Effect of augmented reality books in salivary cortisol levels in hospitalized pediatric patients: A randomized cross-over trial

https://doi.org/10.1016/j.ijmedinf.2021.104404Get rights and content

Highlights

  • Hospitalization induces stress in children affecting their recovery and wellbeing.

  • Augmented reality technology is effective in some psychological disorders.

  • Books with augmented reality lower cortisol levels in hospitalized children.

  • The effect was no greater than reading a standard book.

Abstract

Objective

This study sought to assess the effect of reading augmented reality (AR) books on salivary cortisol levels in hospitalized pediatric patients compared to reading a standard children’s book.

Methods

This was a randomized, two-period, cross-over trial in hospitalized children aged 7–11 years. AR books currently in the market were used as intervention. Complete block randomization was used to randomize the order of the intervention. Children allocated to the ‘AR-first’ group received the book, a tablet and were left to interact independently with the technology for an hour. After a 48 -h wash-out period, children received a standard book. ‘Standard-book-first’ group received only the standard book and after wash-out received the tablet and the AR book. Salivary cortisol and a validated visual analogue scale (VAS) for psychological stress were assessed at the beginning and at the end of each intervention.

Results

A total of 29 children were recruited in the study. One was lost during follow up. Cortisol levels decreased after the AR intervention (P = 0.019). Nevertheless, the decrease was not greater than the one associated to reading the standard book. VAS scores increased after the AR intervention (P < 0.001).

Discussion

There is evidence of order and sequence effects that might explain results. First assessment of AR-based interventions on stress. Results justify further research.

Conclusions

There was no evidence that reading AR books diminished cortisol levels more than reading a standard book. AR-books improved VAS score for psychological stress compared to a standard book.

Introduction

Hospitalization is a stressful event. Being away from home coupled with the uncertainty of the outcome, the invasive nature of hospital procedures and the disease itself trigger a deregulation of the hypothalamic-pituitary-adrenal axis in charge of stress homeostasis [1]. This results in increased production and release of steroid hormone cortisol which has been associated with poor postsurgical outcomes [2], slower speed of wound healing [3] and increased odds of unplanned readmissions [4].

Children are more likely to suffer the deleterious effects of hospitalization. They are more susceptible to hospitalization-induced stress due to their physical and emotional dependence [5]. Furthermore, increased cortisol levels have been associated with long-lasting effects in wellbeing. For instance, children who were hospitalized for over a week had more chances to develop behavioral problems and learning difficulties during adolescence [6]. Also, high cortisol levels during childhood have been associated with poor cognitive functioning [7] and is a risk factor for adult clinical depression [8].

Altogether evidence shows that managing stress in the pediatric hospital environment is of uttermost importance for assuring an integral recovery of the patient. There are several approaches to manage stress in hospitalized children including clown therapy [9], expressive arts [10] and animal-assisted therapy [11]. Nevertheless, these rely on trained personnel or volunteers to be completed. In resource deprived settings, with shortage of both volunteers and personnel, the need to manage stress in hospitalized children is not met.

Emerging technologies such as virtual and augmented reality can be an option to traditional therapies since they do not demand additional personnel. Augmented reality (AR) is a technology that has gathered much attention recently due to its wide use. Nevertheless, the technology has been around since the 1980’s [12]. It consists in the superposition of digital information over physical objects and environments in such a way that the user-technology interaction is enhanced [13].

AR applications are amongst the most promising technologies in health. They are widely used in medical training [14] and surgery assistance [15,16]. Lately, AR-based therapies for psychological disorders have also been proposed and assessed. AR has been effective in diminishing fear and anxiety in patients with small animal phobia [17]. Furthermore, a clinical trial shows that all metrics of phantom limb pain improved after AR-therapy in patients whom conventional therapy had failed [18]. Since research in this topic is still limited, systematic reviews call for more trials to confirm the effectiveness of said therapies in those diseases and other psychological disorders [19]. The effect of augmented-reality-based therapies on stress as an outcome has not been assessed so far.

Books enhanced with AR technology have been in the international market for several years. They consist in a traditional book with unique markers that allow the visualization of digital content with the aid of a mobile device. Markers could be special graphics or symbols in each page that when recognized display the augmented medium. Some authors argue that AR books are the most promising application of AR technology in the educational field since books are now able to provide interactive experiences making them a dynamic source of information [20,21].

The aim of this randomized cross-over trial was to evaluate the effect of reading books with augmented reality technology on salivary cortisol levels in hospitalized pediatric patients. A visual analogue scale (VAS) to assess children psychological stress was the secondary outcome. A standard book, with no mobile device available, was used as a comparator.

Section snippets

Design

The study had two phases. Phase 1 consisted in a formative research study whose main objective was to test how feasible an intervention using augmented reality books in a public hospital in Peru was and to broadly test the acceptability of augmented reality books through a Likert scale. For the second phase of the study we performed a face-to-face, unblinded, randomized, two-period, cross over study to assess the effect of reading AR books in salivary cortisol levels compared to reading a

Formative research

Between June and July 2018, the first phase of the study took place. A total of 18 children were recruited, 12 girls and 6 boys, aged 8.82 ± 1.81. In Fig. 2, the results of the Likert test for book acceptability are shown. Overall, the five books were well accepted by the children and there were no significant differences in the ratings between groups. The two books with the highest ratings were chosen for the randomized controlled trial (book 1 https://editorialkokinos.com/libro/valentina [26]

Discussion

The aim of this study was to assess the effect of reading augmented reality books in physiological and psychological stress in hospitalized children. The results show a decrease in salivary cortisol levels following the intervention with augmented reality. Nevertheless, this decrease is not higher than that observed after reading a standard book.

There are interesting findings regarding how cortisol decreased between groups. For example, cortisol decreases after the treatment with AR only in the

Conclusions

This study could not demonstrate that reading augmented reality books decreased salivary cortisol levels more than reading a standard book in hospitalized children. Nevertheless, the order and sequence effect shown call for further studies with different designs. Furthermore, AR books improved emotional stress as evaluated through the Weisz visual analogue scale justifying further investigation on the effects of AR-technology in stress.

Trial registration

ClinicalTrials.gov Identifier: NCT03537859

Funding

This work was supported by CONCYTEC – FONDECYT (CONV-000229-2015). The funders had no role in study design, data collection nor decision to submit the manuscript for publishing.

The authors would like to thank Dr. Gustavo F. Gonzales for providing the cortisol ELISA kits, Diego Rondón Soto for aiding in fieldwork during the formative phase of the study and the clinical personnel at the Pediatrics and Traumatology Units at Hospital Cayetano Heredia.

Protocol and data availability

Protocol is available in local language at https://osf.io/5q8ha/

Data is available upon reasonable request.

Summary points

  • Augmented reality technology is widely used in health and education.

  • Augmented reality applications in healthcare have shown promise treating psychological disorders, but effects on stress have not been assessed so far.

  • Reading books enhanced with augmented reality technology decreased markers of physiological and psychological stress in hospitalized children.

Declaration of Competing Interest

The authors report no declarations of interest.

Acknowledgements

DEAY and CPC designed the study; DEAY, JPT and DPG participated in fieldwork; DEAY, JPT and NB participated in laboratory analysis; DEAY and CPC analyzed the data; DEAY wrote the first draft of the manuscript; all authors reviewed and approved the final version of the manuscript.

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