Email this article 
Views
Investigating the effect of virtual reality on reducing the anxiety in children: A systematic review
1. BSc Student of Health Information Technology, Department of Health Information Technology, Varastegan Institute for Medical Sciences, Mashhad, Iran, 2. MSc Student of Health Information Technology, Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran , 3. Assistant Professor, Department of Health Information Technology, Varastegan Institute for Medical Sciences, Mashhad, Iran
Abstract
Introduction: Many children may experience anxiety in treatment settings, especially in situations such as before surgery, dentistry and radiology. Virtual reality technology can provide a platform for reducing children's anxiety by creating a sense of presence in an unreal world. The aim of this study was to investigate the effect of virtual reality technology on reducing anxiety in children.
Material and Methods: A systematic review of randomized clinical trial studies was conducted in English without any time limitation by searching for keywords in the reputable scientific databases PubMed, Scopus, EMBASE and Web of Science on September 12, 2021. Studies using virtual reality technology to reduce pediatric treatment anxiety were considered as inclusion criteria. Titles and abstracts were screened independently based on eligibility criteria. The quality of the studies was assessed using the Joanna Briggs institute (JBI) checklist. After that, complete texts were retrieved and independently reviewed based on eligibility criteria.
Results: A total of 197 related articles were obtained, 10 of which were relevant to the objectives of the research. Input studies included a total of 882 children aged 4 to 12 years. In 7 studies, virtual reality has helped reduce children's anxiety during treatment (70%). In 3 of the studied studies, no improvement was seen in reducing children's anxiety (30%). Of the studies found, 3 were related to reducing anxiety in dentistry, 4 were related to preoperative anxiety, 2 were related to radiographic anxiety, and 1 was related to preoperative anesthesia.
Conclusion: The results of systematic review show that virtual reality can make the treatment process more satisfactory and help manage their behavior by creating calmness and distraction, while reducing anxiety in children. However, due to the small sample size (small number of input studies), the evidence is not sufficient to prove the effectiveness of virtual reality in reducing pediatric treatment anxiety. Future studies are proposed to compare the effect of virtual reality technology on reducing treatment anxiety in different age groups.
Received: 2022 April 16; Accepted: 2022 May 9; Accepted: 2022 May 14
Keywords: Key Words Anxiety, Virtual Reality, Child, Intelligent Health.
INTRODUCTION
Many children may experience anxiety in therapeutic settings, especially in situations such as preoperative surgery, dentistry, and radiology [1-3]. These feelings often affect not only medical procedures, but also unintended consequences such as trying to escape treatment and lack of cooperation, eating and sleeping disorders, and increased stress symptoms [4-6]. Some of the symptoms of increased stress include anxiety, distraction, agitation, fear, and increased heart rate [7]. Preoperative anxiety is a potential threat to the patient due to changes in psychological responses, including increased blood pressure and heart rate, and may endanger the patient's health [8].
Children, especially in the early years of life, are vulnerable to this issue because it changes the health of the child as well as the safe and familiar environment for the child. Children, on the other hand, have limited coping mechanisms to resolve stressful situations [9]. In addition, since pain and anxiety can lead to avoidance of health care, intervention is needed to relieve pain and anxiety in pediatric patients [10].
Attention is a common intervention during medical procedures, known for managing behavior during short invasive procedures. Attention is a cognitive-behavioral approach that seeks to divert the child's attention from unpleasant stimuli to more pleasurable stimuli [11]. For example, using music, movies, and television, reading stories, and playing with toys have been shown to reduce children's pain and anxiety [12-14]. Virtual reality (VR) is a relatively new technique for creating distractions and may be more effective than traditional methods. VR consists of a computer environment in which three-dimensional orientation and interaction is possible. VR technology can provide a platform for reducing children's anxiety by creating a sense of presence in an unreal world [15].
Recently, VR exposure has been used as a more preventative method to make patients feel comfortable and increase their familiarity with medical methods and environments. However, studies evaluating the effectiveness of VR technology have not yet been fully developed. Therefore, the purpose of systematic review was to investigate the effect of virtual reality technology on reducing anxiety in children.
Study design
This systematic review is based on PRISMA 2020 guidelines [16, 17]; to report the evidence from the input studies to this systematic review. The text was searched on September 21, 2021 in PubMed, Embase, Scopus and Web of Science databases. The keywords and phrases MeSH and Emtree in the following two categories were used to search the databases:
1. "Anxiety", "Anxiousness", "Nervousness"
2. "Virtual reality", "Virtual Reality Exposure Therapy", "Virtual Reality Immersion Therapy", "Virtual Reality Therapy"
This review was limited to randomized and controlled trials so that we could evaluate the studies with the highest quality of evidence. The study population also included children who used VR technology to control treatment anxiety, which was applied when reviewing the abstract and full text of the articles in this filter. All articles were collected from the literature search and duplicate articles were removed from the review. Titles and abstracts were screened independently based on eligibility criteria. Articles that did not meet the inclusion criteria were excluded from this review. Complete texts were then retrieved and screened by two separate researchers based on eligibility criteria. Disagreements between researchers were resolved through discussion.
Eligibility criteria
Criteria for including studies in this systematic review included the following:
1) Randomized clinical trial studies using VR technology to reduce anxiety before and during treatment in children (under 18 years of age). 2) The full text of the articles was available in English.
On the other hand, exclusion criteria included: 1) studies including books, review articles, letters, studies that were in the form of letters to the editor and conference summaries; 2) Lack of availability of the full text of the articles in English; 3) Lack of relevance of the title, abstract or full text of the articles for the purpose of reading.
Data extraction and synthesis
The same checklist was used to extract the data. Data elements of this checklist included study title, year of publication, country, number of participants, study method, duration of intervention, technology-based approach, study objectives and main findings of the study.
Quality control
In order to evaluate the quality of the input studies to this study, the JBI quality evaluation checklist for randomized controlled trials was used [18]. This checklist included 13 questions to evaluate the quality of the studies. If the answer to a question was yes, he would get a score of 1 and otherwise a score of zero. Therefore, the maximum quality assessment score that each study could achieve was 13. Studies with a score less than 7 were excluded from this study.
Study selection
The process of identifying and selecting studies based on PRISMA diagrams is shown in Fig 1. A total of 197 related documents were selected for review. After reviewing the articles and eliminating duplicate studies (66 articles), 131 articles were obtained and their screening was evaluated based on the titles and abstracts of the article. At the end of the review, 100 articles that had nothing to do with the purpose of this study were deleted. Then, 31 articles were selected to review their full text, of which 21 articles were deleted and finally 10 main articles were included in the study.
Quality Control
The quality assessment results shown in Table 1 show that there was no significant bias in the studies and all quality studies were included in our study.
| Score | 13 | 12 | 11 | 10 | 9 | 8 | 7 | 6 | 5 | 4 | 3 | 2 | 1 | Study |
| 10 | Y | Y | Y | Y | N | Y | Y | Y | N | N | Y | Y | Y | Brazil [19] |
| 9 | Y | Y | Y | Y | N | Y | Y | N | N | N | Y | Y | Y | Iran [20] |
| 10 | Y | Y | Y | Y | Y | Y | Y | N | Y | N | Y | N | Y | Netherlands [21] |
| 10 | Y | Y | Y | Y | N | Y | Y | Y | N | N | Y | Y | Y | Saudi Arabia [22] |
| 11 | Y | Y | Y | Y | N | Y | Y | Y | Y | N | Y | Y | Y | Korea [1] |
| 9 | Y | Y | Y | Y | N | Y | Y | N | N | N | Y | N | Y | Spain [23] |
| 8 | Y | Y | Y | Y | N | Y | Y | N | N | N | Y | N | Y | China [3] |
| 11 | Y | Y | Y | Y | N | Y | Y | Y | Y | N | Y | Y | Y | Korea [2] |
| 9 | Y | Y | Y | Y | N | Y | Y | Y | N | N | Y | N | Y | Korea [24] |
| 10 | Y | Y | Y | N | N | Y | Y | Y | Y | N | Y | Y | Y | Korea [25] |
Characteristics of the study
The characteristics of all the studies included are reported in Table 2. Out of 10 incoming studies, 3 studies (30%) in Korea [2, 24, 25] and other studies in Brazil [19], Iran [20], Netherlands [21], Saudi Arabia [22], Republic of Korea [1], Spain [23] and China [3]. Studies in two categories of randomized trial (20%) [21, 24] and randomized clinical trial (60%) [1-3, 19, 20, 22, 23, 25] Were classified. Input studies included 882 participants. The mean age of participants was from 5.5 [24] to 7.9 [21, 23] years.
| Reference | 1st author | Mean age of participants | Type of intervention media | Number of participants | Objectives | Outcome of the intervention |
|---|---|---|---|---|---|---|
| [19] | Natália Baschirotto CustÓdio | 7.66 | Audio-visual glasses (virtual reality) Audio Visual Eyeglasses (AVE) | 44 | Evaluation of the effectiveness of auditory and visual distraction using VR glasses in comparison with conventional behavior management techniques was during the stages that require local anesthesia. | AVEs were a pleasurable method for distraction, without side effects, mean heart rate in both similar groups (p = 0.47), but a significant increase was observed during treatment in the control group. |
| [20] | Fateme Dehghan | 7.35 | Virtual reality glasses and headphones | 40 | Investigating the effect of virtual reality on preoperative anxiety in children | Virtual reality reduced preoperative anxiety in children (p <0.05). |
| [21] | Robin Eijlers | 7.9 | VR Exposure (VRE) | 191 | Evaluation of the effect of virtual reality exposure for surgical preparation for selective day care in children and anxiety in the control group receiving routine care. | VRE had no beneficial effect on anxiety. But after more painful surgery, the children in the intervention group needed significantly less analgesia. The difference between the two groups was not significant. |
| [22] | Osama M Felemban | 8.4 | VR Goggles | 50 | investigate the effect of virtual reality distraction on anxiety and pain during buccal infiltration anesthesia in sick children. | The use of virtual reality glasses has a similar effect on screen distraction on heart rate during buccal anesthesia in pediatric patients. |
| [1] | Sung-Hee Han | 5.6 | Virtual reality glasses | 99 | The effect of virtual reality education for sick children on anxiety in chest radiography | Decreased anxiety, discomfort and operation time (p = 0.004) and increased parental satisfaction in the intervention group were reported. |
| [23] | Cristina Gómez-Polo | 7.9 | Virtual reality headset VR Headsets |
80 | Evaluating the effectiveness of using a VR headset as a distraction factor for managing anxiety and behavior of pediatric patients during dental treatment | The use of VR headsets during dental treatment significantly reduced anxiety (95% of happy children) and improved behavior (100% positive behavior) compared to the control group (40% and 57.5%, respectively). A virtual reality headset can effectively distract the child's patient and help reduce anxiety and manage behavior during dental treatment. |
| [3] | Longkuan Ran | 5.6 | Videos with helmets and headphones | 120 | Investigating the role of VR distraction on behavior management in short-term dental treatments in children | VR in the intervention group significantly reduced anxiety (P <0.05) and pediatric pain (P <0.05) and the length of dental treatment (p = 0.02). |
| [2] | Jung-Hee Ryu | 6.0 | Virtual reality glasses | 120 | Evaluate the effect of VR compared to standard video on reducing anxiety and discomfort in children with chest radiography | Reducing anxiety in children and increasing the efficiency of methods in the virtual reality intervention group versus the control group by watching video (P = 0.01) |
| [24] | Jung-Hee Ryu | 5.5 | Gamification through a Virtual Reality | 69 | Evaluation of the effectiveness of gamification in the preoperative process through play (VR) in reducing preoperative anxiety in children | Preoperative anxiety (p <0.01) was lower in the gamification group than in the control group. As a result, the VR experience can reduce preoperative anxiety and improve compliance during induction of anesthesia in children undergoing elective surgery and general anesthesia. |
| [25] | J-H Ryu | 6.0 | VR Tour | 69 | Investigating the effect of virtual reality in reducing preoperative anxiety | VR tour in the operating room was effective in reducing preoperative anxiety and increasing adaptation during induction of anesthesia in children undergoing surgery. (P <0.001) |
The effects of virtual reality on children's anxiety
In 7 of the studies (70%), virtual reality has helped to reduce children's anxiety in the treatment process [1-3, 20, 23-25]. The mechanism of all studies focused on children's distraction in order to reduce their anxiety. However, in one study, virtual reality was used as an educational tool [1]. In 3 cases (30%) reduction of anxiety in the two groups of control and intervention was not significantly different [19, 21, 22]. In all studies, the control group received routine care, including routine behavior management techniques and anxiety control pills. In 7 of the studies, children and parents were satisfied with the virtual reality intervention in reducing anxiety, and in all 7 cases, users were highly satisfied [1-3, 19, 23-25]. In 3 cases of studies found from virtual reality technology in reducing pediatric anxiety in dentistry [3, 19, 23], 4 cases before surgery [20, 21, 24, 25], 2 cases related to anxiety before shelf radiography of breasts [1, 2] and one case were used during preoperative anesthesia [22].
DISCUSSION
The purpose of this systematic review was to investigate the effect of virtual reality technology on reducing anxiety before and during treatment in children. The results of systematic review show that in 7 cases (70%) of virtual reality studies, it has helped to reduce the anxiety of children before and during treatment [1-3, 20, 23-25]. In all of these studies, the mechanism of action of virtual reality focused on children's distractions in order to reduce their anxiety. However, in one study, virtual reality was used as an educational tool [1]. In 3 cases (30%) of virtual reality technology studies, there was no significant difference in reducing children's anxiety [19, 21, 22]. In one of the studies to reduce preoperative anxiety in children, the virtual reality game intervention group and the control group underwent routine training. The results of their study showed that virtual reality play is significantly effective in reducing anxiety before surgery and during anesthesia [24]. In 70% of the studies, the level of parental and child satisfaction was measured by virtual reality technology to control children's treatment anxiety, and in all of these studies, their high level of satisfaction was reported [1-3, 19, 23-25].
In line with the results of this study, Ioannou et al. conducted a systematic review to evaluate the effect of VR intervention on symptoms such as anxiety, depression, fatigue and pain in cancer patients. The results of their study showed that VR, as an emotion-focused distraction intervention, reduces the severity of these symptoms [26]. In another study, Oing et al. conducted a systematic review to determine the effectiveness of VR-based therapy for anxiety-related disorders, as well as to explain how modern VR systems need to address the shortcomings of older VR systems.
They concluded that VR technology as a diagnostic tool for paranoid thoughts has been effective in most studies, although previous studies have shown promising and emerging effectiveness in using VR as a therapeutic and diagnostic tool for anxiety-related disorders. VR technology in general needs to be improved to provide a fully immersive and interactive experience that is able to bridge the gap between the real and virtual worlds [27].
In addition, López-Valverde et al. in their meta-analysis study aimed at evaluating the effectiveness of VR on reducing pain and anxiety in dental patients without age restrictions concluded that VR is an effective distraction method for reducing pain and anxiety in patients undergoing various treatments. Are placed dental [28].
One of the limitations of this study was the difference in the type of consequences under consideration and the heterogeneity in the software and platforms under virtual reality, according to which the results will be different under their influence. One of the inclusion criteria was the studies of the population we were studying, which included studies of children under 18 years of age; Therefore, the impact of virtual reality on the adult population is unclear and requires further study.
However, these interventions seem to be more effective in children; because children have more therapeutic anxiety [29] and on the other hand children have more imagination, which increases their level of immersion in virtual reality [30]. In addition, given that studies have used different methods to measure the results of anxiety reduction; therefore, it was not possible to perform meta-analysis or study the effect of these studies as a group.
CONCLUSION
The results of systematic review show that virtual reality can make the treatment process more satisfactory and help manage their behavior by creating calm and attention while reducing anxiety in children. However, due to the small sample size (small number of input studies), the evidence is not sufficient to prove the effectiveness of virtual reality in reducing pediatric treatment anxiety. Future studies are proposed to compare the effect of virtual reality technology on reducing treatment anxiety in different age groups.
AUTHOR’S CONTRIBUTION
All authors contributed to the literature review, design, data collection and analysis, drafting the manuscript, read and approved the final manuscript.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest regarding the publication of this study.
FINANCIAL DISCLOSURE
No financial interests related to the material of this manuscript have been declared.
| 1. | Han, S. Park, J. Choi, SI. Kim, JY. Lee, H. Yoo, H. Effect of immersive virtual reality education before chest radiography on anxiety and distress among pediatric patients: A randomized clinical trial. JAMA Pediatr. 2019 173(11):1026–31. |
| 2. | Ryu, J. Park, J. Choi, SI. Kim, JY. Lee, H. Yoo, H. Virtual reality vs tablet video as an experiential education platform for pediatric patients undergoing chest radiography: A randomized clinical trial. J Clin Med. 2021 10(11):2486. |
| 3. | Ran, L. Zhao, N. Fan, L. Zhou, P. Zhang, C. Yu, C. Application of virtual reality on non-drug behavioral management of short-term dental procedure in children. Trials. 2021 22(1):562 . |
| 4. | Meentken, MG. van, BIM. Legerstee, JS. Helbing, WA. Utens, EM. Medically related post-traumatic stress in children and adolescents with congenital heart defects. Front Pediatr. 2017 |
| 5. | Wong, M. Chia, K. Yam, W. Teodoro, G. Lau, K. Willingness to donate blood samples for genetic research: A survey from a community in Singapore. Clin Genet. 2004 65(1):45–51. |
| 6. | Kain, ZN. Mayes, LC. Caldwell-Andrews, AA. Karas, DE. McClain, BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006 118(2):651–8. |
| 7. | Perry, JN. Hooper, VD. Masiongale, J. Reduction of preoperative anxiety in pediatric surgery patients using age-appropriate teaching interventions. J Perianesth Nurs. 2012 27(2):69–81. |
| 8. | Namazi, M. Akbari, S. Mojab, F. Talebi, A. Majd, HA. Jannesari, S. Aromatherapy with citrus aurantium oil and anxiety during the first stage of labor. Iran Red Crescent Med J. 2014 16(6):e18371. |
| 9. | Hockenberry, MJ. Wilson, D. Rentfro, AR. McCampbell, L. Study guide for wong's nursing care of infants and children. Mosby:2018. |
| 10. | Inal, S. Kelleci, M. Distracting children during blood draw: Looking through distraction cards is effective in pain relief of children during blood draw. Int J Nurs Pract. 2012 18(2):210–9. |
| 11. | McCaul, KD. Malott, JM. Distraction and coping with pain. Psychol Bull. 1984 95(3):516–33. |
| 12. | Al-Khotani, A. Bello, LA. Christidis, N. Effects of audiovisual distraction on children’s behavior during dental treatment: A randomized controlled clinical trial. Acta Odontol Scand. 2016 74(6):494–501. |
| 13. | Mifflin, KA. Hackmann, T. Chorney, JM. Streamed video clips to reduce anxiety in children during inhaled induction of anesthesia. Anesth Analg. 2012 115(5):1162–7. |
| 14. | Whitehead-Pleaux, AM. Baryza, MJ. Sheridan, RL. The effects of music therapy on pediatric patients' pain and anxiety during donor site dressing change. J Music Ther. 2006 43(2):136–53. |
| 15. | Malloy, KM. Milling, LS. The effectiveness of virtual reality distraction for pain reduction: A systematic review. Clin Psychol Rev. 2010 30(8):1011–8. |
| 16. | Liberati, A. Altman, DG. Tetzlaff, J. Mulrow, C. Gøtzsche, PC. Ioannidis, JP. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. J Clin Epidemiol. 2009 62(10):e1–34. |
| 17. | Moher, D. Liberati, A. Tetzlaff, J. Altman, DG. Altman, D. Antes, G. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement (Chinese edition). Journal of Chinese Integrative Medicine. 2009 7(9):889–96. |
| 18. | The, JBI. Critical appraisal checklist for randomized controlled trials [Internet]. :2017 [cited: 1 Dec 2021]. Available from: https://jbi.global/sites/default/files/2019–05/JBI_RCTs_Appraisal_tool2017_0. |
| 19. | CustÓdio, NB. Cademartori, MG. Azevedo, MS. Mendes, M. Schardozim, LR. Sucasas, daCL. Efficacy of audiovisual distraction using eyeglasses during dental care: A randomized clinical trial. Braz Oral Res. 2021 35: e26 . |
| 20. | Dehghan, F. Jalali, R. Bashiri, H. The effect of virtual reality technology on preoperative anxiety in children: A Solomon four-group randomized clinical trial. Perioper Med (Lond). 2019 8:5. |
| 21. | Eijlers, R. Dierckx, B. Staals, LM. Berghmans, JM. van, dSMP. Strabbing, EM. Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial. Eur J Anaesthesiol. 2019 36(10):728–37. |
| 22. | Felemban, OM. Alshamrani, RM. Aljeddawi, DH. Bagher, SM. Effect of virtual reality distraction on pain and anxiety during infiltration anesthesia in pediatric patients: A randomized clinical trial. BMC Oral Health. 2021 21(1):321 . |
| 23. | Gómez-Polo, C. Vilches, A. Ribas, D. Castaño-Séiquer, A. Montero, J. Behaviour and anxiety management of paediatric dental patients through virtual reality: A randomised clinical trial. J Clin Med. 2021 10(14):3019. |
| 24. | Ryu, J. Park, J. Nahm, FS. Jeon, Y. Oh, A. Lee, HJ. The effect of gamification through a virtual reality on preoperative anxiety in pediatric patients undergoing general anesthesia: A prospective, randomized, and controlled trial. J Clin Med. 2018 7(9):284. |
| 25. | Ryu, J. Park, SJ. Park, J. Kim, J. Yoo, HJ. Kim, TW. Randomized clinical trial of immersive virtual reality tour of the operating theatre in children before anaesthesia. Br J Surg. 2017 104(12):1628–33. |
| 26. | Ioannou, A. Papastavrou, E. Avraamides, MN. Charalambous, A. Virtual reality and symptoms management of anxiety, depression, fatigue, and pain: A systematic review. SAGE Open Nurs. 2020 6:2377960820936163. |
| 27. | Oing, T. Prescott, J. Implementations of virtual reality for anxiety-related disorders: Systematic review. JMIR Serious Games. 2018 6(4):e10965. |
| 28. | López-Valverde, N. Muriel, FJ. López-Valverde, A. Valero, JLF. Ramírez, JM. Flores, FJ. Use of virtual reality for the Management of anxiety and pain in dental treatments: Systematic review and meta-analysis. J Clin Med. 2020 9(10):3086. |
| 30. | Lillard, AS. Pretend play skills and the child's theory of mind. Child Dev. 1993 64(2):348–71. |
Refbacks
- There are currently no refbacks.
Frontiers in Health Informatics (Official Journal of Iranian Association of Medical Informatics) ISSN-Online: 2676-7104
No. 4, Rashid Yasami Av., Vali-e-Asr St., Tehran-Iran; SMS: (+98) 9383621232 email: info@ijmi.ir
This work is licensed under a Creative Commons Attribution 4.0 International License which allows users to read, copy, distribute and make derivative works from the material, as long as the author of the original work is cited properly.
The theme is developed by: Gostaresh Afzar Hamara