-related equipment costs.

RESULTS

The total RCT cost was $1,927,807 (Direct: $1,227,903; Indirect: $699,904) with three visits required for each participant. The average cost per participant completing the RCT (79 participants/237 visits) was $24,403 (Direct: $15,543; Indirect: $8860). Due to no-shows and cancellations (198 visits) and dropouts before study completion (61 visits; 56 participants), 496 visits had to be scheduled to ensure complete data collection on 79 participants. If all 496 visits were from participants completing the three-visit protocol, that would correspond to 165 participants, bringing the average cost per participant down to $11,684 (Direct: $7442; Indirect: $4242). Of the subcategories, intervention material development accounted for the largest portion, followed by personnel salaries. While the direct COVID-19-specific cost constituted <1% of the entire budget, the indirect effects were much larger and significantly impacted the trial.

CONCLUSION

RCTs typically involve significant resources, even more so during a pandemic. Future eHealth intervention investigators should budget and plan accordingly to prepare for unexpected costs such as recruitment challenges to increase flexibility while maximizing the intervention efficacy.

The effect of narrative element incorporation on physical activity and game experience in active and sedentary virtual reality games

Narratives are pervasive in video games and have been found to increase physical activity in active video games. However, the effect of incorporating narrative elements has seldom been examined in fully immersive virtual reality games. We investigated the effect of narrative element incorporation (between-subject: narrative vs. no narrative) in active virtual reality and sedentary virtual reality games (within-subject) and examined between- and within-subject effects on physical activity behavior, game experience, and physical activity engagement. We randomized 36 sedentary college students to either the narrative or the non-narrative group. All participants played an active virtual reality and a sedentary virtual reality game in counter-balanced order. Before each game session, they either watched a 5-min narrative video (narrative) or directly played the original virtual reality games without narratives (non-narrative). We collected participants' physical activity data using wrist-worn accelerometers; we obtained their game experience and physical activity engagement via questionnaires. The narrative group spent a greater proportion of time in moderate-to-vigorous physical activity (%) and had less non-movement time during the active virtual reality gameplay than the non-narrative group (all p values < .05). The active virtual reality sessions induced a greater positive affect and greater physical activity engagement ratings than the sedentary virtual reality sessions. The incorporation of narrative elements in active virtual reality increased the relative time spent in moderate-to-vigorous physical activity and reduced non-movement time, compared to the non-narrative group. Active virtual reality encouraged more activity by participants and offered them a more enjoyable gaming experience in which they engaged more. Active virtual reality is a feasible physical activity promotion option among sedentary adults; the incorporation of narrative elements in active virtual reality helps increase relative moderate-to-vigorous physical activity and should be further explored for its efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10055-023-00754-7.

Handheld Weights as an Effective and Comfortable Way To Increase Exercise Intensity of Physical Activity in Virtual Reality: Empirical Study

BACKGROUND

In recent years, there has been a growing interest in active virtual reality games (AVRGs) that provide entertainment and encourage more physical activity (PA). Since playing AVRGs involves primarily arm movements, the intensity of this form of PA may not be sufficient for health benefits. Therefore, it is worth looking for virtual entertainment solutions that are comfortable for users and at the same time increase physical exercise.

OBJECTIVE

The main objective of this study was to evaluate the effect of external loading of the arms in the form of handheld weights (HHWs) on exercise intensity in users playing a popular AVRG. The results obtained in the study were compared with the PA recommendations for health. The study also assessed the perceptions of the users about the attractiveness and usefulness of this type of exercise and discomfort caused by additional load on the arms.

METHODS

The study covered 17 young adults aged 18 to 25 years playing an AVRG (Beat Saber) with no arm load and with HHWs (0.5 kg). A PlayStation 4 PRO console (Sony) with accessories including a head-mounted display and controllers was used in the study. PA intensity was evaluated using a heart rate monitor based on the percentage of maximal heart rate (% HRmax). The usability, attractiveness, and comfort perceived during exercise by users were evaluated using a survey questionnaire.

RESULTS

The measurements showed that the mean % HRmax in participants playing Beat Saber without HHWs was significantly lower (P<.001; Cohen d=1.07) than that observed when playing with HHWs. It should be emphasized that with no additional load, the intensity of PA was low (mean 63.7% HRmax, SD 9.3% HRmax), while with the upper limb load, it increased to a moderate level (mean 67.1% HRmax, SD 10.3% HRmax), which is recommended for health benefits. The survey conducted in the study showed that HHWs (0.5 kg) attached to the wrists did not disturb Beat Saber players.

CONCLUSIONS

Since PA in most of the modern AVRGs primarily involves upper limb movements, the use of HHW seems to be a simple and effective way to increase exercise intensity, especially because, as reported by the study participants, such a procedure does not cause discomfort while using the application.

Developing OurSleepKit: A Couple-focused mHealth Tool to Support Adherence to Positive Airway Pressure Treatment

BACKGROUND AND AIM

Existing interventions promoting positive airway pressure (PAP) adherence focus only on the diagnosed individual, despite the fact that partners are often the most impacted by obstructive sleep apnea (OSA), and are delivered mostly by health professionals, with limited success. The goal of this work is to develop a prototype of OurSleepKit, a couple-focused mobile health (mHealth) tool to coach mutual engagement and promote adherence to PAP treatment.

METHODS

We used an iterative participatory approach working with future end users of OurSleepKit to support the development of this prototype. We conducted a total of 14 semi-structured in-depth open-ended dyadic interviews with OSA patients and their partners. Phase 1 of the development was to inform key functions of an engaging tool. Phase 2 focused on developing functions to engage positive conversation in the dyad and obtained feedback for this initial prototype.

RESULTS

The OurSleepKit prototype was developed and demonstrated high acceptability and engagement. Three key functions included periodic assessments based on developmental stages of PAP treatment, a Coaching Board which provides customized and dynamically updated support content - primarily brief story-telling videos featuring real-life couples' experiences - and timely tailored prompts (for action, learning, and conversation) through push notifications in the evening to facilitate positive conversation in the dyad and offer in-the-moment support for PAP use.

CONCLUSIONS

Going beyond the traditional and prevailing view of PAP use as an individual phenomenon, OurSleepKit is a novel mHealth intervention engaging both the patient and partner holding great promise to promote PAP adherence.

Facilitators and barriers to getting obstructive sleep apnea diagnosed: perspectives from patients and their partners

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a prevalent and debilitating condition that is significantly underdiagnosed. The majority of adults sleep with someone-a partner. Partners can play a significant role in the patient's OSA diagnosis. The goal of this work is to describe facilitators and barriers to OSA diagnosis as discussed by patients with OSA and their partners.

METHODS

This was a qualitative secondary analysis with results drawn from 20 dyadic interviews, conducted 1 couple at a time, in 20 newly diagnosed adult patients with OSA and their partners. Qualitative interview data were analyzed using conventional content analysis.

RESULTS

Facilitators of OSA diagnosis were partners pushing patients to seek care, patients actively seeking care, and care providers identifying the patient's risk of OSA. Barriers to OSA diagnosis were patients' lack of serious attention to symptoms, patients' negative perceptual framing of diagnosis and treatment of OSA, and poor coordination of health care services.

CONCLUSIONS

We recommend engaging partners in the OSA diagnosis and developing educational and behavioral interventions to raise public awareness about OSA. It is important to educate clinicians on atypical presentations of OSA. Further investigation is needed to evaluate the impact of health care services on OSA diagnosis.

CITATION

Ye L, Li W, Willis DG. Facilitators and barriers to getting obstructive sleep apnea diagnosed: perspectives from patients and their partners. J Clin Sleep Med. 2022;18(3):835-841.

New Technologies for Promoting Physical Activity in Healthy Children and in Children with Chronic Respiratory Diseases: A Narrative Review

Physical activity (PA) is proven to benefit children and adolescents in several ways. New technologies may provide children with stimulating modalities for organizing their leisure time, accessing fitness programs, and obtaining daily goal reminders and peer support. Due to the current COVID-19 pandemic, following WHO recommendations for PA is difficult for many children, especially for those living in urban areas. Therefore, the use of digital tools to support and maintain PA could be useful in healthy children, as well as in those with chronic respiratory diseases (CRDs). This narrative review aims to summarize the most recent evidence about the role of new technologies in promoting PA in healthy children and in those with CRDs, in supporting PA during the COVID-19 pandemic, and in enhancing psychological wellbeing in this age group. The use of technological devices for promoting PA, such as web/mobile apps and games, has been proven to be effective both in healthy children and in those with CRDs. In conclusion, new technologies are very promising in terms of feasibility, acceptability, and efficacy in promoting PA. Further studies are required to evaluate the long-term health benefits of using these technologies.

What Type of Body Shape Moves Children? An Experimental Exploration of the Impact of Narrative Cartoon Character Body Shape on Children's Narrative Engagement, Wishful Identification, and Exercise Motivation

Background

The incorporation of narratives helps to enhance children’s engagement in active video games (AVGs), thus increasing moderate-to-vigorous physical activity (MVPA). Specific narrative elements, such as the visual representation of the characters’ body shape, have been rarely manipulated to explore their role in modulating children’s narrative engagement (NE) and exercise motivation.

Objective

To investigate the effects of character body shape manipulation (overweight/obese, average, or athletic slim) on children’s narrative immersion (NI), NE, wishful identification (WI), as well as their mediating effect on AVG and PA motivation.

Methods

Children ages 8–12 years old (N = 87) were randomly assigned to watch a 15-min animated video (designed for an existing AVG) in which the main characters had an overweight/obese, or average^∗, or athletic slim body shape (all other elements were identical). Children’s NI, NE, WI, and AVG and physical activity (PA) motivation were then assessed.

Results

Controlling for social desirability, the analysis indicated that participants with a BMI of greater than the 75th percentile had a significantly higher NI, NE, WI, and PA motivation when video characters were set to the overweight/obese condition, than they did for video characters set to the average or athletic slim conditions. On the other hand, children of equal or less than the 75th percentile exposed to the average character body condition had a greater NE, WI, and PA motivation than overweight/obese or athletic slim conditions. A mediation analysis with structural equation modeling indicated that NE mediated the effect between character body shape and AVG and PA motivation.

Conclusion

Narrative cartoon characters that mirror the target participant’s body shape can increase NE, which in turn mediates AVG and PA motivation. Content producers should identify optimal strategies in character body shape design to encourage children of different weight status to participate in PA with engaging stories to maximize health narratives’ persuasive potentials.

^∗The term average in this sense is not in reference to the national average body weight, but rather an average of the body weights represented in conditions A and C.

Assessment of Active Video Games' Energy Expenditure in Children with Overweight and Obesity and Differences by Gender

(1) Background: Childhood obesity has become a main global health problem and active video games (AVG) could be used to increase energy expenditure. The aim of this study was to investigate the energy expenditure during an AVG intervention combined with exercise, differentiating by gender. (2) Methods: A total of 45 children with overweight or obesity (19 girls) performed an AVG intervention combined with exercise. The AVG used were the Xbox Kinect, Nintendo Wii, dance mats, BKOOL cycling simulator, and Nintendo Switch. The energy expenditure was estimated from the heart rate recorded during the sessions and the data from the individual maximal tests. (3) Results: The mean energy expenditure was 315.1 kilocalories in a one-hour session. Participants spent the most energy on BKOOL, followed by Ring Fit Adventures, Dance Mats, Xbox Kinect, and the Nintendo Wii, with significant differences between BKOOL and the Nintendo Wii. Significant differences between boys and girls were found, but were partially due to the difference in weight, VO2max, and fat-free mass. (4) Conclusions: The energy expenditure with AVG combined with multi-component exercise was 5.68 kcal/min in boys and 4.66 kcal/min in girls with overweight and obesity. AVG could be an effective strategy to increase energy expenditure in children and adolescents with overweight and obesity.