research-article

Open access

Stairway to Heaven: A Gamified VR Journey for Breath Awareness

Authors:

Giovanni Maria TroianoAuthors Info & Claims

CHI '24: Proceedings of the 2024 CHI Conference on Human Factors in Computing Systems

Article No.: 717, Pages 1 - 19

https://doi.org/10.1145/3613904.3641986

Published: 11 May 2024 Publication History

All formats PDF

Abstract

Gamification and virtual reality (VR) are increasingly being explored for their potential to enhance mindful practices and well-being. We further explore the potential of gamification and VR for breath awareness and mindfulness, and contribute Stairway to Heaven, a VR artifact that combines gamification with respiratory sensor biofeedback to cultivate mindful awareness of breathing. In our mixed-method study with 21 participants, we evaluated the usability and effectiveness of our artifact in promoting breathing frequencies between 4 and 10 breaths per minute (BPM). We integrate breath-driven teleportation as a virtual locomotion technique (VLT) using respiratory biofeedback to gamify progression through a virtual wilderness. Additionally, we supplement our design with a mindfulness audio guide. The results of our user study showcase the potential of combining actionable gamification and VR, guided mindfulness, and breath-driven VLT to foster slow breathing self-regulation successfully.

Figure 1:

1 Introduction

“Now, bring your awareness to your breath…” is a common phrase in mindfulness training. Attention to one’s breathing can reduce mind-wandering and support mindfulness (see [43]). The multifaceted relationship between mindfulness, mental health, and well-being [69] strategically positions mindful breathing as an effective practice in various applications, including biofeedback therapy [44]. However, supporting sustained attention to breathing in technology-mediated spaces is challenging. Interactive applications for mindfulness, including apps for smartphones [57], smartwatches [23], and virtual reality (VR) [64], often use breath as a focal point for enhancing attention to the present moment, guiding users to mindful regulation of physiology by helping them modulate the depth and pace of their breathing.

Previous work in human-computer interaction (HCI) [90] and social science [48] showed how the use of VR technology can help engage individuals in sustained attention to breathing and thus enhance mindful breath awareness. Hence, VR has garnered significant traction in HCI research as a medium for the design and study of mindfulness applications [13, 18, 24, 63, 64].

The effectiveness of VR technology largely stems from the immersive qualities of the medium and its ability to minimize external distractions [2]. By designing immersive environments that promote heightened interoception [26] (i.e., the awareness of internal bodily changes) and facilitate decentering [2] (i.e., the development of a nonjudgmental self-awareness), VR has promise for effective mindfulness practices.

Recently, researchers have successfully experimented with a gamified approach to mindful breathing in VR settings (e.g., [78, 87, 92]). For context, the term gamification is broadly referred to as “the integration of game design elements into non-game contexts to motivate desired behaviors” ([22], p.10). Their work shows how combining immersive VR environments with gamification strategies presents promising avenues for overcoming common challenges in traditional biofeedback therapies, including sustaining motivation [49], enhancing focus [55], and effectively transferring learned skills into everyday contexts [44]. These can be further reinforced by linking the VR environment to a user’s physiology using biofeedback (e.g., [4]).

Building on existing HCI work in VR and mindfulness, particularly research focusing on breath awareness and breathing interaction [21, 61, 63, 64, 68, 78], we introduce Stairway to Heaven. This VR artifact leverages gamification strategies to promote sustained attention to and mindful self-regulation of breathing. In Stairway to Heaven, we engage users with deep breathing (i.e., breathing from the abdomen or diaphragmatic breathing [27]) as the sole means of game interaction. Stairway to Heaven provides users with real-time feedback and positive reinforcement, a technique used successfully with neurofeedback games [66], to support self-regulation of deep breathing. Using a low-cost respiration sensor and open-source software, we designed a gamified VR experience where users control progression via VR teleportation (i.e., the virtual locomotion technique, or VLT, for instantly moving from one place in the virtual world to another) using their breathing to advance through the three stages of the game (Figure 1).

Our study of Stairway to Heaven provides insight into the design of gamification and VR to support self-regulation of mindful breathing. Breathing frequency data reveal that users engaging with diaphragmatic breathing and slowing their breathing towards therapeutic frequencies while engaging with Stairway to Heaven—aligning their breathing with biofeedback therapy targets of 4–10 breaths per minute [71]. Survey results demonstrated good usability, with no significant correlations found between immersive tendencies, meditation history, or previous VR use and users’ reported sense of presence in Stairway to Heaven. Overall, our participants were positively engaged by the gamified progression mechanics, where interview findings emphasize the need for careful design to balance varied user experiences and reactions to VR-based mindfulness training.

The results of our user study highlight the effectiveness of integrating actionable gamification [14] and VR, coupled with guided mindfulness and breath-driven VLT, in promoting successful self-regulation of slow breathing. These findings bear implications for the design of future breathing self-regulation approaches, emphasizing the use of gamification and immersive technologies like VR.

2 Breath Awareness and Mindfulness

Breath awareness, deeply rooted in ancient Eastern traditions, has evolved into a cornerstone of contemporary “open-monitoring’’ mindfulness practices [1, 58, 63, 81]. Mindfulness was defined by Nyanaponika Thera as “the clear and single-minded awareness of what happens to us and in us at the successive moments of perception” ([83], p.5), and it involves non-judgmentally observing one’s moment-to-moment experiences, including thoughts, emotions, and bodily sensations. For a review of how the term mindfulness is generally understood and used in HCI, see [82]. Mindfulness meditation is founded on the millennia-old techniques for breath awareness, which focus on the breath to cultivate present-moment awareness. Historically integral to practices like Yoga and Buddhist meditation [8], breath awareness is now recognized for its effectiveness in developing mindfulness skills across various contexts [71]. In contemporary mindfulness practices, breath awareness often involves controlled breathing techniques such as diaphragmatic breathing [27, 90], box breathing [19, 31], and paced breathing [53], which are not only integral to yogic traditions but also used for health-related goals such as healing [9], anxiety relief [12], and improved focus [45].

Drawing on historical principles and contemporary techniques, we integrated immersive VR environments [40], respiration-driven biofeedback [63], and progression gamification [68] to enhance and encourage breath awareness and self-regulation. As a result, we designed Stairway to Heaven to foster direct, non-judgmental present-moment awareness of breathing within an experiential context—a VR journey into wilderness—where users can become mindful of their breathing patterns, facilitated by gamified progression mechanics that encourage the self-regulation of breathing. Our gamified VR artifact is then best positioned within related work that explored (1) VR for breath awareness, including VR using respiration-driven biofeedback for input and control [20, 68], and (2) gamification that engages users in expanding their breathing awareness within immersive virtual environments [64]. Recognizing the extensive and varied research on breath awareness for health and well-being [95], our focus is on exploring the unique design considerations and affordances of VR in integrating breathing biofeedback, which presents distinct opportunities for therapeutic applications in HCI.

Table 1:

VR System	Input and Interaction Mechanics			Data Analysis
	Sensors	Breath Type	VLT	Breathing	Survey	Interview
Stairway to Heaven	Stretch	Diaphragmatic	Teleportation	✓	✓	✓
Breathero [92]	Airflow, Stretch	Fire, Box, Full			✓
Rockstroh et al. [68]	VR Controller	Diaphragmatic	Continuous		✓
Stepanova et al. [80]	Stretch	Diaphragmatic			✓
Attending to Breath [64]	Stretch	Chest, Abdomen	Up and Down	✓		✓
Breathvr [78]	Stretch	Abdomen			✓	✓
BreathCoach [87]	Smartwatch	Paced		✓	✓	✓
Life Tree [54]	Airflow	Airflow, Exhalation			✓	✓
Inner Garden [70]	Stretch, Cardiac	Abdomen			✓	✓
Soyka et al. [77]	Stretch, Cardiac	Paced		✓	✓
DEEP [90]	Stretch	Diaphragmatic	Fluid		✓
OSMOSE [20]	Vest	Chest	Fluid

Table 1: Related VR systems integrating breathing as input, types of sensors used, breathing style targeted by the system, virtual locomotion technique (VLT), and data analysis approaches. Stairway to Heaven maps diaphragmatic breathing to teleportation-driven progression and analyzes breathing, survey, and interview data.

2.1 VR for Breath Awareness and Mindfulness

VR applications supporting breath awareness are emerging; they engage users through various interactions and media, including art (e.g., [20, 80]), exergames (e.g., [54]), meditation in virtual landscapes (e.g., [70]), and VR-based breathing training [64, 77, 90] (see Table 1). These applications differ in how they engage users with breathing and their objectives. For instance, Char Davies’ OSMOSE [20] used a motion-tracking vest with breathing and balance sensors to facilitate navigational control as part of a contemplative art experience. Two decades later, DEEP [90] emerged as a VR approach for reducing anxiety in children through an immersive underwater VR environment; after playing DEEP for 7 minutes, 86 children reported decreased anxiety. Prpa et al.’s Attending to Breath [64] linked breathing to audiovisual feedback to explore the emotional impacts of breathing biofeedback in VR. In their study, Prpa et al. explored the effects of user breathing on virtual experiences through micro phenomenology and mixed methods, finding that participants preferred a system where inhaling raised them, akin to rising when breathing in, creating a calming effect—their VR approach was deemed by participants as a potential tool for relaxation and overcoming water-related anxieties through engaging with breath awareness. Inspired by Prpa et al., we link breath to VLT in Stairway to Heaven to test the use of our teleportation progression mechanics, where users move from one “checkpoint” to the other to engage with guided breathing exercises (see Figure 2). Other examples of VR for breath awareness and mindfulness include Inner Garden [70]—a multisensory mixed-reality environment where users’ breathing and heart rate dynamically shape the virtual world, and Life Tree [54]—where users synchronize their breathing to a rhythmic breathing sound and a virtual tree expands and contracts following users’ inhale and exhale. The above-mentioned work emphasizes user-driven interaction, where changes in the virtual environment are directly influenced by input from users’ physiological signals; this approach prioritizes personal exploration and internal awareness over structured tasks or objectives.

In Stairway to Heaven, we support user-driven interaction while fostering self-regulation of slow diaphragmatic breathing through actionable gamification [14]. Actionable gamification is based on Chou’s framework called “Octalysis,” which assumes eight core drives that motivate people to take action. These core drives are based on human psychology and include elements such as meaning, empowerment, social influence, unpredictability, avoidance, scarcity, ownership, and accomplishment. We leverage Chou’s actionable gamification to enhance intrinsic motivation, player empowerment, and goal-achievement beyond badges and leaderboards (e.g., [86]), which are articulated in our gamified VR in the form of progression mechanics. In so doing, we scaffold breathing regulation in the gamified VR setting to instruct and motivate users toward achieving therapeutic slow breathing.

2.2 Gamification and VR for Breath Awareness and Mindfulness

Gamification has been effectively applied in diverse areas, including VR training in manufacturing and medicine [52, 88], as well as in virtual learning environments [65]. Examples of prior work combining gamification and VR include BreathVR [78], which allows users to play a VR first-person shooter (FPS) or a VR Pong using both controllers and respiratory sensor inputs—to engage “superpowers” such as fire-breathing, in the games. Sixteen participants tested both games, revealing breathing actions enhanced presence and increased interest and were favorably rated for novelty and usability. Participants with prior VR experience and gamers preferred breathing actions, and challenges included potential fatigue and difficulty memorizing all actions. The results of BreathVR suggest that more research on different action mappings is needed to understand the dynamics of direct physiological control in gamified VR. Breathero [92] weaves specific breathing techniques—Kapalabhati, Box Breathing, and Full Yogic Breathing—into its fast-paced gaming experience, transforming breathing exercises into interactive game elements. The game features imitative breathing feedback, associating skills with breathing techniques, and a boss battle requiring the strategic application of learned techniques. Implemented with a wind and flex sensor, the hardware detects and measures breathing patterns as input. The user study, involving eight participants, indicates positive feedback on the game experience, the feasibility of merging respiratory training with VR action, and the effectiveness of breathing feedback and associated learning on breathing techniques. However, participants found it hard to swiftly switch between different breathing techniques during gameplay, with some feeling overwhelmed while breathing and attempting to defeat in-game sprites simultaneously. In Stairway to Heaven, we use respiratory sensor input as the sole means of interaction for (1) minimizing users’ distractions when focusing on their breathing and (2) maximizing relaxation and mindful breath awareness.

Another example of gamified VR was provided by Moroz and Calagiu [49], who exemplified how VR and gamification could be combined to address common challenges in mindfulness practices, including restlessness and doubt. Despite the apparent differences between meditation (focused on well-being) and games (goal-oriented play), the authors argue that they share motivational aspects. They address how gamification counters hindrances to mindfulness practice from the Theravada tradition, using tailored virtual environments, loving-kindness meditation, physiological feedback via heart rate monitors (HRM), virtual journeys, simulated motion, and progress statistics. The authors did not conduct a user study. Rockstroh et al. [68] devised and assessed a mobile VR game that uses biofeedback and respiratory-driven technology to teach diaphragmatic breathing. In a longitudinal study with 45 participants, they assessed their approach for user experience, breath parameters, and mental health. The results revealed that engaging with the gamified VR experience enhanced diaphragmatic breathing, increased ease of breathing, heightened breath awareness, improved relaxation, reduced stress, and lowered burnout symptoms. The game effectively promoted diaphragmatic breathing and positively impacted mental well-being. In Rockstroh et al., diaphragmatic movements are sensed by having users holding a controller against their abdomen. While this approach offers simplicity, it poses challenges such as system sensitivity and potential disruption of user immersion. For increased accuracy and immersion, we used a respiratory sensor belt as an input device to sense diaphragmatic breathing instead of VR controllers.

Figure 2:

BreathCoach [87] is a smartwatch-based VR experience providing at-home coaching for treating Respiratory Sinus Arrhythmia biofeedback-based Breathing Training (RSA-BT). RSA-BT is a complementary treatment for breathing diseases like asthma and is also used to mitigate the symptoms of anxiety. In BreathCoach, the breathing signal gathered from users’ breathing is monitored in real-time for detecting parameters like breathing pattern (BP), inter-beat interval (IBI), and RSA amplitude; the system calculates optimal breathing patterns based on previous and current real-time measurement of users’ breathing. The smartwatch accelerometer and photoplethysmography (PPG, an optical measurement method for monitoring the heart rate) sensors are used to monitor BP and IBI and quantify the RSA in real-time, and based on the emerging value the BreatCoach system will recommend optimal breathing patterns to users. Then, users perform breathing patterns to interact with two environments in VR: (1) Balloon, where users control the movement of a virtual red balloon using their breathing, and (2) Pilot, where users’ RSA peak-valley estimation is mapped to control altitude and speed in a “flight simulator”. The system was demonstrated at CHI 2018.

In Stairway to Heaven, we emphasize the therapeutic potential of diaphragmatic breathing by using a respiratory sensor belt around the abdomen as the sole input mechanism. This approach minimizes signal noise and provides real-time visual feedback while ensuring accurate breathing recordings for analysis. Building on previous gamified VR methods for breath awareness and mindfulness, Stairway to Heaven advances these concepts by (1) introducing a progression mechanics framework using self-regulated breathing, (2) simplifying user interaction to focus on breathing with teleportation-based virtual locomotion, and (3) implementing an actionable gamification approach [14], which uses game design techniques to encourage specific actions and behaviors. Here, we apply actionable gamification principles to unite three design elements (e.g., self-regulation of slow breathing, breath-driven teleportation, and guided mindfulness) to enhance breath awareness.

3 Stairway to Heaven

“Dear lady, can you hear the wind blow? And did you know your stairway lies on the whispering wind?” (Led Zeppelin, Stairway to Heaven, 1971)

We designed a virtual environment that positions players in a tranquil forest landscape (Figure 2), where their goal is to perform deep breathing while ascending to the top of a hill. We use procedural generation tools to craft a virtual environment simulating a natural wilderness terrain, using ambient sounds and lighting to enhance aesthetic features and increase immersiveness. We use respiratory sensing to modulate player progression along a predefined path using teleportation. Further, we base our design on Attention Restoration Theory (ART) [38], which suggests that time spent in nature can reduce stress and provide restorative mental health benefits. By framing Stairway to Heaven as a journey through a virtual wilderness and by making breathing the user’s sole means of system input, we emphasize attention to breathing in the game mechanics, where breathing becomes the subject and object of the experience.

Figure 3:

3.1 Design Rationale and Articulation

The design of Stairway to Heaven is based on a framework for extending breath awareness by Prpa et al. [63] comprising four pillars: (1) mindfulness, (2) regulation, (3) soma, and (4) social. However, Stairway to Heaven, being a single-player experience, does not incorporate the social pillar, which involves peer-to-peer interactions [49]. According to Prpa et al., [63], mindfulness focuses on attention to self and can be enhanced by clearly articulating support of breath awareness. In designing Stairway to Heaven, we facilitate mindful breathing self-regulation using visual and auditory feedback. For example, common gaming elements like beacons and loading bars visually guide players’ breathing (Figure 3b). For the audio guide, we incorporated (with permission) selections from the mindfulness audio guide Finding Stillness by Dr. Eva Selhub ¹.

To enhance breath regulation, as in “the effective control of breathing rate for optimal respiratory function” ([63], p.9), research indicates that guiding the pace and depth of breathing can also regulate heart rate and stress response [4, 21, 64, 74, 76]. In regulatory design, intuitive and real-time mirroring of the user’s breath state is important for effectively guiding and prompting desired breathing behaviors. Prior work used “simplistic” representations, such as an image of lungs expanding and contracting with the breath, as a cue for users [63]. We follow these prior works to design gamified VR mechanics that support users in the self-regulation of their breathing. We use a green loading bar (Figure 3b) to visually represent inhalation and exhalation status, filling up as players inhale fully, while the breathing depth needed for progression is tailored to each player through initial calibration (see Section 4). Calibration sets the parameters of empty and full breaths, but the pace of each breath cycle between these states is entirely self-regulated in Stairway to Heaven. Our system does not regulate the pace of breathing; instead, we allow users to find their own frequency while meeting the depth parameters. We aim to inspire rather than coerce players toward a therapeutic breathing frequency and find the frequency that best resonates with their own mental and physical state. Richard Shusterman [75] describes soma in terms of somaesthetics, a field encompassing the theory, empirical study, and practical application of bodily perception, performance, and presentation. In breathing training, user understanding of their body can be enhanced by the interactive functions and affordances of the media [32]. Prpa et al. [63, p. 9] suggest that breathing sensors placed on the body can serve as “body-centric artifacts guiding attention to breath-awareness.” In Stairway to Heaven, we use the respirator sensor belt around the abdomen to enhance somatic awareness within the virtual world.

Figure 4:

3.2 Virtual World and Game Mechanics Design

We built the virtual world featured in Stairway to Heaven using Unity3D and Gaia Procedural Worlds software [10, 89]. We sculpted the island terrain, populated it with Gaia’s coniferous forest assets, and created a path illuminated with stone markers to define the breathing checkpoints along the VR journey [3]. There are 20 checkpoints, divided into three stages:

(1)

In Stage One, ten stone markers delineate the path of the VR journey and highlight checkpoints with yellow orbs of light throughout a densely forested section (Figure 2, foreground).

(2)

Stage Two is characterized by nine markers highlighted with blue lights, placed along a path that goes up a steep hill (Figure 2, background).

(3)

Stage Three features a campfire where players complete the breathing training (Figure 4).

We designed the virtual journey with progression mechanics to gamify breathing training, requiring players to perform diaphragmatic breathing to advance. The number of breaths taken directly influences their in-game progression. In Stage One, one breath is needed to move to the first checkpoint, two to the second, and so forth—in short, the number of breaths to perform for advancing through the forest increases by one at each checkpoint until the tenth. This design is inspired by the usability heuristics for game design articulated by Celia Hodent [28], in particular the use of informative signs and inviting signs (p. 115-116). This progression design scaffolds player mastery of the breathing-to-progress mechanic and spatially maps user achievement to the metaphor of a wilderness journey.

Halfway through Stage One, audio guidance from Finding Stillness: Meditations from the Benson-Henry Institute for Mind-Body Medicine by Dr. Eva M. Selhub [73] begins playing. This audio gently guides users in mindful breathing, emphasizing self-care and deeply relaxing the body and mind. Nine breaths are required to reach the final checkpoint in Stage One, and the tenth checkpoint represents the journey’s midpoint. From this checkpoint, positioned at the forest’s edge, ten breaths are required, and Stage Two lies ahead with an open view of the sky. In Stage Two, each successive checkpoint requires one fewer breath for progression, rewarding players with mastery and achievement. By the end of Stage Two, players will have completed 100 deep breaths, which roughly conditions a 10 - 20 minute diaphragmatic breathing exercise. This duration is consistent with the Cleveland Clinic’s recommended parameters for slow breathing therapy [16]. When players next arrive at a campfire, they are asked to perform ten final deep breaths and reflect on the power of deep breathing for physical and mental well-being. To conclude, the player’s point of view shifts into the sky above the island, allowing them to reflect on the journey of breathing to climb a Stairway to Heaven (Figure 8).

3.3 Gameplay and Set Up

Stairway to Heaven begins with an onboarding phase (Figure 3a), where an audio introduction guides players through the respiration sensor calibration. Players are asked to take several deep breaths from their abdomen while the system monitors sensor values for the upper and lower bounds. We use these values to set the breathing thresholds that count the player’s breaths throughout the game and monitor the amplitude of their breathing. After calibration, the narrator instructs participants to practice the breath-based VLT by taking two deep breaths to move to the edge of the onboarding platform. With the players’ breathing then linked to the heads-up display (HUD, Figure 3b), visual feedback shows the state of their diaphragmatic breath, according to the sensor calibration. The HUD remains visible throughout the gamified VR experience for users to monitor the current breath count, the count of the breaths needed for progression, and the status of their breathing. The breath count and required number of breaths are refreshed at each checkpoint along the journey. Players do not amass points in our system but focus on the benefits of deep breathing as a reward and end goal.

To integrate breathing into Stairway to Heaven, participants wear a Vernier Go Direct Respiration Belt (GDX-RB) [91]. This belt, worn around the abdomen, is connected to a PC via USB. It captures changes in abdominal distention, translating physical breathing into a digital signal. The signal is processed using Python and the Lab Streaming Layer (LSL) libraries [5, 6, 41], creating a bridge between the sensor and Unity. The system logs users’ breathing data via LSL Lab Recorder to store data in an extended document format (XDF) for facilitating data analysis. The Python script samples sensor data at 100 millisecond intervals, sending this information to Unity. This process enables the game to represent the player’s breathing cycle dynamically and link their breath to their in-game progression.

4 Study Design

To test our gamified VR experience, we set up a user study with Stairway to Heaven. Through a mixed-methods approach, we aimed to gain insight into the player experience with gamified breath awareness, including specifically using the breathing sensor for teleportation VLT. In this section, we detail the study design: participants, procedure, and data analysis. This study was approved by our institutional review board. Two users reported a tingling sensation in their cheeks due to the prolonged deep breathing exercise. However, no users reported experiencing cybersickness or a level of discomfort that would warrant ceasing the study according to our protocol.

4.1 Participants

We recruited 22 participants. However, the test of P12 was interrupted by technical difficulties, leaving (n = 21) for survey and interview data analysis. Our sample for breathing analysis was reduced to (n = 18), following an improvement in our sensor calibration scripting. (8 female, 13 male; M age = 30 years, SD = 9.18). 15 had limited or no prior VR experience, while six were frequent VR users. Regarding meditation practice, 10 participants engaged frequently (more than twice weekly), and 11 seldom or never practiced meditation. The VR experience was conducted using an Oculus Quest 1 VR headset connected to an Alienware M15 R3 laptop (Intel Core i9, Nvidia GeForce RTX 2070 Super).

4.2 Procedure

Participants first received an overview of the study’s purpose and protocol (Figure 5). We demonstrated the respiratory sensor’s use and placement, and then the initial survey was conducted while we gathered baseline breathing recordings from participants. After familiarizing them with the VR headset, we showed a video on diaphragmatic breathing [29] and allowed practice time. The second breathing recording commenced just before starting the VR game, where audio narration guided users through the experience. Upon completion, participants filled out the post-game surveys, and the final breathing recording was taken. With surveys completed and the respiratory sensor removed, the study concluded with a semi-structured interview.

Figure 5:

Figure 6:

4.3 Data Collection & Analysis

We compiled all data for preliminary analysis, explored survey results, transcribed interviews, and formatted breathing recordings. We gained initial insights during the process, guiding our further data analysis. Below, we describe our data collection and cleaning steps for each data type and further detail our analyses.

4.3.1 Surveys.

Our study used three survey instruments: the Immersive Tendencies Questionnaire (ITQ) [94], the iGroup Presence Questionnaire (IPQ) [33, 72], and the System Usability Scale (SUS) [7]. The SUS was adapted to assess the usability of our VR system and the respiratory sensor. The ITQ assesses individuals’ propensity for VR immersion [94], while the IPQ, comprising 14 questions across three subscales (spatial presence, involvement, and experienced realness), evaluates the user’s sense of presence in VR [47, 72]. Post-experience, participants reported their sense of presence in Stairway to Heaven using the IPQ [33]. We used 7-point Likert scales for all surveys to provide a consistent response format. Hence, we also adapted the SUS, using originally a 5-point Likert scale, to a 7-point Likert scale. The change in scale also aimed to enhance the granularity of user feedback on usability, leveraging the nuanced insights that a wider range of response options can provide. This adjustment aligns with research suggesting the increase of scale points can improve measurement precision [25, 60]. To maintain a maximum score of 100, we use a multiplier of 1.43 to attain final scores.

4.3.2 Breathing data.

We used MATLAB to read the time series data from XDF files, then cleaned, smoothed, and plotted each user’s breathing recordings [46]. These plots visualize the changing force exerted on the respiration sensor, indicating the peaks and valleys of inhales and exhales. To reduce signal noise, we use the Savitzky-Golay Smoothing Filter [59]. We then continued our analysis of breathing frequencies in Python, calculating intervals between peaks in the data and aligning these with the stages of the game design using calibration threshold data and the known number of breaths required at each stage. This allowed for detailed within-subject quantitative and qualitative analysis to explore the game’s impact on the user’s breathing pattern through the VR experience.

For each participant, we made three sets of breathing recordings: before, during, and after the VR session; before and after recordings were used to compare default breathing patterns against those influenced by the VR session. Due to the technical improvement of our calibration scripting method following the trial of our third participant (P3), we based our breathing recording data analysis on the remaining 18 participants.

To visually analyze the data, we plot, inspect, and qualitatively code our observations in the time series data of the VR session (Figure 6 a). To structure our analysis, we divided the VR session over the four periods of the journey. We aggregate the first 45 breaths of Stage One to define the first period (S.1), the ten breaths at the midpoint of the journey (Mid) as the second period, the 45 breaths of Stage Two as the third period (S.2), and the final ten breaths of the training in Stage Three as the fourth period (S.3). We use these four periods of the game to provide a structure for operationalizing user engagement with our artifact. As our design aimed to support and sustain users’ engagement with therapeutic slow breathing, we chose three features to define their engagement: (1) achieving therapeutic breathing (frequencies between 4–10 BPM) [71], (2) achieving slower breathing over time (reducing breathing frequency), and (3) achieving greater consistency over time (reducing the standard deviation of breathing frequency). With this strategy, we graph each player’s breathing pattern in the journey (Figure 6 b).

4.3.3 Interviews.

Participant interviews addressed two key questions: (1) general feedback about the experience, both positive and negative, and (2) suggestions for changes or additions. We transcribed the interviews, aggregating them into a single document for coding. This process helped identify initial categories, subcategories, and specific aspects of the participants’ experiences. Using affinity diagramming, three researchers agreed on emergent themes and sub-themes. We then closely examined participant quotes to understand their interactions with the game and their breath awareness, as well as to gather design feedback. Interview insights complemented our survey and breathing data analyses, contributing to the development of our initial pattern analysis framework.

4.3.4 Data Analysis Consolidation.

We compiled all data (i.e., survey, breathing recordings, and interviews) into an interactive online whiteboard using Miro to examine the data holistically. We created initial player profiles based on demographic data (e.g., meditation frequency, history of VR use, and ITQ) and defined additional variables from interviews and breathing recordings. We organized all data in a table format, adding breathing recording plots, plots of each user’s presence profile from the IPQ survey, and the trend line graphs.

4.3.5 Pattern Analysis.

Using the consolidated data table to begin our pattern analysis, we sorted players by the amount of time spent in the game from shortest to longest. We then qualitatively coded each user’s breathing recording, noting aspects of their experience, such as breathing too shallow to count towards the user’s progression. We first subjectively assessed the engagement level of participants based on all our data: survey results, interview quotes, and the coded time series breathing plots. This analysis led us to categorize one participant, P15, as Not Engaged. P15’s data suggested they merely went through the motions, failing to embrace the mindful self-regulation of slow breathing that our VR experience was designed to promote. P15’s breathing record showed a rapid increase in breathing frequency, indicating muscular manipulation of the sensor. Finding no other indications of participants being Not Engaged, we proceeded with our analysis pipeline to initiate the clustering process.

In our study, we aimed to identify patterns of participant engagement and assess how well their breathing matched the experiment’s goals. To achieve this, we utilize K-means clustering, drawing methods from [39] and [35]. Our time-series breathing data, with inherent noise, required preprocessing to ensure meaningful input for clustering. Feature extraction from time-series data is a detailed endeavor involving various signal processing and analysis techniques, as discussed in [15] and [35]. To streamline this process, we leveraged strategies from [30] to focus our feature extraction approach on using the inherent characteristics of our data and the structured stages of the game’s design. We considered three variables for our case: (1) the average breathing frequency during each stage, (2) the increase or decrease in average breathing frequencies between stages, and (3) the change in the variability (standard deviation) of breathing frequency between stages. Therefore, two of the variables were related to mean values, and one related to the variance of the breathing frequencies.

Our methodology was enhanced by incorporating techniques suggested by [50] and [35], particularly applying statistical methods for feature extraction. We calculated the mean and standard deviation for the aggregated data per stage and participant, which would form our two variables, in addition to participants’ trajectory of average breathing (i.e., decreasing or increasing) calculated by means per stage and taking their subtractions. This technique aligned our data processing with the nuances of Stairway to Heaven’s design, thus effectively revealing the engagement patterns of the study participants.

The analytical pipeline for pattern analysis started with preprocessing the raw data and concluded with cluster aggregation. In between, we follow two feature extraction steps. In the first step, we compute features by determining the mean and standard deviation during different game phases; in the second step, we input these features as described below. We then apply the K-means clustering algorithms to scrutinize patterns of player engagement according to our selected features. Specifically, we employed the mathematical formulation outlined in Appendix A to identify the players’ breathing patterns defined by our three key features of engagement. Each feature produces a value from 0 to 1, indicating the consistency of these patterns throughout the game for each player:

•

Mean Breathing Frequency Below 10 BPM—This feature assesses the regularity of a player’s average breathing rate falling below 10 BPM across all game stages.

•

Reduction in Mean Breathing Frequency Between Stages—This calculates how often a player’s average breathing rate decreases from one game stage to the next.

•

Decrease in Breathing Frequency Variability Across Stages—This feature evaluates the frequency of reduction in the variability (standard deviation) of the player’s breathing rate from stage to stage.

5 Results

Our results analysis considers player experience with Stairway to Heaven using surveys, breathing recordings, and interview data. Following the reporting of these individual data sets, we examine the data for emergent patterns.

5.1 Surveys

SUS scores ranged from 48.57 to 97.14, with an average score of 81.36 (SD = 11.82), indicating the system has good usability. ITQ results from our participants ranged from 53 to 104 (M = 78.05, SD = 13.28). Using the quartiles from ITQ totals, we defined three user groups: low (n = 7), average (n = 9), and high immersive tendencies (n = 5). We defined these groups to assess potential correlations between the ITQ and our other results. No statistically significant correlations were found between ITQ totals and SUS or IPQ measures. We compare the results of the IPQ between users with prior meditation and VR experience. For users with a meditation history (n = 10) and those without (n = 11), Spearman’s rho correlation coefficients showed no statistically significant correlations between the history of meditation and the three presence factors (Involvement: ρ = .142, p = .539; Experienced Realness: ρ = −.183, p = .428; Spatial Presence: ρ = .238, p = .300). For users with a history of VR use (n = 6) and those without (n = 15), Spearman’s rho correlation coefficients showed no statistically significant correlations (Involvement: ρ = .140, p = .546; Experienced Realness: ρ = −.026, p = .910; Spatial Presence: ρ = .175, p = .448). There was no significant correlation between users’ prior experience with meditation or VR and their perceived presence in Stairway to Heaven.

5.2 Breathing Recordings

Breathing records were made before, during, and after the VR experience. Comparing averaged frequencies before to those during the experience, we find breathing frequency was reduced by 56.7% (M = 10.11 BPM, SD = 2.30). This slowing of breath was statistically significant as confirmed by a one-way ANOVA F (1, 38) = 83.527, p < .0001). The duration of the VR experience varied according to the users’ self-regulated breathing pace, averaging 15.7 minutes (SD = 3.94), with the longest and shortest experiences lasting approximately 25 minutes (M = 5.64 BPM, SD = 1.48, 0.094 Hz.) and 10.5 minutes (M = 15.30 BPM, SD = 18.05, 0.255 Hz.) respectively. Qualitative analysis of breathing plots revealed aspects of the users’ experience, such as breaths too shallow for their progression thresholds and changes in breathing frequency (Figure 6 a). We examine the K-means clustering analysis of users in groups of 3 and 4 clusters based on residuals and silhouette scoring [39]. Considering these in our pattern analysis (See 5.4), we find four clusters optimal for understanding the differences between user engagements.

5.3 Interviews

Participant interviews revealed key insights into the usability of Stairway to Heaven, with the design feedback from users exposing tensions emerging from our design strategy. Our analysis of the interview data identified three primary themes: (1) Influence of Users’ Mental Model, (2) Gamification and VR, and (3) Perception of Breath Awareness.

5.3.1 Influence of Users’ Mental Model.

Although we introduced Stairway to Heaven as a mindfulness breath awareness training in VR, participants’ prior experiences shaped their expectations and engagement with the system. This was particularly evident in user associations with meditation, which was occasionally perceived as the primary focus of Stairway to Heaven, rather than as we intended for the mindfulness guide to serve as a secondary support for sustained attention to slow breathing. For instance, P10, who does not regularly meditate, remarked: “I assume that the goal of this experiment was to make the user meditate in a virtual space.” Among our 10 participants with meditation practices, we observed responses suggesting the engagement with Stairway to Heaven required additional effort. These participants needed not only to learn and orient themselves to breathing in the VR but also to reconcile the experience with their established meditation practices. P16 commented: “It was not similar to other meditations I have done.” Similarly, P3 shared “When I’m meditating... I close my eyes, and... [sit] in... Asana pose as you do in yoga. I think breathing exercises are central to any kind of meditation, so it’s pretty much what I was doing through the VR experience, but it was not close to the experience that I usually have in meditation.” Seven other participants also mentioned closing their eyes. P14 stated: “I like to close my eyes when I meditate, so sometimes that happened.”

These sentiments were echoed by others, indicating users felt inclined toward meditation during the VR experience. Furthermore, P20 pointed out the tension between the desire to engage traditionally (e.g., closing eyes) and the need to interact with the VR setting: “I was tempted to close my eyes a couple of times... but I assumed that what I needed to do was keep engaging in the virtual environment.” This tension reveals a challenge participants encountered in reconciling their preconceived notions and experiences of traditional meditation with the interactive elements of our VR design. While nine users reported feeling peaceful and relaxed during the VR experience and slow breathing exercise, they also faced challenges in managing attention between breath awareness and other aspects of the experience. These observations are key to understanding the variations in breathing recordings, highlighting how users’ existing mental frameworks shaped their interaction with Stairway to Heaven.

5.3.2 Gamification and VR.

As with meditation, users’ previous experiences with VR and gaming influenced their orientation to Stairway to Heaven. VR novices appreciated the novelty and relaxation, while more experienced VR users noted the non-traditional nature of the interaction. The idea of relaxing in VR had divergent reception. P17, a non-VR user, shared: “There was not too much to see and to do, just a pretty environment which, together with the easy voice and the music, made it pretty relaxing.” While P3 explained: “As far as the immersiveness of the VR experience in itself was concerned, I think it was pretty good, but... my experience with VR has been more to do with gaming. It is not so relaxing.”

The novel use of a respiratory sensor as input had a learning curve for all users, regardless of their VR familiarity. After the initial adjustment to the sensor and HUD feedback, the progression mechanics, despite their simplicity, were found to be engaging, and likening to an adventure. P4 shared about their learning: “With the breathing patterns… at the start... I was just getting used to breathing with the sensor on and seeing the green bar moving.” While P5 found a sense of adventure and challenge in our design, reporting: “I really liked it, and after the second circle [checkpoint], I was feeling that I’m present; it was feeling good in the virtual environment… When looking at the mountain and I saw so many more [checkpoints], I was like, Woah! What’s happening, and… OK, this is going to be fun.”

While Stairway to Heaven incorporates gamification, it differs from traditional VR games like Beat Saber by focusing solely on breathing for progression. P20’s experience exemplifies how this design choice led to a deep engagement with breathing mechanics, showing a blend of challenge and mindfulness. (P20): “I started seeing it like a game where it [the HUD] would count the numbers and the green line; if my breath didn’t let the green line go all the way to the other ring, then I knew it wasn’t going to count [toward progression], so, then I would actively try to breathe deeper.”

Participants gave mixed feedback on the audiovisual elements of the VR environment. While some enjoyed the 360-degree scenery and found it immersive, others felt distracted or desired more realism and sensory engagement. The balance between immersion and distraction in this work emerged as a highly individualized fine line, with some users desiring more interaction and others more relaxation. Users shared their favorite parts of the virtual world. (P18): “I liked that it changed scenery, although there was scenery I wish I could go back to; I liked the lake... I wanted to see it more. I was looking for it when it went away.” P22 found the checkpoints and landscape design working as we intended to map and motivate their progression: “I didn’t notice until the halfway point that you could see the progressive moments where you have been before; it’s nice because then there is this receding perspective that I could kind of stretch my awareness further out.”

P13 noticed features of the audio feedback and guidance working for them: “I noticed that when the meditation thing happened, like when they started talking, it really comforted me.” P21 further commented: “The meditation was really great, the guided part... it really set you up well to finish on your own because it doesn’t last until the very end, so that was nice because I liked the support, but then I was even more aware, and I felt better to carry on the breathing exercises on my own.” The variety of attentional opportunities and their balance in our design worked better for some than others. For example, P18 found conflict in the audio design: “I felt as though I was a little distracted between the music and the voice because they didn’t always match up... so it kind of took me out of the meditation.”

Participants had a lot to share about improvements they could imagine and desires for expanding the experience. This feedback highlights the importance of usability testing with diverse audiences, particularly in applications creating non-traditional engagements in VR, such as mindfulness and relaxation. P14 imagined: “I don’t know if you could include smells of nature, or even if there was a breeze and you could feel, so you could encompass more senses than just the visual.” P9 shared a similar perspective: “Maybe adding a sense of smell because visually you are there, you feel you are there, with the grass and the bushes there in front of you, it’s kind of weird like you are there, but maybe if you had a sense of smell then maybe it would be more immersive.” Three users also wished for a more realistic VLT, finding the teleportation mechanic disruptive to the continuity of their experience. P8 explained: “I would like to be able to breathe and walk toward my destination rather than getting teleported over there.”

Five participants remarked about the visual feedback in the HUD. P20 noticed that while our design strategy for conditioning user attention to breathing was effective, at times, it also felt overbearing: “I wonder if... that gauge, the green line, that bar to capture the breath moving, I wonder if that wasn’t there... the experience would have been different because there was this thing I had to do, I had to do this breathing thing, which didn’t let me really relax the way I might have otherwise.” Additionally, P19 imagined the HUD improved by adjusting the parameters of the breathing training task: “In the meter that is in there... I would probably want to change that so it puts me in more of a relaxing breath.” Also, the breathing task, as defined by our calibration thresholds, did not always deliver the ideal challenge, and four users reported becoming tired from it or finding it harder towards the end, P5: “Some of the breathing parts, it was a little bit hard to do... to reach the maximum, I had to force it, and I was feeling a little bit competitive to reach the max.”

5.3.3 Perception of Breath Awareness.

Four participants reported changes in breathing habits, focusing on diaphragmatic breathing and bodily sensations. Feedback from the respiratory sensor in VR, along with the physical sensation of wearing the sensor, heightened their somatic awareness. For instance, P4 noted the physicality of the sensor belt enhanced awareness of their breathing pattern: “Having the respiration sensor on, I’m sort of getting somewhat of that feedback from the resistance of the sensor itself on where I am in the breathing pattern: that physical feedback.”

The virtual environment evoked realistic sensations, as described by P18 and P7, who felt as if they experienced an actual breeze. This blend of physical and virtual sensations led participants to focus inwardly, with P13 finding the virtual water’s reflection soothing enough to close their eyes for deeper meditation. (P13): “I liked the reflection on the water; it was very calming, and after a while, when the water was there, actually, I was so calm that I preferred to close my eyes and just listen to the music and what they were talking about... It really calmed me down, and I preferred to close my eyes for a little bit to get into the meditation a bit more.”

However, not all somatic experiences were pleasant. P16 experienced postural discomfort, and P9 and P19 reported feeling tingling. P19 explained they found the breathing becoming more demanding, requiring deeper and more conscious breaths. (P19): “At the end, it got harder to get the sensor to the end... And I think that was because I was relaxing; I was breathing shallower if that makes sense, and I needed to think about it, like: ‘Okay, now you need to exhale all the way so that you can inhale all the way again.” Participant P6, who initially approached the experience as a traditional game, realized the importance of slowing down and relaxing into the experience. (P6): “Initially, I was not paying attention to what the audio was saying because it was trying to slow me down, and I was going for the repetitions, and it got harder and harder. But on the return track from 10 to one, that is when I properly settled in to start listening to the audio cues and started taking breaths slowly, and it was really relaxing in the last part.”

Five participants mentioned consciously adjusting their breathing style, with P3, for example, making a deliberate effort to shift from chest breathing to abdominal breathing. This shift illustrates the training’s impact on participants, prompting them to focus on and modify their breathing patterns. (P3): “My natural tendency is to have the chest rise and fall rather than breathing from the abdomen, so again, that was something I was consciously aware not to do.” These insights from participants underline the effectiveness of the VR experience in modifying breathing habits and fostering a deeper connection with one’s body. However, they also highlight the need for careful balance in design to accommodate varying experiences and reactions to the virtual environment and breathing training.

Figure 7:

5.4 Pattern Analysis

K-means clustering analysis was utilized to segment players into four distinct groups based on their engagement with our artifact. The silhouette score was instrumental in identifying the optimal number of clusters for the participants[35]. We have labeled these clusters as follows: (1) Progressive Breathers, (2) Optimal Breathers, (3) Developing Breathers, and (4) Emerging Breathers. By plotting the average trend lines for each cluster, we consider each group and its members to gain insight into the dynamics of user experience and engagement (Figure 7).

5.4.1 Cluster 1, Progressive Breathers.

The breathing trends of this group (n = 5) show an initial phase of slow breathing below 10 BPM, with reduced variance in the first half of the game. However, as the journey progresses, their breathing frequency increases above 10 BPM, accompanied by greater variance. This pattern initially appears contrary to our goal of promoting slow breathing. Yet, a detailed look at individual records suggests a more complex scenario. The increased breathing rate towards the end reflects not just mastery of diaphragmatic breathing but also heightened engagement and excitement as participants near the game’s conclusion. These findings highlight the multifaceted nature of player interaction with the experience. While these users demonstrate learning and interest, the shift in breathing patterns may indicate the need for more nuanced engagement strategies supporting and engaging users’ focus on therapeutic slow breathing throughout the experience.

5.4.2 Cluster 2, Optimal Breathers.

In this cluster (n = 7), users began their VR journey with slow breathing at therapeutic levels and progressively slowed their breaths as they advanced in the game. The collective trend line for this cluster shows not only a consistent slowing of breathing rates but also a notable decrease in breathing frequency variability by the end. This pattern exemplifies the successful realization of our design goal: fostering users’ ability to self-regulate therapeutic slow breathing over an extended period.

An individual analysis of participants within this cluster reveals unique breathing patterns, yet all align with the overarching trend of effective engagement with the game’s objectives. A prime example is P13, whose breathing pattern we observe in Figure 6 b. P13 begins the session above 10 BPM but quickly adapts to the system’s requirements. Their increased breathing variability in the latter half of the session, as reflected in the standard deviation of their breathing frequencies, can be linked to specific moments in their journey. For instance, at key timestamps (Figure 6 a, minute 8:45 and 10:00), P13’s breathing did not meet the inhalation threshold for progression. This deviation aligns with P13’s interview insights (see Section 5.3.1), where they mentioned closing their eyes to immerse more deeply in the mindfulness audio and bodily sensations. Such behavior from P13 indicates learning and adaptation but also an exploratory and successful engagement with the overall goal of maintaining slow therapeutic breathing.

5.4.3 Cluster 3, Developing Breathers.

These participants, (n = 3), began their journey above 10 BPM and remained unchanged in their frequency and variance until the second half of the game. From the mid-point onward, these users then begin to make steady progress, slowing their breathing while improving its regularity over time. By the end of the experience, these users arrive at the therapeutic breathing threshold. An example user from this group, P6, stated that they had initially treated the experience as a traditional game but, in the second half, came to understand that the experience was not about speeding through or materializing points but the opposite, slowing down to achieve mindfulness of breathing and materialize a state of calm in the body and mind. For the learning needs of users in this group, additional levels or multiple engagements may be beneficial.

5.4.4 Cluster 4, Emerging Breathers.

Players in this category (n = 2) exhibit breathing behaviors somewhat similar to our Developing Breathers, making partial gains toward slow therapeutic breathing but without achieving this goal. While this group does improve the regularity of their breathing over time, their breathing frequency increases rather than decreases towards the end of the game. As with our Progressive Breathers, there are nuanced reasons for this. Examining the qualitative data of these two individuals, P10 and P20 both shared particular challenges in the game. For example, during the interview, P20 stated that they experienced tension between the designed elements we included to support their focus on breathing. They explained that their interest in embracing meditative and relaxing aspects of our design seemed at odds with the breath-to-progress requirement (see P20 as quoted in Section 5.3.1). Each of these users also felt that their calibration at the start of the game could have been improved, and while the method was adequate to support the successful completion of the experience, improved calibration would likely have better supported these users’ achieving deeper engagement with Stairway to Heaven.

6 Discussion

We explored how gamified VR like Stairway to Heaven supports mindful breath awareness. Our approach proved effective, and our analysis provided insight into user experiences with the artifact, revealing breathing trends and user engagements that show promise for similar future endeavors. Compared to prior gamified VR, our artifact contributes the unique integration of actionable gamification [14] using principles of empowerment and achievement, and VR for mindfulness using three distinct elements: (1) self-regulation of slow breathing, (2) breath-driven teleportation, and (3) guided mindfulness. Next, we consider the implications of our work for gamified VR and breath awareness with biofeedback-driven interactions while outlining current limitations and avenues for future work.

6.1 Designing for Breath Awareness With Gamified VR

Collectively, the findings of this study highlight how gamified VR environments can effectively foster mindfulness, relaxation, and breath awareness. Compared to prior gamified VR outlined in the related work [78, 87, 92], we proposed a more “minimalistic” approach to game design, favoring a focus on breathing and mindful attention while keeping users engaged with simple in-game goals—follow the audio guide, breathe with proper intensity and frequency to teleport through the VR environment, and reach a campfire by completing the virtual journey. Corroborated by the cluster analysis and qualitative insights, our approach effectively fostered self-regulated, deep breathing while producing an engaging in-game user experience. However, further research is needed to establish whether our approach can or will produce the same results over a long period of time. Despite this, our work shows that specific goals can be amplified in the context of gamified VR, depending on what elements of the design one wants to prioritize (e.g., engagement vs meditation). While games and mindful (or meditative) practices may seem “divergent” from each other [49], we have demonstrated how they can be effectively complemented by strategically crafting a balance between in-game engagement and the objectives of mindful attention to breathing. For that, we encourage future work to (1) continue experimenting with the design of gamified VR for health-related goals and (2) systematically explore the design space of gamified VR to identify best practices for balancing in-game engagement with therapeutic goals.

Through interview findings, we see how further reflecting on gamified VR design could improve user engagement. For instance, P13 expressed a desire to tune in more to the sensations of their body and focus more deeply on the mindfulness audio guide. P4 noted that they could have used more time to become familiar with the virtual environment and have more time to acquire the mechanics of the breathing sensor. Further, P20 and P19 both stated they would have preferred more customization and less objective breathing tasks to find greater relaxation in the experience.

In addition, challenges emerged from the unique dynamics of each player’s interests in the game and their breathing style and were influenced by their backgrounds in VR and meditation. Interestingly, those with prior experience in these areas did not always find it easier to engage with our VR environment. This suggests a potential advantage for those with a ‘beginner’s mind,’ who lacked preconceived notions about VR or mindfulness and could engage openly with these aspects of the experience. These findings highlight the effects of the users’ mental model in conditioning their interaction with the VR system. A practical insight from this would be to design time into the start of the experience for setting the stage, creating common ground, and explicitly contextualizing the objectives of the interaction uniformly for all users. Regardless of prior experience, remaining attentive and engaged with slow diaphragmatic breathing for 10–20 minutes is a challenge. Our goal with the functions of our design was to support users in remaining attentive to their breathing, but participants had their own goals and interests. While attention to breathing was our principal aim, at times, users expressed more interest in exploring the virtual world or deeply relaxing and focusing on their internal experience, consistent with [62, 64].

6.2 Implications for Breath Awareness

Stairway to Heaven functions as an interactive system that encourages slow breathing, uniquely emphasizing user initiative rather than prescribing a specific pace. This approach highlights our design’s reliance on user engagement to achieve therapeutic outcomes, distinguishing it from traditional biofeedback applications developed for clinical interventions, which typically have a prescribed frequency or series of frequencies users need to adhere to, as replicated in the work of BreathCoach [87]. We deliberately crafted our design to support the autonomy of users’ self-regulation and inspire their mindfulness of slow breathing. Interview feedback suggested even greater autonomy was desired from users. Such interview responses indicate more adaptable designs that can better meet diverse user preferences and needs are warranted. This insight raises further questions for HCI about achieving such flexibility in design and effectively translating the learning potential from VR experiences into the real world.

While the primary goals of our work aimed to create our artifact and assess the functionality and appeal of our design, further investigation will be needed to examine the potential changes and learning potential for a user’s breathing and breath awareness that may develop following repeated engagement. The longitudinal work of Rockstroh et al. [68] provides a foundation for exploring this idea further, and Johnson et al.’s [36] work, teaching breathing regulation to develop muscle memory skills useful to welding, suggests potential avenues for other real-life applications for breathing’s related development of muscular control. Our reflections on interview feedback suggest that building additional levels in the virtual world would aid the examination of learning effects on user engagement and offer additional opportunities for repeated use, more varied breathing training, and expanded studies on the influence of design elements on mindful breath awareness.

6.3 The Role of Biofeedback

In Stairway to Heaven, we made the respiratory biofeedback central, displaying it prominently in the HUD and making awareness of it essential for progression. However, our user data showed that while we made breathing the principal focus of our design, users also gravitated towards other aspects like relaxation and the mindfulness audio guide, challenging our initial conception of biofeedback’s role. Users had difficulty remaining focused on their breathing, and some were more interested in doing so than others, but tensions emerged for users who, for example, also wanted to close their eyes and focus more deeply on the mindfulness audio guide. Insight from this work about the challenges players faced can be further studied in designs that, as we have done here with breathing input, attempt to isolate elements of complex interactive systems to evaluate the nature of their dynamics as independently as possible.

We designed Stairway to Heaven for users to engage with respiratory biofeedback mechanistically and for achieving progression in the game; however, links between user physiology and gameplay can do more to personalize the potential of such mind-body related connections for therapies and training. For example, using biofeedback to both monitor and direct a user’s attention would allow a design to engage with the concept presented by Choo and May [13], who suggest that distraction could be used as a tool in more advanced meditation training. In Stairway to Heaven, users reported that moving from place to place could be distracting to them and also that, had they not been moving around, they would likely have become bored. Integrating biofeedback in design, even in simple direct linkages we constructed, we can see the potential power of respiration physiology in gameplay to direct and support users in the modulation and self-regulation of their breathing. Further, we have shown that this can be accomplished by creating a designed context for the desired behavior that implicitly encourages the desired effect while providing latitude for users to self-orient to the goal of therapeutic slow breathing. Reflecting on our results through the lens of player engagement with our artifact, we can better understand and appreciate how design and HCI can support users in the mindful cultivation of self-awareness [4], self-efficacy [93], and self-transformation [2, 40, 67].

Figure 8:

7 Limitations and Future Work

Our study presents various limitations. First, while we accommodated users’ breathing through a respirator sensor via calibration, the calibration system had technical limitations. Thanks to the trials of P2 and P3, we tweaked the calibration algorithm and fixed it for the later study sessions. Notably, the SUS scores for these users (P2 = 48.6, P3 = 61.4) were the two lowest in our study and likely linked to the inadequacies of our initial calibration script.

We found that prior meditation experience may have hindered the experience with Stairway to Heaven for users who were already practicing meditating. However, our results are limited in that (1) they may be partly contingent on our game design and (2) are based on a small sample population and cannot be generalized. Future studies may want to explore the impact of pre-existing mental models on users’ perception of a novel approach (e.g., [85]), like gamified VR, to produce more conclusive results. Notably, our study was limited by the brevity of the designed gamified VR experience, which lasted between a minimum of 10 minutes and a maximum of 25 minutes. Future studies should longitudinally apply our approach (e.g., [17]) and observe the long-term effects, benefits, and drawbacks of user exposure to similar gamified VR approaches.

We focused on a single input mechanic, but our user feedback suggests opportunities to explore more interactive elements to enrich user immersion and engagement. Additionally, monitoring other physiological measurements (e.g., blood pressure, heart rate, and heart rate variability) would afford greater insight into the therapeutic potential of self-regulating slow breathing (e.g., see [42, 51, 79]). Future design can learn from our creation and examination of Stairway to Heaven and consider more advanced interactions and sensor engineering to engage users and effectively monitor and guide physiological changes, respectively. We opted to use VR for its immersive affordances and deliberately designed Stairway to Heaven as a VR experience. While VR opens up many future opportunities, such as eye-tracking, an open question remains: what outcomes will be achieved through other interactive media with the same single biofeedback input mechanic, such as a mobile app or a 2D software application? Based on current work that compares VR with other interactive media [11, 84], we expect that VR will indeed be considered more immersive by its users. Ultimately, however, design is critical (see [37]), and we encourage future designs to consider its medium carefully. For that, future efforts may consider (1) applying our approach through a different medium and extending our results or (2) performing comparative assessments of gamified VR vis-à-vis other media [56]. Finally, future work may want to experiment with a more dynamic gamified VR design, which is capable of adjusting to individual user needs and potentially enhancing the effectiveness of VR (e.g., adaptive VR [34, 96]).

8 Conclusion

We contributed Stairway to Heaven, a gamified VR artifact that leverages actionable gamification in the form of teleportation mechanics that motivate and meter user progression through the virtual world. We employ principles of empowerment and achievement by engaging users with respiratory-driven biofeedback to support and train their attention to the mindful self-regulation of diaphragmatic breathing. Through a mixed-method study comprising breathing pattern analysis, survey, and interview inquiries, our proposed approach emerged as engaging and effective at helping users reach therapeutic breathing frequencies. Our approach exemplifies how actionable gamification, which intrinsically motivates users to engage with gamified experiences beyond points, badges, and leaderboards, can be effectively combined with immersive VR to support mindful interactions and have potentially beneficial effects on health and well-being. Our approach demonstrates the potential for gamification and VR to further advance technologically mediated therapeutic applications in HCI.

Acknowledgments

We would like to thank Bardiya Akhbari and Soomin Jeon from the Massachusetts General Hospital for their assistance with digital signal processing. Furthermore, we would like to thank Dr. Darshan Mehta from the Benson-Henry Institute of Mind-Body Medicine for providing inspiration and guidance on mindfulness resiliency training and Dr. Eva Selhub for the audio guide.

A Appendix

A.1 Mathematical Formulation of Features

In these formulations, each feature for a player p yields a value between 0 and 1, representing the normalized frequency of the respective condition being met across the stages. For each player p:

Feature 1 - Mean Breathing Frequency Below Threshold (\(M\_{\text{below}\_\text{10}}\)):

Let M_{p, s} be the mean breathing frequency of player p in stage s.

\[M_{\text{below}\_\text{10}_p} = \frac{\sum _{s=1}^{4} \unicode{x1D7D9}\lbrace M_{p,s} < 10\rbrace }{4}\]

Here, \(\unicode{x1D7D9}\lbrace.\rbrace\) is the indicator function that returns 1 if the condition inside is true, else 0.

Feature 2 - Decrease in Mean Breathing Frequency Across Stages (\(M\_{\text{decrease}}\)):

\[M_{\text{decrease}_p} = \frac{\sum _{s=1}^{3} \unicode{x1D7D9}\lbrace M_{p,s} > M_{p,s+1}\rbrace }{3}\]

Feature 3 - Decrease in Standard Deviation of Breathing Frequency Across Stages (\(SD\_{\text{decrease}}\)):

Let SD_{p, s} be the standard deviation of the breathing frequency of player p in stage s.

\[SD_{\text{decrease}_p} = \frac{\sum _{s=1}^{3} \unicode{x1D7D9}\lbrace SD_{p,s} > SD_{p,s+1}\rbrace }{3}\]

Footnote

https://www.drselhub.com/product/finding-stillness/

Supplemental Material

MP4 File - Video Preview

Video Preview

Transcript for: Video Preview

MP4 File - Video Presentation

Video Presentation

Transcript for: Video Presentation

References

[1]

Joanna J Arch and Michelle G Craske. 2006. Mechanisms of mindfulness: Emotion regulation following a focused breathing induction. Behaviour research and therapy 44, 12 (2006), 1849–1858.

Abstract

1 Introduction

2 Breath Awareness and Mindfulness

2.1 VR for Breath Awareness and Mindfulness

2.2 Gamification and VR for Breath Awareness and Mindfulness

3 Stairway to Heaven

3.1 Design Rationale and Articulation

3.2 Virtual World and Game Mechanics Design

3.3 Gameplay and Set Up

4 Study Design

4.1 Participants

4.2 Procedure

4.3 Data Collection & Analysis

4.3.1 Surveys.

4.3.2 Breathing data.

4.3.3 Interviews.

4.3.4 Data Analysis Consolidation.

4.3.5 Pattern Analysis.

5 Results

5.1 Surveys

5.2 Breathing Recordings

5.3 Interviews

5.3.1 Influence of Users’ Mental Model.

5.3.2 Gamification and VR.

5.3.3 Perception of Breath Awareness.

5.4 Pattern Analysis

5.4.1 Cluster 1, Progressive Breathers.

5.4.2 Cluster 2, Optimal Breathers.

5.4.3 Cluster 3, Developing Breathers.

5.4.4 Cluster 4, Emerging Breathers.

6 Discussion

6.1 Designing for Breath Awareness With Gamified VR

6.2 Implications for Breath Awareness

6.3 The Role of Biofeedback

7 Limitations and Future Work

8 Conclusion

Acknowledgments

A Appendix

A.1 Mathematical Formulation of Features

Feature 1 - Mean Breathing Frequency Below Threshold (\(M\_{\text{below}\_\text{10}}\)):

Feature 2 - Decrease in Mean Breathing Frequency Across Stages (\(M\_{\text{decrease}}\)):

Feature 3 - Decrease in Standard Deviation of Breathing Frequency Across Stages (\(SD\_{\text{decrease}}\)):

Footnote

Supplemental Material

References

Cited By

Index Terms

Recommendations

Life Tree: Understanding the Design of Breathing Exercise Games

Attending to Breath: Exploring How the Cues in a Virtual Environment Guide the Attention to Breath and Shape the Quality of Experience to Support Mindfulness

Fostering Interactive Mindfulness Experiences in VR

Comments

Information

Published In

Sponsors

Publisher

Publication History

Check for updates

Author Tags

Qualifiers

Conference

Acceptance Rates

Upcoming Conference

Contributors

Other Metrics

Bibliometrics

Article Metrics

Other Metrics

Citations

Cited By

View options

PDF

eReader

HTML Format

Login options

Full Access

Figures

Other

Share

Share this Publication link