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Social anxiety disorder (SAD; also known as social phobia) is a psychiatric disorder that is distinguished by a fear of humiliation or negative evaluation by others []. Current guidelines highlight the use of cognitive behavioral therapy to treat SAD []. This can involve activities such as psychoeducation, relaxation, distraction, cognitive restructuring, exposure therapy, and relapse prevention []. Despite the efficacy of cognitive behavioral therapy for SAD treatment [,], many who are diagnosed do not go on to seek help []. This is partly due to the in vivo (real-life) nature of the exposure therapy used to desensitize and habituate patients to feared situations. It takes significant time, effort, and resources to accurately recreate scenarios that will incite an appropriate level of fear response in social settings []. For example, to conduct in vivo exposure therapy with an individual with a fear of public speaking, a therapist would need to gather an audience in an appropriate context (ie, ensuring confidentiality and nonjudgment). Furthermore, social anxiety–provoking environments can be unpredictable, providing therapists with little control and a higher chance that a patient is embarrassed, leading to higher attrition rates []. To potentially overcome these issues with delivering in vivo exposure therapy, some researchers have examined the use of virtual reality (VR) technology [].
VR TechnologyVR technology provides a digital modality to deliver psychological interventions [,]. It involves the use of computer hardware and software technology (eg, stereoscopic displays of digital environments) to simulate real-world experiences []. For instance, one may enter a virtual environment that mimics a physical environment and could adopt a virtual avatar to interact with this virtual environment []. VR was first formulated in the 1960s, with the first commercial device developed in the 1980s []. As technology has developed, the quality of images has improved, and costs have been reduced.
VR systems can be divided into 2 categories: immersive and nonimmersive systems []. Immersive systems, such as head-mounted displays (HMDs) or cave automatic virtual environments (CAVEs), provide users with a realistic experience of VR environments, whereas nonimmersive systems, such as computer monitors, result in users not feeling as present []. Presence in VR refers to the extent of an individual’s perception of being in a particular environment []. For VR therapy to be effective, an individual must feel present and immersed in the digital environment []. A CAVE system consists of an empty room with multiple screens arranged in a cubelike formation with users wearing stereoscopic glasses and interacting with virtual objects projected onto the screens []. Although CAVE systems have the potential to be more immersive than nonimmersive systems, they are expensive and complex to set up, require frequent physical and digital adjustments, and require dedicated personnel []. Conversely, a recent systematic review found that current HMDs offer a more immersive experience than CAVEs and are significantly more user-friendly in cost and setup, with a “plug-n-play” setup solution [].
When integrated with therapy, VR technology can help address factors that influence the success of exposure-based treatments. For instance, VR allows for the creation of controlled digital environments, which enables therapists to predictably customize exposure scenarios to the specific needs and fears of individual clients []. VR can also improve accessibility to exposure therapy for individuals who find it logistically challenging or emotionally overwhelming to engage in real-world scenarios []. The immersive nature of VR helps bridge the gap between simulated experiences and real-life situations, fostering a sense of presence and engagement that can potentially enhance treatment adherence and effectiveness [].
Effectiveness of VR for SADVirtual environments and avatars can be used to simulate socially distressing situations for SAD treatment. For example, a study immersed participants with SAD into a computer-generated classroom where they were asked to speak publicly on a topic while a therapist controlled the virtual audience’s reactions according to the stage of therapy []. VR environments have also been shown to provide acceptable levels of presence and immersion that are necessary for exposure therapy in youth with social anxiety []. Several systematic reviews and meta-analyses have demonstrated the effectiveness of VR exposure therapy (VRET) in the treatment of SAD [,-]. Indeed, researchers have established a large effect size for VRET versus waitlist (g=0.90), a medium to large effect size for VRET versus psychological placebo conditions (g=0.78) [], a large overall effect size for VRET (g=0.82) [], and a medium to large effect size for VRET at the 12-month follow-up (g=−0.74) []. This consistent pattern of symptom reduction can be observed across various contexts, such as participant countries (eg, the United States, France, Israel, and South Korea) and treatment settings (eg, universities, hospitals, and clinics) [,-]. However, although existing reviews have explored VR-based therapy from an effectiveness standpoint (eg, reduction in anxiety symptoms), there are gaps in the literature on evaluating the VR user experience for people with SAD on key concomitant outcomes of safety, usability, acceptability, and attrition in different contexts.
User Experience of VR for SADSafetyStudies using VR for workplace training, physical rehabilitation, psychological therapy, and other settings highlight a significant safety issue: simulator sickness []. Simulator sickness (otherwise known as VR sickness or cybersickness) [-] is characterized by general discomfort, headache, eyestrain, nausea, difficulty concentrating, fatigue, blurred vision, dizziness, and vertigo. On the basis of postural instability theory, simulator sickness is arguably due to VR technology inducing sensory differences in the visual and vestibular systems, which coordinate balance and movement [-]. The human body may interpret these disparities as possibly deadly causes (ie, consuming poison) and seek to purge as a result []. Consequently, simulator sickness can have a negative impact on participants during VR use and for hours following use []. Other aspects of safety include physical injuries from repetitive strain, users colliding with objects in the real world, poor posture, headset discomfort, risk of inducing epileptic seizures, negative mood changes, and infection control []. Overall, these issues might put participants at risk of harm or cause them to discontinue using VR. Thus, a comprehensive examination of VR safety for SAD is necessary.
UsabilityThere does not yet appear to be a framework for the evaluation of VR usability in therapy-based applications. Nielsen [] defines usability as a “quality attribute” that assesses how easy it is to interact with an interface. He highlighted 5 components: learnability (how easy it is for a beginner to use the interface), efficiency (once the user has learned to use the interface, how quickly they can perform tasks), memorability (re-establishing proficiency after a period of absence), errors (frequency, severity, and recoverability of errors), and satisfaction (level of pleasure from using the interface) []. Although this framework is applied to website design, it can also be applied to participants’ perceptions of the usability of VR. Furthermore, the application of VR in real-world settings (eg, in a therapy room) would likely be performed by a clinician rather than a specialized technician. It is important to note that usability issues may arise among clinicians. For example, they may give up on the technology if components fail to load or connect to each other. For this reason, this review included both clinician experiences in administering VR-based therapy and client experiences.
AcceptabilityAcceptability is a crucial consideration when evaluating VR interventions []. It involves assessing the degree to which the new intervention and its components are received and aligned with the needs of the target population []. For example, a study examining VR use in adults with SAD defined acceptability as a participant’s willingness to use a VR program []. They measured acceptability by observing rates of attrition and responses to the following question—“Would you recommend this program to others who might have problems similar to yours?”—and inviting further feedback. Participants’ additional feedback was coded into 2 themes: satisfaction (sense of realism, insight, and utility) and perceived effects of the treatment (impact on anxiety). The findings indicated that VR was considered acceptable by participants on all measures []. Nevertheless, although there are recent systematic reviews that have addressed the acceptability of VR use for the general population [], psychosis [], panic disorder [], and posttraumatic stress disorder [,], a review of the literature on the acceptability of VR in individuals with SAD does not yet exist based on our current knowledge.
AttritionAttrition, the discontinuation of therapy before treatment completion and resolution of symptoms, can have profound negative effects []. These can include the client not fully benefiting from therapy and being discouraged from seeking treatment in the future [] as well as the effect that this may have on the therapist (eg, loss of revenue, demoralization, and feelings of failure) []. A recent meta-analysis of VRET showed significant heterogeneity in attrition rates in the treatment of anxiety disorders, highlighting reasons such as failure to immerse in the virtual environments, simulator sickness, vision complications, and difficulty communicating with a therapist that the participant could not see []. A systematic review examining the available literature on rates of attrition of VR-based interventions (both VRET and non-VRET) with participants with SAD does not yet appear to exist based on our current knowledge.
This StudyThis study aimed to systematically identify and review available evidence regarding the effectiveness and user experience (ie, safety, usability, acceptability, and rates of attrition) of VR interventions in the treatment of SAD. The following objectives aided in the provision of a comprehensive and up-to-date account of the empirical status of VR therapy for SAD: (1) provide an overview of the existing literature and identify areas in which further research is needed on the treatment of SAD; (2) assess the potential of using VR as a treatment option for SAD, specifically in terms of effectiveness and user experience; and (3) provide guidance and recommendations for future research regarding the use of VR as a treatment option for SAD.
This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist () []. The protocol of this systematic review was prospectively registered in the PROSPERO international database (CRD42022353891).
Eligibility CriteriaFor articles to be included in this systematic review, the study participants needed to be people diagnosed with SAD regardless of age. If a study had a mix of people with and without SAD, that study would be included if subgroup analyses were available on the participants with SAD or if they made up the vast majority (ie, ≥80%). All studies needed to examine direct participant use of a VR intervention, which includes any system that incorporates immersive VR hardware (ie, HMD or CAVE systems). Only studies that were published after 2012 were included as this marked the introduction of widely available commercial HMD hardware such as the Oculus Rift []. Such hardware allowed for the delivery of VR experiences comparable with previously expensive commercial setups at a cheaper cost as well as easier accessibility to researchers []. Studies with research design comparators of any kind (eg, comparing VR with other non-VR interventions) were eligible for inclusion. All studies were required to report on VR intervention effectiveness and participant user engagement outcomes. This broadly included any standardized or unstandardized measure indicative of usability or acceptability (including attrition rates). Studies of all designs (ie, quantitative, qualitative, and mixed methods) were eligible for inclusion. No studies were excluded based on methodological quality. All the articles needed to be written in English and published in peer-reviewed journals.
Search StrategyProminent scientific research databases were searched between January 1, 2012, and April 26, 2022: Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science. The following keywords were used to search the databases: (“virtual reality” or “VR”) and (“social anxiety” or “social phobia”). The reference lists of eligible articles were also searched.
Article SelectionThe search results for all databases were deduplicated, and the remaining article titles and abstracts were scanned. Full-text appraisal was performed on promising articles, and the final study inclusion was agreed upon by the researchers using the eligibility criteria. Divergent views on inclusion were resolved through discussion and mutual agreement.
Data ExtractionData from the included studies were extracted by one reviewer (SS) into a standardized coding sheet and then checked by a second reviewer (JK). The data types extracted from eligible papers included the following:
Reference source: author surnames, year of publication, and paper title.Sample: country; sample size; and nonidentifiable participant characteristics such as age, sex, and diagnosis.Study design: methodology, comparator trial arms, and measurement points (pretest, midtest, and posttest measurement and follow-up).VR intervention details: intervention program name, purpose of intervention (eg, exposure therapy, cognitive distraction, or relaxation), virtual environment type, hardware (eg, HMD or CAVE system), and treatment length.Effectiveness: standardized measure names, outcomes, and effect sizes.User experience: reported outcomes of intervention safety, usability, acceptability, attrition, and intention-to-treat analyses.Attrition in this review was defined and measured as the relative number of participants who began using the VR intervention but did not complete measurements during or after the intervention.
Quality AssessmentThis systematic review included randomized controlled trial (RCT) and nonrandomized studies. Therefore, the Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of all the included studies []. The MMAT was used as it assesses methodological quality across 5 study categories: RCTs, nonrandomized quantitative studies, quantitative descriptive studies, qualitative studies, and mixed methods studies.
Data AnalysisA narrative synthesis approach was used in this systematic review. This involved summarizing and explaining the findings using text as a statistical meta-analysis was not possible because of data heterogeneity across the included studies.
shows that the literature search yielded 683 articles, of which 391 (57.2%) remained after deduplicating citations. Of these 391 records, 18 (4.6%) met the eligibility criteria.
Figure 1. Flowchart of the systematic review search results. HMD: head-mounted display; SAD: social anxiety disorder. Participant CharacteristicsA total of 808 participants were recruited for the VR studies (). They were largely from South Korea (n=368), followed by the United States (n=163), the Netherlands (n=60), Canada (n=59), Sweden (n=23), Czech Republic (n=10), Denmark (n=9), and Brazil (n=2). The country of origin was missing for some participants (n=114). It is unclear whether participants were unique in 11% (2/18) of studies conducted by research teams with some of the same researchers [,]. The sample sizes ranged from 1 to 115 participants, with a median of 48 participants. Participants’ ages ranged from 18 to 65 years. Participants were mainly female, with an average sample proportion of 51.31% (SD 5.36%; range 0%-77.3%). Most participants were diagnosed with SAD. There were 9 participants with a diagnosis of flight phobia and 8 participants with a diagnosis of acrophobia; however, subgroup analyses were available for the participants with SAD in this study []. All participant diagnoses were obtained through clinical interviews delivered in person, by phone, or via videoconferencing. In total, 3 therapists were interviewed in addition to the sample of participants in one study [].
Table 1. Description of participants and research designs in the reviewed studies.StudyCountrySample sizeaTotal sample mean age (years; SD)Total sample age range (years)Total sample percentage of female participantsStudy designTreatment conditionsbMeasurementsAnderson et al []United States9739.03 (11.26)19-6961.9RCTcEGTd: 25; VRETe: 25; WLf: 25Pre- and posttest measurement and 3- and 12-month FUgArnfred et al []Denmark925.4 (6.54)19-3566.7InterviewVRET: 9Posttest measurementBouchard et al []Canada5934.5 (11.9)18-6572.9RCTVRET: 17; in vivo: 22; WL: 20Pre- and posttest measurement and 6-month FUGeraets et al []NRh1534.9 (12.4)18-6553.3Single groupVRET: 15Pre- and posttest measurement and 6-month FUHur et al []South Korea73NRNR42.6Case controlledVRET: 25; HCi: 22Pre- and posttest measurementJeong et al []South Korea115NRNR34.8CohortETj: 52; NTk: 43; SEl: 20Pre- and posttest measurementKampmann et al []The Netherlands6036.918-6563.3RCTVRET: 20; WL: 20; iVETm: 20Pre- and posttest measurement and 3-month FUKim et al []South Korea5423NR57.7Controlled clinical trialVRET: 22; HC: 30Pre- and posttest measurementKim et al []South Korea74NR19-3156.9LongitudinalVRET: 32; HC: 33Pre- and posttest measurementKim et al []South Korea52NR19-30NRRCTVRSn: 24; WL: 28Pre- and posttest measurementKovar []Czech Republic1034.6 (11.7)19-5150Nonrandomized parallel comparison trialPsychotherapy: 5; psychotherapy+VRET: 5Pre- and posttest measurementLindner et al []Sweden2340.61 (10.15)≥1857CohortVRET: 23Pre- and posttest measurementMoldovan and David []NR32NR≥1846.9RCTVRCBTo: 16; WL: 16Pre- and posttest measurement and FUPerandré and Haydu []Brazil223.5 (4.9)20-270Case studyVRET: 2Pre- and posttest measurement and 1- and 3-month FUPrice and Anderson []NR6740.31 (11.55)NR69RCTVRET: 33; EGT: 34Pre-, mid-, and posttest measurementRubin et al []United States21NR18-6561.9RCTVRET: 10; VRET+AGTp: 11Pre- and posttest measurement and 1-week FUTrahan et al []United States136NR0Case studyVRET: 1Pre- and posttest measurementZainal et al []United States4423.3 (9.32)18-5377.3RCTVRET: 26; WL: 18Pre- and posttest measurement and 3- and 6-month FUaRefers to the total number of participants in the study.
bRefers to the number of participants in each treatment condition.
cRCT: randomized controlled trial.
dEGT: exposure group therapy.
eVRET: virtual reality exposure therapy.
fWL: waitlist control.
gFU: follow-up.
hNR: not reported.
iHC: healthy controls.
jET: early termination.
kNT: normal termination.
lSE: session extension.
miVET: in vivo exposure therapy.
nVRS: virtual reality self-training.
oVRCBT: virtual reality cognitive behavioral therapy.
pAGT: attention guidance training.
Details of the VR InterventionsAll the studies included VR-based exposure therapy. Nearly all the studies (15/18, 83%) tested a unique VR intervention except for the studies by Jeong et al [] and Kim et al [,] (). VR hardware included standard computers, smartphones, and HMDs. In total, 17% (3/18) of the studies [,,] did not identify the headset brands. The studies used custom-built software that immersed participants in VR environments that simulated social situations increasing in difficulty with audio, video, text, and interactivity. The treatment lengths ranged from 1 to 14 sessions of exposure therapy, with a mode of 8. A total of 17% (3/18) of the studies [,,] terminated the sessions early if habituation occurred before the completion of the sessions. Participant VR use time ranged from 5 minutes to 3 hours per session, and 17% (3/18) of the studies delivered the VR in a single session [,,]. All VR interventions were tested with therapist or facilitator guidance even though 22% (4/18) [,,,] were designed to be delivered as self-help.
Table 2. Details of the virtual reality (VR) interventions.StudyVirtual environmentsHeadsetTreatment length (duration)Anderson et al []Conference room, classroom, and auditorium—a4 exposure sessions (30 min each)Arnfred et al []Supermarket, meeting, cafeteria, party, and auditoriumOculus Go8 exposure sessions (45 min each)Bouchard et al []Meeting room, job interview, apartment, coffee shop, neighbors, store, and neutraleMagin Z8008 exposure sessions (20-30 min each)Geraets et al []Street, bus, café, and supermarketSony HMZ-T114 exposure sessions (40 min each)Hur et al []College student groupHTC Vive6 exposure sessions (5-8 min each)Jeong et al []School, business, and daily lifeSamsung Gear VR powered by OculusETb (1-8 exposure sessions); NTc (9-10 exposure sessions); SEd (11-17 exposure sessions)Kampmann et al []Audience, stranger, clothes shopping, job interview, journalist interview, restaurant, and blind datenVisor SX7 exposure sessions (60 min each)Kim et al []School, business, and daily lifeSamsung Gear VR powered by Oculus8 exposure sessionsKim et al []College student groupHTC Vive6 exposure sessionsKim et al []School, business, and daily lifeSamsung Gear VR powered by Oculus8 exposure sessionsKovar []Public speaking, telephone call, receiving criticism, job interview, refusal of job offer or unwanted product, and working lunchHTC Vive8 exposure sessionsLindner et al []Board room, conference room, and classroomOculus Go1 exposure session (180 min)Moldovan and David []Presentation and interview—1 exposure session (90 min)Perandré and Haydu []Food court in shopping centerOculus Rift8 exposure sessionsPrice and Anderson []Conference room, classroom, and auditorium—8 exposure sessionsRubin et al []Conference room and auditoriumOculus Rift DK21 exposure session (45 min)Trahan et al []Grocery storePlastic HMDe bracket for mobile phone12 exposure sessions (12-15 min each)Zainal et al []Dinner party and job interviewPico Goblin VR8 exposure sessions (25-30 min each)aBrand not reported.
bET: early termination.
cNT: normal termination.
dSE: session extension.
eHMD: head-mounted display.
Research Designs and Comparatorssummarizes the research designs and comparators. Nearly half (8/18, 44%) of the studies appraised participant VR use through RCT designs. Comparators included exposure group therapy, in vivo exposure, early and extended termination, attention guidance training using VR, psychotherapy, and waitlist control. All studies (18/18, 100%) had pre- and posttest assessments of user outcomes, although 39% (7/18) also had follow-up assessments, with the longest being 12 months [].
Effectiveness Measures and OutcomesThe details of the effectiveness measures and outcomes of VR treatment for SAD are summarized in . VR treatment effect sizes across all studies that reported them ranged from medium to large. Almost all studies (15/18, 83%) demonstrated a decrease in symptoms following VR treatment.
Table 3. Details on social anxiety measures and virtual reality (VR) effectiveness outcomes.Study and measuresVR effectiveness outcomesAnderson et al []aPRCS: Personal Report of Confidence as a Speaker.
bCohen d effect size.
cFNE-B: brief Fear of Negative Evaluation Scale.
dBAT: behavioral avoidance task.
eNSQ: nonstandardized questions.
fLSAS-SR: Liebowitz Social Anxiety Scale–Self-Report.
gSPS: Social Phobia Scale.
hSIAS: Social Interaction Anxiety Scale.
iFNE: Fear of Negative Evaluation Scale.
jPERS: Post-Event Rumination Scale.
kHADS: Hospital Anxiety and Depression Scale.
lKSAD: Korean Social Avoidance and Distress Scale.
mLSAS: Liebowitz Social Anxiety Scale.
nSPIN: Social Phobia Inventory.
oSADS: Social Avoidance and Distress Scale.
pBAI: Beck Anxiety Inventory.
qPSAS: Public Speaking Anxiety Scale.
rSSPS: Self-Statements During Public Speaking scale.
sPRCA-SF: Personal Report of Communication Apprehension–Short Form.
tPRPSA: Personal Report of Public Speaking Anxiety.
uSUDS: Subjective Units of Distress Scale.
vSAD composite: average standardized scores of the Social Phobia Diagnostic Questionnaire and the SIAS.
wHedges g effect size.
xMASI: Measure of Anxiety in Selection Interviews.
User Experience With the VR InterventionsThe average attrition rate was 11.36% across all studies in the active VR treatment phase, with a range of 0% to 45.2% (). A total of 22% (4/18) of the studies reported the use of an intention-to-treat analysis. To measure VR user experience, 56% (10/18) of the studies used standardized measures, and 11% (2/18) of the studies used nonstandardized questions. A total of 67% (8/12) of these studies reported positive VR user experience findings in various areas of presence, usability, acceptability, or satisfaction. Low levels of simulator sickness were reported in 75% (3/4) of the studies that used standardized questions; however, 25% (1/4) of these studies reported higher levels of simulator sickness in participants with SAD than in controls without SAD []. No other safety issues, such as physical injury, user collision, postural complaints, headset discomfort, seizures, or infection, were reported.
Table 4. Virtual reality (VR) interventions and user experience outcomes.StudyMeasuresVR user experience findingsAttrition (%)ITTaAnderson et al []CSQbHigh satisfaction with VR was reported after treatment and maintained at the 12-month follow-up.5/30 (17)YesArnfred et al []NSQcA high level of presence in virtual environments for some participants but not all. There were technical issues with setting up and storing away equipment for the group. Wearing the HMDd in front of strangers was more anxiety provoking than the virtual environments for some participants. All patients found VR to be a meaningful addition to their therapy sessions, with several wanting more exposure.0/9 (0)—eBouchard et al []SSQf, PQg, and GPQhNo significant increases in simulator sickness after exposure sessions (P>.20). Good level of presence that increased with a higher number of exposures.2/17 (12)YesGeraets et al []—VR treatment was well tolerated and deemed acceptable for most participants.2/15 (13)—Hur et al []——16/73 (21)—Jeong et al []——52/115 (45)—Kampmann et al []—Simulator sickness led one patient to drop out.5/20 (25)YesKim et al []SSQParticipants with SADi experienced significantly more simulator sickness than participants without SAD (P=.003).2/54 (4)—Kim et al []——9/74 (12)—Kim et al []SSQLow levels of simulator sickness.3/24 (13)—Kovar []——0/10 (0)—Lindner et al []NEQjHigh stress levels and low levels of satisfaction.3/23 (13)YesMoldovan and David []ITQk and PQNo moderating effect of immersion and presence on pre- and posttest anxiety.0/32 (0)—Perandré and Haydu []SPIlHigh sense of presence reported by both participants.0/2 (0)—Price and Anderson []—From a randomly selected subset of videotaped sessions (14%), high participant compliance was found, with 92% of the VR treatment protocol being completed.0/33 (0)—Rubin et al []——2/21 (10)—Trahan et al []SUSmHigh usability reported by the participant.0/1 (0)—Zainal et al []NSQ, IPQn, and SSQAcceptable presence and low levels of simulator sickness. High levels of homework compliance. Participants (85%) would recommend it to others with SAD. High levels of acceptability and usability.9/44 (21)—aITT: intention-to-treat analysis.
bCSQ: Client Satisfaction Questionnaire.
cNSQ: nonstandardized questions.
dHMD: head-mounted display.
eNot reported.
fSSQ: Simulator Sickness Questionnaire.
gPQ: Presence Questionnaire.
hGPQ: Gatineau Presence Questionnaire.
iSAD: social anxiety disorder.
jNEQ: Negative Effects Questionnaire.
kITQ: Immersive Tendencies Questionnaire.
lSPI: Sense of Presence Inventory.
mSUS: System Usability Scale.
nIPQ: Igroup Presence Questionnaire.
Quality Assessment Results[-] contains a table of quality assessment results for the included studies. In all RCT studies [,,,,,,,], randomization was reported, but schedule details were unclear in 11% (2/18) of the studies [,]. All RCT studies reported comparable baseline group analyses. In total, 38% (3/8) of the RCT studies reported complete outcome data, which is defined as ≥80% [,,]. All but the RCT studies by Kim et al [], Moldovan and David [], Price and Anderson [], and Rubin et al [] reported blinding of outcome assessors, which was applied at the pretest measurements. All RCT studies except those by Bouchard et al [], Kampmann et al [], and Rubin et al [] reported that participants adhered to their assigned VR interventions.
In the quantitative descriptive studies [,,], the sampling strategy was relevant to the research question except in 33% (1/3) of the studies, in which details were unclear []. All quantitative descriptive study samples were representative of the target population, and the measures fulfilled the inclusion criteria. Nonresponse bias was low in all studies except one (2/3, 67%) []. Statistical analyses were appropriate to answer the research question in 33% (1/3) of the studies [] but unclear in the other 2 [,].
In the quantitative nonrandomized studies [,,,-], participants were representative of the target population, measurements were appropriate regarding both the outcome and intervention, and there were complete outcome data (defined as ≥80%) in all but 2 studies (4/6, 67%) [,]. Confounds were accounted for in the design and analysis of 50% (3/6) of the studies [,,]. In total, 67% (2/3) of the quantitative nonrandomized studies reported that the intervention was administered as intended [,].
In the single qualitative interview study [], the qualitative approach was appropriate to answer the research question; the data collection methods were adequate to address the research question; findings were adequately derived from the data; the interpretation of the results was sufficiently substantiated
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