JMIR Publications

ABSTRACT

Background:

Brief behavioral treatment for insomnia is an effective short-term therapy focusing on stimulus control and sleep restriction to enhance sleep quality. As a crucial part of this therapy, diaphragmatic breathing is often recommended when patients fail to fall asleep within 30 minutes. With the rise of health applications and gamification, these tools are increasingly seen as effective ways to boost self-efficacy and user engagement; however, traditional games tend to increase attention, which can negatively impact sleep and contradicts the aim of sleep therapy. This study thus explored the potential for gamification techniques to promote relaxation without disrupting sleep processes.

Objective:

The study developed four breathing guidance mechanisms, ranging from concrete to abstract: number countdown, zoom in/out, up/down, and color gradients. The objective was to explore the relationship between game mechanics, cognitive load, relaxation effects, and attention as well as to understand how different designs impact users with varying levels of insomnia.

Methods:

The study was conducted in two phases. The first phase involved a questionnaire on the four guidance mechanisms. In the second phase, 33 participants classified by insomnia severity completed a sleep self-efficacy scale. They then engaged in five minutes of diaphragmatic breathing using each of the four interfaces. Relaxation effects were measured using heart rate variability via a smartwatch, attention and relaxation levels via an EEG device, and respiratory rate via a smartphone. Participants also completed the Game Experience Questionnaire and NASA-TLX, followed by user interviews.

Results:

The results indicated that competence, immersion, tension, and challenge significantly influenced cognitive load. Specifically, competence and immersion reduced cognitive load, while tension and challenge increased cognitive load. Additionally, challenge and negative affect were shown to impact relaxation, with higher challenge levels correlating with increased respiratory rates and negative affect positively correlating with mean RMSSD. Cognitive load was found to affect both relaxation and attention, with a negative correlation between mental demand and attention and a positive correlation between temporal demand and respiratory rate. Sleep self-efficacy was negatively correlated with temporal demand and negative affect and positively correlated with competence and immersion.

Conclusions:

Interfaces offering moderate variability and neither overly abstract nor too concrete guidance are preferable. The up/down interface was most effective, showing the best overall relaxation effect. Conversely, the number countdown interface was stress-inducing, while the zoom in/out interface had a significant impact on insomnia-related issues, making them less suitable for insomnia-related breathing exercises. Participants showed considerable variability in their response to the color gradient interface. These findings underscore the importance of carefully considering game design elements in relaxation training. It is essential that breathing guidance designs account for the impact of game experience to effectively promote relaxation in users.