Keywords

1 Introduction

In Brazil Therapeutic Toy (TT) is a tool used by health professionals with hospitalized children. In general, the Therapeutic Toy is applied in the hospital environment in order to explain to the child the procedure he/she will undergo and try to prepare him/her for it, as a way to minimize anxiety after the procedure or to contribute to the improvement of the medical treatment [4, 15].

This source aims to develop the reliability between the child and the health professional by stimulating recovery and performing as a physical and psychological exercise. The professional usually uses physical materials, such as dolls and hospital accessories, for the child to expose his/her feelings.

However, in addition to physical materials, there is a possibility of exploring Virtual Reality (VR) and Augmented Reality (AR) systems to develop a therapeutic toy in a digital and interactive way, here named Digital Interactive Therapeutic Toy (DITT), that can be applied in different contexts in the health field in order to assist hospitalized children. The present work is part of a bigger context that focuses on establishing a reference model to develop the Digital Interactive Therapeutic Toy.

The main goal of this paper is to present results of a Systematic Review (SR), based on the specialized literature, which seeks to identify if Three-Dimensional Virtual Environments (3D VEs) have been employed with a focus on assisting the hospitalized child and which interaction strategies have been applied. In this context, interaction strategies are considered games, collaborations, avatars and virtual humans, intelligent agents and natural interfaces. The human factors that may influence the children’s emotional and social aspects by exploring such environments are also investigated in the SR, given that interaction is composed of human factors.

In addition to this introduction, this article is structured into the following sections: Sect. 2 describes the methodology used in this research, Sect. 3 presents the state of the art with the results of the Systematic Review, and Sect. 4 discusses the results found, including the preliminary suggestion of a Reference Model for conceiving the Digital Interactive Therapeutic Toy. Finally, Sect. 5 details the final considerations of this research.

2 Methodology

The investigation methodology applied in this study was the process of a Systematic Review of the literature that was based on a searching strings combination, varying between database IEEE, ACM, ISI Web of Knowledge, Springer and Google Scholar by trying to answer the following research questions:

  1. (1)

    What are the interaction strategies that have been applied in 3D VEs to assist the hospitalized children?

  2. (2)

    What are the human factors that influence the emotional and social aspects of hospitalized children and how they can be exploited with the use of the conventional therapeutic toy or therapeutic toy supported by 3D VEs?

In the preliminary selection phase, the title and abstract of each article were analyzed. The works included and excluded by the Systematic Review in the final selection phase were defined according to the inclusion and exclusion criteria established in the protocol of the Systematic Review, which consisted of analyzing the full text of the articles included in the preliminary selection. After the final selection, the extraction results followed.

Initially, publications were sought from the last five years, aiming to identify new approaches. However, some previous publications, which were considered relevant, were included in the Systematic Review.

Figure 1 presents a flowchart of the different phases arising from the Systematic Review, based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [9]. This flowchart aims to present a quantitative SR process, from the initial identification of studies through database search to the final selection of articles included in the data analysis.

Fig. 1.
figure 1

Distribution of studies included and excluded from Systematic Review

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As observed in Fig. 1, 54 studies were found by applying search strings. In the preliminary selection phase, 24 articles were selected, out of which only 13 articles were included in the final SR selection. These articles sought to answer the research questions posed in the SR protocol.

The following attributes were selected from each study: application environment, interaction strategies and explored human factors. Subsequently, a relational analysis was conducted of the main interaction strategies and the identified human factors.

Considering the results obtained from the Systematic Review, a foundation was proposed for a preliminary version of the Reference Model for the development of the Digital Interactive Therapeutic Toy, which is presented in Sect. 4.

3 Results of the Systematic Review

The following paragraphs present a summary of the 13 articles that were analyzed. Each one of the articles was individually analyzed. It should be highlighted that, out of the 13 articles included in the final SR selection, three articles refer to the investigation of Therapeutic Toy application using physical objects, such as dolls and hospital accessories, in order to simulate real hospital procedure situations. These studies symbolize the first steps of the study, and also render a deeper understanding of the context of the investigation, since these aspects translate the motivation to develop Digital Interactive Therapeutic Toy.

In this perspective, a study by Kiche and Almeida [7] investigated the use of Therapeutic Toy before the process of changing surgical dressings in order to compare pain reactions uttered by children during the dressing change, both before and after emotional preparation with Therapeutic Toy. The authors observed that, based on the experiments that were conducted, employing TT before the hospital procedure significantly reduced the children’s level of pain and muscle tension.

Another research by Fontes et al. [4] defends the application of Therapeutic Toy to relieve tension in children due to hospitalization. By employing dramatization, healthcare professionals prepared the child for a surgical procedure. The authors show evidence that playing interactively causes hospitalized children to interact with the hospital environment and express their feelings and emotions, and it also provides resources for humanized assistance.

The study by Silva et al. [12] analyzed a specific health field database published from 1998 to 2006 and verified that Therapeutic Toy has been applied in Brazil in different forms, including the waiting room of a children’s outpatient department as well as in the assistance to children with cancer. The authors highlight that the hospital routine can incorporate the advantages of playing as a therapeutic resource since it allows the child to express their feelings and understand the procedures that are about to be conducted and it may lead to a closer bond between the child and the healthcare team.

Considering the studies above, we can say that the application of Therapeutic Toy has been widely investigated in the health field for many years with evidence that interactive play can, in addition to the aforementioned aspects, build a feeling of trust between the hospitalized child and the healthcare professional, stimulate recovery and act as physical and psychological exercise.

The remaining 10 articles included in the final SR seek to answer research questions and apply different interaction strategies in order to explore the physical and emotional aspects of children. Section 3.1 presents a summary of the article analysis.

3.1 3D VEs Applied as Therapeutic Toy

The study by Tarrin, Petit and Chêne [14] proposes the development of 3D network applications with the aim of improving the quality of life in hospitalized children who need to be isolated in sterilized rooms. Although this research was published more than five years ago, the proposal is still relevant to our research. The applications are built in a multimodal platform, which includes networked 3D graphics, sound and forced feedback, whose main aim is to provide physical interaction between children and other people who are outside their room, using tactile senses and thus offering entertainment to the hospitalized child. Another aim of the research is to elaborate a methodology of haptic design in which users are involved in the process of designing. The researchers suggest using 3D network applications with game-based 3D VEs. The idea is innovating; however, we did not find publications that show experiments conducted with hospitalized children.

In this context, Chan et al. [3] present a study that applies a game-based 3D VE, aiming to reduce pain during surgical dressing changes in children who suffered burns. The VE scenario occurs in an ice cream factory because the cold sensation may suggest pain relief considering the experience of having been burned [3] apud [16]. With the VR system intervention, even when children were not completely immersed in the game during their dressing change, their feelings and behavior were more controlled and manageable. Thus, results suggest that 3D VE can be useful in relieving pain and anxiety in anticipation associated with pediatric care for burns. Nonetheless, according to the authors, further studies are required with larger trials. Furthermore, when children were recruited for the study, they were already in the third or fifth round of dressing change and had likely developed fear in anticipation.

In a study by Bickmore, Pfeifer and Jack [2], the authors developed a VE with “Virtual Humans” in order to represent nurses in the hospital environment. The purpose of the research is to remove communication barriers between the health professional and the children. Thus, children talk to virtual nurses about many hospital situations, thus developing a communication ability. In addition, the child can interact with the nurse at any moment, thus minimizing the sensation of abandonment, considering that in low-income hospitals there is a shortage of healthcare professionals. The experiments conducted produced results that show “Virtual Humans” can contribute to communication ability and aid in the therapeutic treatment of hospitalized children.

Research developed by Schmitt et al. [13] investigates the effects of immersive Virtual Reality as an analgesic technique to help treat children who suffered burns. Through game-based SnowWorld immersive VE, the child, equipped with Oculus Rift, uses the mouse or keyboard to throw snowballs at penguins, igloos, mammoths, snowmen and other animals, entities or objects that remind them of very cold places. Experiments with 54 hospitalized children and teenagers aged six to nineteen, during five days, were monitored by a therapy specialist. The results suggest that immersive Virtual Reality is a non-pharmacologic technique that is effective to relieve pain in children with burns and minimize the need for strong medication, in addition to improving their mood.

In the study presented by Akabane et al. [1], the authors developed the collaborative game-based 3D VE “Puchi Planet”. The environment simulates a “trip” around the world. In the VE, the child can be a photographer or a pilot, in addition to storing whichever data is considered relevant, such as the most interesting places visited. When the child remains hospitalized for long periods of time, there is a tendency towards reducing communication which, many times, restricts interaction to family members only. Furthermore, the child stops discovering new places, which can discourage curiosity and knowledge acquisition. This way, “Puchi Planet” seeks to stimulate the children’s interaction with other people through a collaborative environment, besides allowing the child to explore new places.

González, Collazos and González [5] highlight that children who are hospitalized for long periods of time are susceptible to developing stress and anxiety caused by the discomfort resulting from treating the illness, fear of medical procedures, among other factors. Thus, a recommended solution to compensate the situation would be promoting activities with games and/or therapeutic toys. In this context, the authors developed a collaborative game as an alternative to interaction and entertainment. The game aims to create bonding activities with children who are constantly in hospital, as well as bring them closer to family members and colleagues who used to be part of their lives. In the game, the child needs to undergo individual and collective stages, in addition to accomplishing cooperative missions. Experiments were conducted with children in a hospital context and the results were generally satisfactory. In the negative side, factors of apprehension and/or frustration were found in the first moments of the game, but they were overcome by participants.

A study by Pykhtine et al. [10] investigates play therapy, which deals with a therapeutic approach currently used with children. Considering that digital technology is now a big part of children’s lives, the authors state that game and Virtual Reality applications have succeeded when employed in psychotherapy for treating a wide range of anxiety, panic disorders and phobias. Thus, as part of a user-centered design process, researchers monitored, throughout one year, the application of non-directive therapeutic play with children. Based on this experience, the authors propose a set of design requisites to develop digital technologies that seek to act as toys within the play therapy context. In order to do so, the authors developed the Magic Land prototype based on the requisites raised. The first results were positive.

Tranquada, Chen and Chisik [15] present the development of a game-based VE called “Hospital Hero”. The aim of the VE is to help the children deal with stress, anxiety and fear of visiting emergency rooms, by becoming familiar with the environment, tools and equipment, medical team, patients and medical procedures, thus rendering the experience less traumatic. Furthermore, VE allows the child to meet other hospitalized children in similar situations. Hospital Hero is a game that helps patients; for instance, in a situation in which patients who are lost and are supposed to collect hospital tools and supplies in a maize that simulates hospital hallways. Although the game has not yet been formally employed in a hospital, the prototype was tested on a tablet with university students in order to verify usability problems and interface design. The prototype was also tested in primary school children to gather preliminary results and evaluate the experimental project.

The study by Huerga, Lade and Mueller [6] proposes a game-based 3D VE that, along with the physical environment, involves physical play and stimulates the child’s imagination. The system is divided into three stages: i) corporal games that occur in real physical spaces, where the child plays with a puppet that simulates an animal, ii) virtual games, in which the child explores body movements by means of a Kinect device using a 3D VE; and iii) corporal-virtual games, in which both former steps are combined in a 3D VE controlled by the child’s glove and connected by movement sensors. The proposal of the spatial-corporal design aims to reformulate the corporal perception of the hospitalized child in order to improve self-confidence. Authors declare that the results obtained with children were positive and that work can help designers who display interest in developing digital play for sick children.

Lastly, a 3D imagery therapy game design, which explores image psychotherapy, is proposed by Sajjad et al. [11]. In this context, the 3Dimensional Graphical Imagery Therapy (3D GIT) meant for brain tumor children seeks to avoid psychological diseases that can be accentuated by anxiety, fear, anger and perception of inferiority. The theme of the game explores the child’s “battle” against the disease, which in this case is cancer, using guns (white blood cells) to attempt to vanquish the enemy (brain tumor). Each dead enemy in the game increases the player’s “lifespan”. As the phases go by, the child finds some fruit and medication, which help the child improve his/her life condition. It is worth highlighting that enemies can vary in type, such as viruses and bacteria.

Experimental tests with users were conducted in three hospitals, analyzing different behaviors of a cancer patient, before and after applying the therapy with the proposed game design. The results showed significant improvement in behavior of children with brain tumors, especially decreased anger and anxiety and increased self-confidence. Therefore, the authors state that the proposed game design can be effective.

4 Discussion

Considering the results of the Systematic Review, we show how academic literature portrays the conception of the 3D VE applied to assist hospitalized children in different contexts. The main resources of interaction identified in the included studies are presented in Fig. 2, which answers to the first research question - 1) What are the interaction strategies that have been applied in 3D VEs to assist hospitalized children?

Fig. 2.
figure 2

Distribution of interaction strategies found in 3D VEs

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Figure 2 shows a percentage of the 13 studies according to interaction strategies. There is evidently large interest in games, since 90 % of studies conceive 3D VEs based on games. This interest can be related to the fact that games favor multiple interactions and stimulate participants to explore their limitations in a pro-active and exploratory manner.

Regarding the second question of the research – “2) What are the human factors that influence the emotional and social aspects of hospitalized children and how can they be explored with the use of the conventional therapeutic toy or therapeutic toy supported by 3D VEs?”, literature shows that:

  • There are many human factors explored in 3D VEs conceived in order to assist hospitalized children: agitation, anxiety, fear, feelings of isolation, learning deficit, pain, inferiority complex and stress. These factors represent negative psychological aspects of the child and are generally triggered by disease and hospitalization. Other human factors can be stimulated with the application of 3D VEs and were identified in the SR, such as: curiosity, confidence and familiarity with the healthcare team.

  • In order to avoid maintaining a linearity of events, the content addressed in 3D VEs conceived to assist hospitalized children relate the scenario and interaction strategies with human factors that are meant to be explored in the child.

  • Initiatives of conception of 3D VEs are applied in specific situations, seeking to explore communication, creativity, socializing, entertainment, self-confidence, the reduction of pain or trauma during a medical procedure, exploring unknown places or as a stimulus to learning.

  • The studies seek to maintain the focus of the child away from characteristics that can revert the positive evolution of medical treatment, considering that distress caused by the hospital environment, especially in cases of long periods of stay, can be harmful to the child, leading to psychological problems such as depression, anxiety, learning disorders, among others.

From the discussions held by the results of the systematic review it is possible to relate the most favorable interaction techniques for each type of human factor identified as limitations and characteristics of hospitalized children.

Thus, it should be highlighted that the results of the Systematic Review allowed researchers to formulate hypotheses from interaction strategies and human factors identified and to specify a preliminary Reference Model for the development of Digital Interactive Therapeutic Toy, as is illustrated by Fig. 3, which presents the components of the model.

Fig. 3.
figure 3

Suggestion of preliminary reference model for the conception of digital interactive therapeutic toy.

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The preliminary Reference Model includes Human Factors and the Interaction Strategies identified in SR, the Development Requirements and Technical Support. Note that the proposal is to develop Digital Interactive Therapeutic Toy that can be executed in mobile devices and the data should be accessed and sent to cloud storage.

It should be noted that the target audience includes hospitalized children, both literate and illiterate, as foresees the component Target Audience illustrated in Fig. 3. Regarding the component Technical Support, the model suggests an area of FAQ (frequently asked questions), Know Issues and Know-how, described below:

  • FAQ – seeks to help users by displaying the most common doubts concerning situations of constant difficulties encountered by the user when employing the 3D VE.

  • Known Issues – problems identified by users and reported for being considered in the next 3D VE update. Includes a contact area between the user and the developer.

  • Know-how – destined to clarify different situations, including tutorials and tips that users can apply to improve their experience in using the 3D VE.

5 Final Considerations

The concept of 3D VEs, especially game-based 3D VEs, has been a research topic in the context of hospitalized children, as can be observed in the SR results. This interest is linked to the advances of technology and digital accessibility in different age ranges and social classes.

The foundation of the scientific research serves as an incentive to the development of Therapeutic Toys, in digital format, in order to aid in the treatment of hospitalized children, with a focus on reducing distress developed by these children, learning disabilities, and lack of communication between patient and health professional.

In this sense, the study of human factors that influence the behavior of the children who will use the toys is crucial. It is up to researchers and developers of these artifacts to create strategies for considering these factors in the design of the applications. One of the challenges of these research studies is recording and measuring user behavior and how feelings are expressed, such as the need for choosing appropriate methods, the complexity of treatments which patients undergo, and the subjectivity concerning the human being.

Research studies with this approach, as the HCI field mandates, require an interdisciplinary development, which should involve, in addition to specialists in technology, therapists, psychologists, pedagogues, medical doctors, among others professionals in related fields.

Regarding the model, this preliminary version offers useful elements to projectors who intend to develop Digital Interactive Therapeutic Toy. The elements of the model consider human factors and interaction strategies that are relevant to the audience being targeted.

Finally, as future research, we suggest investigating methodologies regarding the development of Digital Interactive Therapeutic Toy that can allow the inclusion of users in conceiving tests and solutions, considering human factors. One of these include participatory design [8], which allows an interdisciplinary treatment of these matters. Another line of investigation concerns methods and parameters of usability assessment and knowledge acquisition in 3D VEs that develop the role of a Therapeutic Toy.