Virtual Reality-Based Mindfulness Meditation: A Systematic Review of Sensory Design and Attentional Control

Virtual Reality-Based Mindfulness Meditation: A Systematic Review of Sensory Design and Attentional Control | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Virtual Reality-Based Mindfulness Meditation: A Systematic Review of Sensory Design and Attentional Control Qiong Xie, Yumeng Zhan, Xiaoyue Wu, Xingyi Lu, Huiting Zeng, Xian Wu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8305873/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose of Review Mindfulness meditation is widely recognized for its benefits in stress reduction and attentional regulation, yet many practitioners face barriers of distraction and disengagement. Virtual reality (VR) provides immersive, multisensory environments that may enhance mindfulness by anchoring attention and reducing external interference. This systematic review synthesizes empirical studies examining VR-supported mindfulness interventions with a specific focus on sensory design, visual aesthetics, and attentional outcomes. Recent Findings A synthesis of 15 empirical studies and supplemental references reveals that VR mindfulness programs commonly employ nature-based visuals, ambient soundscapes, breathing guides, and occasional multisensory or embodied features across diverse populations, including adolescents, clinical patients, and healthy adults. Evidence indicates that these design elements improve state mindfulness, emotional regulation, and user engagement, although challenges remain regarding long-term efficacy and cybersickness. Comparisons with traditional audio- or video-based mindfulness suggest that VR offers equal or greater short-term attentional benefits and stronger user appeal. Summary This review highlights interdisciplinary contributions from design, psychology, and immersive technology, providing practical guidelines for optimizing VR mindfulness environments. While VR demonstrates potential as a powerful tool for attentional regulation, future research should employ larger trials and component analyses to clarify effective design mechanisms and sustainable outcomes. Virtual reality Mindfulness meditation Sensory design Attentional regulation Immersive technology Interdisciplinary design Figures Figure 1 Introduction Mindfulness meditation, defined as intentional attention to present-moment experience in a non-judgmental manner, has demonstrated robust benefits for stress reduction, emotional regulation, and cognitive performance [1, 2]. However, despite its evidence base, many individuals—particularly novices—struggle to maintain concentration due to both external distractions and internal mind-wandering [3]. Conventional delivery formats such as audio recordings or instructor-led classes can be perceived as monotonous or difficult to sustain, resulting in limited adherence and reduced therapeutic benefit [4]. Virtual reality (VR) technologies offer new opportunities to address these limitations. Through immersive, multisensory environments, VR can limit external distractions and provide attentional anchors, thereby creating conditions conducive to mindfulness practice [5]. Unlike two-dimensional media, VR affords presence and embodiment, potentially enabling users to more readily access meditative states [6]. For example, visual breathing guides, ambient soundscapes, or nature-based scenes can serve as salient cues to redirect wandering attention [7]. Early feasibility studies suggest that VR mindfulness is both acceptable and engaging across populations, including students, patients with chronic pain, and veterans with substance use disorders [8, 9]. Beyond feasibility, a critical question concerns how VR systems should be designed to optimally support mindfulness. Prior work emphasizes that design features such as visual aesthetics, sound composition, interactivity, and spatial minimalism can profoundly influence attentional outcomes [3, 10]. Naturalistic environments with low-saturation color palettes, stable horizons, and slow temporal pacing have been associated with calming effects and enhanced focus [11]. In contrast, cluttered or overly dynamic environments may overload attentional resources and disrupt meditative flow [12, 13]. Similarly, congruent multisensory elements (e.g., gentle scents, tactile feedback) can deepen presence, while incongruent cues risk distraction [14, 15]. These findings align with theories from environmental psychology and design research, underscoring the need for an interdisciplinary perspective that integrates psychology, human–computer interaction, and art/design disciplines. Despite growing interest, systematic understanding remains limited. Existing reviews have addressed VR for mental health broadly, but few have specifically synthesized how sensory and visual design elements in VR mindfulness applications contribute to attentional regulation [1, 3]. Moreover, much of the evidence is fragmented across pilot trials, design prototypes, and feasibility studies with heterogeneous outcomes [16, 17]. This fragmentation hampers the ability of researchers and practitioners to identify consistent principles and design guidelines. The present review addresses this gap by conducting a PRISMA-based systematic review of VR-based mindfulness meditation interventions, with a dedicated focus on sensory design and attentional outcomes. We synthesized findings from 15 eligible studies, supplemented by 10 cross-disciplinary references from design and psychology [18, 19]. Our objectives were threefold: To describe the range of VR design strategies employed in mindfulness applications, including visual environments, auditory and multisensory cues, embodiment, and biofeedback. To evaluate evidence linking these design strategies to attentional, emotional, and user experience outcomes. To identify interdisciplinary contributions from art and design that can inform future development of VR mindfulness systems. By highlighting both effective practices and unresolved challenges, this review aims to guide researchers, clinicians, and designers in developing VR mindfulness environments that maximize attentional regulation and user benefit. Furthermore, by situating VR mindfulness at the intersection of technology, psychology, and design, we emphasize the role of aesthetic and sensory considerations as central, rather than peripheral, to therapeutic efficacy. Methods Search Strategy This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A systematic search was conducted in Web of Science (Core Collection and allied indexes), PubMed, Scopus, IEEE Xplore, and ACM Digital Library, covering publications from January 2010 to January 2025. The search terms included combinations of: “virtual reality” OR “VR” AND “mindfulness” OR “mindfulness meditation” AND “design” OR “visual aesthetics” OR “sensory” AND “attention” OR “focus.” To reduce irrelevant results, exclusion terms included “augmented reality,” “AR,” “mixed reality,” “MR,” “game,” “animal study,” and “technical development.” Boolean operators and truncations were tailored for each database. Additionally, reference lists of included studies were hand-searched for relevant sources [1, 3]. Eligibility Criteria Studies were included if they: (1) explicitly described a VR-based intervention for mindfulness or meditation; (2) reported design features related to visual, sensory, or attentional strategies; and (3) included empirical evaluation, whether feasibility studies, pilot trials, or research protocols. Exclusion criteria were: (1) reviews, commentaries, and conference abstracts that did not contain original empirical data; (2) studies not involving VR or not focused on mindfulness; and (3) non-English publications. This approach allowed for the inclusion of early-stage empirical work, such as feasibility studies, pilot trials, and research protocols, which are valuable for understanding the field’s design landscape and future directions. Study Selection and Screening Two reviewers independently screened titles and abstracts for relevance. Full texts were then assessed according to inclusion and exclusion criteria. Discrepancies were resolved by consensus. The initial search yielded 48 records. After removing duplicates and applying exclusion criteria, 19 full texts were assessed. Four were excluded for being reviews or for being unrelated to the core topic, leaving 15 studies for final synthesis. Fig. 1 presents the PRISMA flow diagram of the search and selection process. Data Extraction Key information was extracted from each included study: authorship, year, population, VR system hardware, virtual environment characteristics (e.g., natural vs. abstract design, color palettes, motion pacing), sensory features (audio, olfactory, haptic), attentional guidance strategies (e.g., breathing cues, embodiment, biofeedback), study design, and outcomes related to mindfulness, attention, emotional well-being, and user experience. Extraction was validated by cross-checking with a structured spreadsheet prepared by the student research team. Synthesis Approach Given heterogeneity across interventions and outcome measures, a narrative synthesis approach was used. Studies were grouped under thematic categories: (a) VR environment design and sensory features; (b) mindfulness and attentional outcomes; (c) emotional, stress-related, and clinical outcomes; and (d) user experience and acceptability. Within each theme, findings were compared, and recurring design principles were identified [5, 7]. Quantitative outcome data were reported descriptively; qualitative insights were incorporated where relevant to illustrate user experience and design implications. Results Study Characteristics A total of 15 studies were included, spanning diverse populations and settings. This review synthesizes various research types, including empirical studies, design prototypes, feasibility studies, and research protocols, to comprehensively reflect the design and methodological landscape of this field. Sample sizes ranged from healthy university students and adolescents to clinical groups, such as cancer survivors with chronic pain, hemodialysis patients, veterans with substance use disorders, and post-COVID rehabilitation cohorts [ 2 , 7 , 9 , 18 ]. Most studies were small-scale pilots or feasibility trials, with sample sizes between 15 and 60 participants. Interventions varied from single-session experiments to 6–8 week programs. Hardware primarily included Oculus Rift/Quest or HTC Vive head-mounted displays, while some telemindfulness interventions used cloud-based VR systems compatible with mobile devices [ 5 ]. Table 1 Characteristics of Included Studies Study Title Author & Year subjects VR Environment & Sensory Features Outcomes The potential of virtual reality to support adolescent mental well-being in schools: A UK co-design and proof-of-concept study S. Hugh-Jones, M. Ulor, T. Nugent, Hugh-Jones et al. [ 7 ] Adolescents (UK, 15–18); Emotional/Attention Needs ; Mainstream/Specialist Education. Immersive 360° Calm Scenes (Beach/Forest); Guided Audio (Optional Narrators/Ambient Sound); Minimal Interaction; Mindfulness Support. ↑ Post-Session Mood; ↑ Sustained Attention ; ↑ Content Recall/Practice Completion; Strong Presence; ↑ In-the-Moment Emotion Regulation; Stress Reduction ("Step Out"). Study protocol for improving mental health during pregnancy:a randomized controlled low-intensity m-health intervention by midwives at primary care centers Jimenez-Barragan et al. [ 16 ] Pregnant Women (Spanish-Speaking, ≥ 18); Mild Anxiety/Depression (EPDS 9–12); Early Gestation (12–14 weeks); Primary-Care Setting. Home-Based VR (Oculus GO); 14-min Cordless App; Three 360° Relaxation Modules; Avatar Narrator; Paced Breathing/Muscle-Relaxation Cues; Ambient Sound; Controller-Free. 6-Week Daily Use;↓ Anxiety/Depression Symptoms (STAI, EPDS, SCL-90); High Usability; ↑ Focused Attention; ↑ Recall of Relaxation Steps; Strong Presence; Detachment from Daily Stressors. Positive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial Hernandez et al. [ 17 ] Adults (≥ 21); Maintenance Hemodialysis ≥ 3mos); Comorbid Depression (BDI-II ≥ 11); Chicago Dialysis Centers. Meta Quest Pro Headset; In-Session Use (During Dialysis); 3D/360° Worlds (Garden, Gallery, Beach); Head-Gaze Navigation; Interactive Tasks (Virtual Photos, Mini-Games, Quizzes); Bilingual Audio. Pilot Data; Significant ↓ Depression (BDI-II, PROMIS);↑ Life Satisfaction/Positive Affect/Optimism/Emotional Vitality;↑ Attention to Content;↑ Homework Recall; Strong Presence; Momentary Clinic Escape. Understanding How Virtual Reality Can Support Mindfulness Practice: Mixed Methods Study Seabrook et al. [ 1 ] General Population (N = 37, mean age 38); Varying Mindfulness Experience; No Severe Mental Illness/VR Sickness. 15-min App (Oculus Go); Controller-Free; Immersive 360° Forest Video; Spatial Nature Sounds; Guided Voiceover (Attentional Anchors); User-Selected Focus Points. Significant ↑ State Mindfulness/Positive Affect (Large Effect Size: d = 1.80); ↑ Present-Moment Attention;↑ Recall of Practice Steps; Pronounced Sense of Presence; Attentional Anchor (VE as tool); Thought Detachment ("Step Away"). Mindfulness-based relapse prevention combined with virtual reality cue exposure for methamphetamine use disorder: Study protocol for a randomized controlled trial Chen et al. [ 20 ] Methamphetamine Users (N = 180, 18–55 yrs); Abstinent (≥ 3 mos); Rehab Center (Beijing). HTC VIVE System; Room-Scale VR (3x4m); Single 60-min Session; Virtual Living-Room (Drug Cues: Foil/Paraphernalia); VR Cue Exposure ; Therapist-Guided Mindfulness ; Physiological Streaming (SC/HR/EEG). ↓ Self-Reported Craving; ↓ Attentional Bias (Emotional Stroop); ↑ Sustained Attention; Strong Presence ("In the using scene"); ↑ Recall of Coping Steps; ↑ Regulation of Drug-Related Memory; ↑ On-Task Focus. Patients perceptions of virtual reality therapy in the management of chronic cancer pain Garrett et al. [ 8 ] Adults (N = 12, Canadian); Chronic Cancer Pain (> 3 mos, NRS ≥ 4); Mostly Post-Treatment; VR-Naïve. Home Sessions (HTC Vive); 45-min Sessions; User-Choice Modules (Mindful Walk, Puzzles, Sci-Fi); 3D/360°; Navigation by Head-Turn/Controller; Seated/Standing. Transient but Significant Pain Reduction;↑ Attention; ↑ Memory for Coping Steps; Strong Sense of Presence ("Forgot pain"); Relaxation/Distraction Preferred; Minor Cybersickness/Eye-Strain Noted. Using Artificial Intelligence-informed Experience-Based Co-Design (AI-EBCD) to create a virtual reality-based mindfulness application to reduce diabetes distress: protocol for a mixed- methods feasibility study Ghosal et al. [ 21 ] Adults; Type 2 Diabetes (> 12 mos); Self-Reported Diabetes Distress; Smartphone Owner (Android). 15-min Unity VR App; Co-Designed (Generative AI/Users); Immersive Audiovisual Scenes; Interactive Breathing Cues; Personalized Content. Pilot Data; Significant ↓ Diabetes Distress (DDS);↑ Quality of Life (DSQoLS); ↑ Attention Regulation; ↑ Recall of Mindfulness Steps; Strong Presence; Focus Shift from Daily Stress. Attention Regulation Framework: Designing Self-Regulated Mindfulness Technologies Niksirat et al. [ 19 ] Adults; Meditation Naïve; Novices/Unfamiliar with Mindfulness. Mobile-Based VR; Non-Intrusive Detection-Feedback; Subtle Movement Input (Finger/Body Motion); Multimodal Sensory Cues (Audio-Visual/Haptic); Attention Regulation Focus. ↑ Attention (ANT scores); ↑ Memory (Theta/Alpha EEG ↑); ↑ Presence (Self-Reported); ↓ Stress Markers (↑ HR Variability); ↓ Mood Disturbances (POMS). Virtual reality mindfulness training for veterans in residential substance use treatment: Pilot study of feasibility and acceptability Van Doren et al. [ 9 ] Veterans (N = 20, mostly male); Residential Substance Use Treatment; High Rates PTSD/Depression. Self-Guided VR Headset; 360° Nature Scenes; Ambient Sounds; Guided Audio Instructions; Passive Interaction (Gaze/Listening). Significant ↓ Negative Affect/Anxiety; ↑ Positive Emotions/Calmness; ↑ State Mindfulness;↑ Attention Focus; ↑ Sense of Presence. Design Considerations for Supporting Mindfulness in Virtual Reality Kelly et al. [ 3 ] General Population (N = 9); Varying VR/Mindfulness Experience (Novices/Practitioners). VR App "Place"; Omnidirectional Forest Videos; Natural Sounds; Guided Voiceovers; Minimal Interaction (Head Gaze/Auto-Transitions); Mindfulness Support. ↑ State Mindfulness/Relaxation/Positive Affect; ↑ Attention Regulation;↑ Memory Anchoring (Sensory Cues); Enhanced Sense of Presence; Non-Overwhelming User Experience. Putting Oneself in the Body of Others: A Pilot Study on the Efficacy of an Embodied Virtual Reality System to Generate Self-Compassion Cebolla et al. [ 22 ] University Students (N = 16); Meditation Naïve; No Mental Disorders; RCT Design (VR vs. Audio). TMTBA-VR System (Oculus Rift); Body-Swap Illusion; Third-Person View; Visual/Auditory/Proprioceptive Feedback; Self-Compassion Meditation. Both Groups ↑ Self-Compassion/Mindfulness; VR ↑ Adherence (esp. for Low Imagery Ability); VR ↑ Attention; VR ↑ Memory Anchoring; VR ↑ Sense of Presence. Virtual reality–guided mindfulness for chronic pain in cancer survivors: protocol for the virtual mind study—a single-group feasibility trial Baydoun et al. [ 2 ] Adult Cancer Survivors (N = 15); Chronic Cancer-Related Pain (> 3 mos); Moderate-Severe Pain Interference. Standalone Headset (Pico Neo 3 Pro, 4K); Head Tracking/Built-in Audio; Daily 10–15 min Sessions; VR-Guided Mindfulness; Nature-Themed Environments. ↓ Pain/Anxiety/Depression/Fatigue; ↑ Sleep/Quality of Life/Trait Mindfulness/Sense of Presence; Data Collection: Pain Ratings, VR Engagement, Attention Focus, Memory Anchoring, Immersive Effects. A Cloud-Based Virtual Reality App for a Novel Telemindfulness Service: Rationale, Design and Feasibility Evaluation Cikajlo et al. [ 5 ] Hospital Employees (↑ Stress); Outpatients (TBI/Brain-Tumor) with Anxiety; 8-Week Trial (N = 8 total). Samsung GearVR; User-Selected 360° Scenes (Nature/Virtual Rooms); Natural Interaction (Head Movement/Voice); Real-Time Instructor Audio-Video; Music/Natural Sound Stream. ↑ Patient Life Satisfaction/MAAS Mindfulness;↓ High-Frequency Head Motion (Physiological Marker); Improved Attention/Memory Engagement (Inferred from Head Motion); Strong Presence; High Ease-of-Use. Real - time virtual reality co - creation: collective intelligence and consciousness for student engagement and focused attention within online communities Wang, Sun [ 13 ] Tenth-Grade EFL Students (N = 66, Taiwan); Quasi-Randomized Design; VR vs. 2D vs. Paper Groups. CoSpaces Edu; 3D VR Co-Creation; Shared VR Scene; Drag-and-Drop Objects/Coding; Google-Cardboard Immersion (First-Person); Real-Time Co-Editing/Tap Navigation. Significant ↑ Emotional Engagement (VR > 2D > Paper); No Significant ↑ Behavioral/Cognitive Engagement/Focused Attention; VR ↑ Situational Interest/Memory Encoding (Temporary Boost); Suggests Need for Longer Intervention. A multimodal group-based immersive virtual reality intervention for improving cognition and mental health in patients with post-COVID-19 condition Cano et al. [ 18 ] Adults (N = 31, mean age 50.3, 76.9% women); Post-COVID Cognitive Complaints; Elevated Depression/Anxiety (PHQ-9 ≥ 6, GAD-7 ≥ 10); Quasi-Assigned (IVR vs. Usual Care); 15-Session. IVR (Immersive Virtual Reality); Group Sessions; Headset-Free (MK360 360° Projection over 3 Walls/Ceiling); Multimodal Training; 10-min Mindfulness/30-min Interactive Cognitive Tasks (Park Walk/Emoticon Search); Real-Time Visuals/Sound/Therapist Cues; Shared Space Movement/Response. Large-Effect Improvements vs. Controls;↑ Global Cognition;↑ Attention (↓ CPT Omissions); ↑ Processing Speed;↑ Episodic Memory; ↓ Depressive Symptoms (↓ PHQ-9 6 pts); High Enjoyment/Perceived Improvement; Stable Fatigue; Strong Presence; Sustained Engagement (No Overload). VR Environment Design and Sensory Features Most interventions employed nature-based environments—forests, beaches, rivers, or mountains—reflecting biophilic design principles known to promote calmness and restoration [ 7 , 10 ]. Visual features emphasized low-saturation colors, horizon stability, and minimal clutter [ 3 ]. Temporal pacing, such as slow drifting or breath-synchronized animations, reduced exogenous attentional capture [ 1 ]. Audio design consistently included ambient natural sounds and soft narration, with positive feedback regarding immersion [ 8 ]. Multisensory enhancements, such as olfactory pine scent [ 14 ] or tactile water spray [ 15 ], deepened presence and embodiment. Embodiment strategies, including body-swap illusions and biofeedback-driven environments, supported interoceptive awareness and attentional focus [ 19 , 22 ]. Focusing on the visual design, the visual design of nature-based settings was often highly detailed. Examples included 4K omnidirectional (360°) video of a real forest, captured at a 1.3-meter height to simulate a seated perspective [ 1 ], 360° calm scenes of beaches [ 7 ], and 3D computer-generated worlds featuring mountain meadows, white sands, and spring creeks [ 2 ]. However, environments were also purpose-built for non-relaxation goals. For substance use disorder, Chen et al. [ 20 ] constructed a virtual living room containing drug paraphernalia (eg, foil) to specifically conduct virtual reality cue exposure (VRCE) therapy. For hemodialysis patients, Hernandez et al. [ 17 ] designed interactive 3D/360° worlds (eg, garden, gallery) that included mini-games and quizzes to support a positive psychology curriculum. Beyond the visual elements, auditory design was a critical component for immersion. Studies used ambient sounds recorded on-site [ 1 ] or provided user-selectable streams of music and natural sounds (eg, birds, wind, waves)[ 5 ]. The narrator's voice and pacing were key design considerations. For example, Kelly et al. [ 3 ], through iterative user testing, found that a slower pace and longer pauses in the narration were essential to allow users time for unguided practice. Furthermore, multisensory and embodiment strategies were explored in depth. A prominent example is the study by Cebolla et al. [ 22 ], which used "The Machine to be Another" (TMTBA-VR) system. This setup induced a "body swap illusion" by feeding a performer's first-person visual perspective to the user's VR headset while they synchronized movements, allowing the user to feel embodied in another person's form and see themselves from a third-person perspective to enhance self-compassion. Other systems integrated biofeedback. Niksirat et al. [ 19 ] developed a framework where subtle finger movements on a smartphone's touchscreen provide real-time audio-visual feedback to help self-regulate attention, eliminating the need for external sensors. Visual breathing guides, such as the "Breathing Sphere" animation for adolescents, were also employed [ 7 ], as were interactive breathing cues in co-designed apps [ 7 , 21 ]. Mindfulness and Attentional Outcomes Across studies, immediate improvements in state mindfulness, present-moment focus, and reduced mind-wandering were observed [ 1 , 9 ]. Adolescent participants reported that breathing-ball animations improved attention regulation [ 7 ]. Post-COVID participants in group VR interventions demonstrated gains in attention and cognitive function [ 18 ]. However, when VR tasks were complex or interactive, attentional benefits were reduced, indicating potential cognitive load issues [ 13 ]. The immediate enhancement of state mindfulness is a highly consistent finding. Seabrook et al. [ 1 ] reported a large and statistically significant increase in State Mindfulness Scale scores (Cohen's d = 1.80) after a single 15-minute session. Van Doren et al. [ 9 ] also noted significant increases in state mindfulness among veterans, who qualitatively reported that the VR environment helped them "zone in." Qualitative feedback from other studies supports this, with participants describing the immersive visuals and sounds as effective "attentional anchors" that helped them "rein in" a wandering mind more quickly than traditional practice [ 1 , 9 ]. Objective measures of attention further support these self-reports. Cano et al. [ 18 ] found that post-COVID patients in their group IVR intervention showed significant gains in attention, specifically a reduction in omission errors on the Continuous Performance Test (CPT). The framework proposed by Niksirat et al. [ 19 ], which uses subtle finger movements for self-regulation, led to improved scores on the Attentional Network Test (ANT) and corresponding increases in theta/alpha EEG activity, which are associated with memory and attention. Similarly, Chen et al. [ 20 ] found that their VRCE-plus-mindfulness group showed a reduction in attentional bias as measured by the Emotional Stroop test. However, the cognitive demands of the VR interaction itself can be a limiting factor. Wang and Sun [ 13 ] compared VR co-creation (using CoSpaces) to 2D and paper methods. While VR significantly boosted emotional engagement, it failed to show significant gains in cognitive engagement or focused attention. The researchers posited that the cognitive load of navigating the complex 3D authoring tool in a short period consumed the attentional resources that would have otherwise been directed at the task itself. Emotional, Stress-Related, and Clinical Outcomes VR mindfulness interventions showed consistent calming and affective benefits, with reductions in anxiety, stress, and pain reported across populations [ 2 , 4 ]. Clinical contexts highlighted VR’s feasibility for oncology, hemodialysis, and chronic pain patients [ 8 , 17 ]. While results are promising, heterogeneity of measures and small samples limit generalizability. Participants consistently reported strong calming benefits. Van Doren et al. [ 9 ] found that veterans, after a single session, experienced significant reductions in negative affect (including anxiety) and significant increases in positive emotions and calmness. This was mirrored by Seabrook et al. [ 1 ], who also measured a significant increase in positive affect. In the study with adolescents, post-session mood ratings increased on average from 3.15 to 4.56 (out of 5) in mainstream schools, and from 2.78 to 4.17 in a specialist setting, demonstrating an immediate affective boost [ 7 ]. In specific clinical populations, these interventions demonstrated clear therapeutic potential. For cancer survivors with chronic pain, Garrett et al. [ 8 ] reported that participants found "transient but significant" pain reduction after using VR modules, including a "Mindful Walk." The protocol by Baydoun et al. [ 2 ] is designed to formally test these outcomes, aiming for reductions in pain, anxiety, and depression. For post-COVID patients, Cano et al. [ 18 ] found their multimodal IVR intervention produced a large-effect improvement in depressive symptoms (a 6-point drop on the PHQ-9). Similarly, protocols are in place to test the efficacy of VR interventions on reducing depression in hemodialysis patients [ 17 ] and reducing anxiety and depression in pregnant women [ 16 ]. Ghosal et al. [ 21 ] also aim to show a reduction in diabetes distress. For substance use, Chen et al. [ 20 ] reported that VRCE combined with mindfulness reduced self-reported craving. User Experience and Acceptability Acceptability was high across most studies, with participants describing VR as immersive, private, and engaging [ 3 , 8 ]. Cybersickness was infrequent and generally mild when design minimized motion and maintained frame stability. Session length optimization (5–15 minutes per session) and cultural adaptation of narratives were noted as practical considerations [ 5 , 7 ]. Overall, user experience findings reinforced the importance of simple design, congruent multisensory cues, and ergonomic usability for successful VR mindfulness adoption. A key advantage highlighted by participants was VR's ability to reduce distractions. Veterans in residential substance use treatment noted that in traditional mindfulness groups, the presence of others was disruptive [ 9 ]. The VR headset provided a sense of privacy and safety, which was particularly valued by participants with PTSD, who reported feeling less hypervigilant and more able to relax in the "bubble" of the VR environment [ 9 ]. The novelty and engaging nature of the technology were also frequently cited as positive factors that increased motivation [ 1 , 8 ]. The most common negative feedback related to hardware discomfort. Cybersickness was reported, though infrequently, and was primarily associated with experiences that simulated movement, such as flying [ 8 ]. More pervasive were complaints about the physical ergonomics of the headset, including its weight, the pressure it exerted on the face, and incompatibility with eyeglasses [ 3 , 8 , 9 ]. Technical limitations, such as mobile phones overheating in GearVR systems, also prompted designers to limit session durations to 30 minutes to ensure user comfort and system stability [ 5 ]. The need for personalization and co-design was a strong theme. Participants in the focus groups conducted by Kelly et al. [ 3 ] revealed that users desire a variety of environments (eg, day vs. night scenes) and the ability to select one based on their current mood. This feedback aligns with findings from Garrett et al. [ 8 ], where patients showed distinct preferences for either contemplative experiences (like the mindful walk) or cognitive-challenge games, but rarely both. This highlights that a "one-size-fits-all" design is suboptimal. Consequently, newer protocols are explicitly built around co-design, such as involving adolescents in the design process [ 8 ] or using generative AI to create personalized content with adults who have type 2 diabetes [ 21 ]. Discussion Summary of Findings VR sensory and design features influence mindfulness practice. Evidence consistently indicated that nature-based environments, stable visual horizons, ambient soundscapes, and congruent multisensory cues were effective in improving attentional focus and emotional regulation [ 1 , 3 ]. Multisensory and embodiment features enhanced presence, but overly complex interactions risked cognitive overload. Importantly, the findings converge across adolescent, clinical, and healthy adult populations, underscoring the broad applicability of design-driven mindfulness interventions. This convergence was evident in both the chosen modalities and the reported outcomes. For instance, the effectiveness of nature-based environments was validated not only in high-fidelity 4K omnidirectional videos [ 1 ] but also in more stylized, computer-generated 3D worlds [ 2 , 17 ]. Furthermore, the role of embodiment in enhancing presence was powerfully demonstrated by the "body swap illusion" technique, which leveraged multisensory feedback to deepen self-compassion [ 22 ]. Conversely, the risk of cognitive overload was explicitly confirmed by Wang and Sun [ 13 ], who found that while a complex 3D co-creation task (CoSpaces) increased emotional engagement, it failed to improve focused attention, suggesting attentional resources were consumed by the tool itself. These findings provide a more granular understanding of the trade-offs between immersion and cognitive load. Comparison with Existing Literature When compared with traditional 2D or audio-guided modalities, VR-based interventions demonstrate distinct advantages. For instance, studies comparing computer-generated VR (CG-VR) with 2D high-definition video found that the increased sense of presence in CG-VR mediated significantly greater improvements in positive affect [ 23 ]. Similarly, VR-enhanced mindfulness has been shown to produce a greater increase in decentering—a key metacognitive skill involving the ability to observe one's thoughts without entanglement—than audio-only guidance [ 4 ]. However, the simple equation of immersion with effectiveness is challenged by a critical design dichotomy: photorealism versus abstraction. While realistic renderings can evoke a stronger sense of presence, they risk triggering real-world semantic associations that may distract from introspective focus. This paradox is partially resolved by evidence suggesting that visual coherence and quality may be more critical than realism itself. An internally consistent, stylized world could be more effective than an imperfectly realistic one, as it minimizes the risk of incongruent elements breaking the meditative state [ 24 ]. This shifts the design focus from a simple pursuit of realism to the creation of a cohesive virtual space that best supports attentional control. The findings from this review reinforce these distinct advantages over audio-only modalities. For example, Cebolla et al. [ 22 ] directly compared their embodied VR system to an audio-only meditation and found that while both groups improved, the VR intervention significantly increased adherence, particularly for participants with low imagery ability. This suggests VR acts as a powerful scaffold for individuals who struggle to generate or sustain mental images, a common barrier in traditional practice. Furthermore, participants in multiple studies [ 1 , 9 ] explicitly stated that the primary benefit of VR over audio-only guides was its ability to eliminate external distractions and provide a persistent visual "attentional anchor," which helped them "rein in" a wandering mind and fostered a greater sense of safety and privacy [ 9 ]. Interdisciplinary Contributions This review highlights the critical importance of interdisciplinary integration, where principles from art, design, and psychology converge to inform effective VR mindfulness systems. Artistic and aesthetic strategies are not merely decorative but foundational to the therapeutic experience. For example, the use of spatial aesthetics inspired by Japanese gardens—emphasizing negative space and asymmetrical layouts—can create a contemplative and meditative virtual space, a principle also observed in the design of immersive virtual museums [ 25 ]. Color psychology also plays a crucial role; the deliberate use of low-saturation color palettes, particularly in the green-blue spectrum, aligns with theories suggesting certain color schemes can directly induce calmness and reduce physiological arousal [ 26 ]. Furthermore, insights from social psychology explain the enhanced effects of group-based VR interventions. The mechanism of rhythmic synchrony, where individuals perform actions in unison, can amplify compassion and prosocial emotions, strengthening therapeutic alliance and adherence [ 27 ]. Finally, the technical implementation of embodiment is deeply rooted in cognitive psychology, where the non-hierarchical integration of visual form, touch, and spatial cues is essential for generating a convincing sense of body ownership and agency [ 6 ]. Collectively, these contributions underscore that VR mindfulness is not simply a technological tool, but a practice situated at the rich intersection of art, social science, and human-computer interaction. The studies in this review provide concrete examples of this interdisciplinary convergence. From a Human-Computer Interaction (HCI) perspective, Niksirat et al. [ 19 ] developed an 'Attention Regulation Framework' that translates cognitive theory into a tangible interaction model, using subtle finger movements on a touchscreen as a real-time proxy for attention. This work exemplifies how HCI design can create biofeedback loops without intrusive sensors. From clinical psychology, the work of Chen et al. [ 20 ] merges traditional cue exposure therapy for addiction with bespoke VR environment design, creating a high-risk virtual scenario to practice mindfulness skills safely. Furthermore, the work by Cano et al. [ 18 ] demonstrates an integration of neuropsychology and social psychology, using a shared, headset-free IVR space for group-based cognitive rehabilitation, showing that the social presence of a group can be combined with immersive technology to enhance outcomes. Design Implications for Practice Based on the synthesized evidence, we propose a set of actionable design guidelines for practitioners and researchers. First, in visual design, prioritize simplicity and coherence over photorealism. This involves using low-saturation color palettes and minimalist spaces to reduce cognitive load [ 26 ], but more importantly, ensuring the internal consistency of the chosen aesthetic, whether abstract or stylized [ 24 ]. Second, multisensory integration must be congruent and purposeful. Olfactory and tactile cues should be carefully timed and matched to the visual environment to enhance presence without causing distraction, as inappropriate stimuli can disrupt the meditative state [ 28 ]. Third, interaction design should follow a principle of "less is more." Iterative user feedback often reveals the need for longer pauses, slower pacing, and simpler interactions to be effective [ 29 ]. For specific populations, such as those with substance use disorders, incorporating social elements into VR can increase ecological validity, but these must be introduced carefully to manage cue reactivity [ 30 ]. Finally, user agency and personalization are key. Providing choices in visual and auditory anchors allows users to select what is most effective for them, ultimately supporting engagement and adherence. These principles form a foundation for creating VR mindfulness experiences that are not only technologically immersive but also psychologically attuned and therapeutically effective. This review also highlights several specific, practical implications. First, the design of the guided narration is as critical as the visuals. Iterative user testing by Kelly et al. [ 3 ] revealed that users strongly prefer slower-paced narration with extended pauses (eg, up to 70 seconds, as in Cano et al. [ 18 ]), as this allows them to shift from passive listening to active, unguided practice. Second, hardware ergonomics cannot be an afterthought. Multiple studies reported that the weight of the headset, pressure on the face, and incompatibility with eyeglasses were significant barriers to immersion and comfort [ 3 , 8 , 9 ]. Future designs must prioritize lighter, more comfortable, and wireless hardware. Finally, the design process itself is an implication. The success of co-design approaches [ 7 , 21 ] suggests that involving the target population (eg, adolescents, patients with diabetes) from the outset is crucial for creating applications that are not only usable but also relevant, trusted, and engaging. Limitations and Future Directions Despite the promising findings, the current evidence base has notable limitations, including a predominance of small-scale pilot studies, heterogeneous outcome measures, and a lack of long-term follow-up data. These limitations highlight several critical directions for future research. First, there is a need for systematic component analysis to understand how specific design choices impact outcomes. For example, future studies should compare how different avatar designs—from photorealistic to stylized or abstract—influence the sense of embodiment and therapeutic outcomes such as self-compassion [ 31 ]. Second, research should move beyond static environments to explore dynamic, biofeedback-driven systems. Innovations such as gamified, breath-driven locomotion, where virtual movement is tied to respiratory rate, offer a pathway to externalize interoceptive states and create a more engaging, self-regulated experience [ 32 ]. Third, for clinical applications like substance use disorder, interventions must increase their ecological validity. Future VR cue-exposure paradigms should incorporate social contexts, such as peer pressure from virtual avatars, which are often more potent relapse triggers than object-based cues alone [ 30 , 33 ]. Finally, to improve accessibility, research on mitigating cybersickness is crucial. This includes exploring adaptation protocols, such as gradually increasing optic flow, which may help users build tolerance and engage more comfortably in VR experiences [ 34 ]. Addressing these areas will be essential for maturing VR mindfulness from a promising novelty into a robust, evidence-based therapeutic modality. The studies reviewed here point directly to these future directions. For example, the non-intrusive biofeedback method proposed by Niksirat et al. [ 19 ], which uses simple finger movements, could be expanded using modern smartphone haptics to create a closed-loop, self-regulating experience without any visual interface. Similarly, the profound effects of the "body swap illusion" [ 22 ] are just the beginning. Future systems could combine this with generative AI to allow a user to interact with a virtual avatar of their past self or a future, healthier self, providing a powerful new paradigm for self-compassion and behavioral change. Looking beyond these specific technical steps, the societal context in which this technology is emerging suggests a more profound and urgent role for VR. We are entering an era defined by the splintering of attention due to fragmented internet information, the disorienting impact of pervasive AI, and the potential for increased isolation within nascent metaverse platforms. This combination presents a significant risk for widespread psychological distress, anxiety, and a detachment from the present moment. In this future, immersive technologies like VR and Mixed Reality (MR) will not be mere novelties; they may become essential tools for psychological survival and healing. As these devices become as ubiquitous as smartphones, their unique ability to create a "digital sanctuary"—a controlled, immersive, and restorative space—will be critically important. The true future value of VR mindfulness, therefore, may be as a necessary, scalable counterbalance to the very technologies that will otherwise dominate the next computing era, offering a vital pathway back to attentional focus and emotional regulation. Conclusion VR-based mindfulness interventions demonstrate strong potential in enhancing attentional regulation and emotional well-being. By synthesizing findings from 15 empirical studies, this review shows that carefully designed sensory and visual elements—such as nature-inspired environments, ambient soundscapes, and embodiment strategies—play decisive roles in supporting mindfulness practice. The interdisciplinary integration of psychology, design, and immersive technology highlights that aesthetic decisions are not secondary but essential to therapeutic impact. While limitations remain regarding methodological rigor, sample diversity, and long-term efficacy, the convergence of evidence supports VR as a promising complement to traditional mindfulness. Future research should refine design mechanisms, conduct rigorous large-scale evaluations, and develop culturally inclusive, scalable applications to establish VR mindfulness as a reliable and widely accessible therapeutic modality. Statements and Declarations Funding No funds, grants, or other support were received for conducting this study. Competing interests The authors have no competing interests to declare that are relevant to the content of this article. Ethics approval This article is a systematic review of previously published studies. No ethical approval was required because no new studies with human participants or animals were performed by any of the authors. Consent to participate Not applicable. Consent to publish Not applicable. Data availability This review is based on data extracted from previously published articles cited in the reference list. No new datasets were generated. Additional extraction sheets or coding templates used in this review are available from the corresponding author on reasonable request. Human and animal rights This article does not contain any studies with human participants or animals performed by any of the authors. References Seabrook E, Kelly R, Foley F, Theiler S, Thomas N, Wadley G, et al. Understanding How Virtual Reality Can Support Mindfulness Practice: Mixed Methods Study. JOURNAL OF MEDICAL INTERNET RESEARCH. 2020;22(3). doi: 10.2196/16106. Baydoun M, Gajtani Z, Patton M, McLennan A, Cartwright S, Carlson LE. 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Audio-visual-olfactory immersive digital nature exposure for stress and anxiety reduction: a systematic review on systems, outcomes, and challenges. FRONTIERS IN VIRTUAL REALITY. 2024;5. doi: 10.3389/frvir.2024.1252539. She Y, Wang Q, Liu F, Lin L, Yang B, Hu B. An interaction design model for virtual reality mindfulness meditation using imagery-based transformation and positive feedback. Computer Animation and Virtual Worlds. 2023;34(3-4):e2184. doi: https://doi.org/10.1002/cav.2184. Lee JS, Namkoong K, Ku J, Cho S, Park JY, Choi YK, et al. Social Pressure-Induced Craving in Patients with Alcohol Dependence: Application of Virtual Reality to Coping Skill Training. PSYCHIATRY INVESTIGATION. 2008;5(4):239-43. doi: 10.4306/pi.2008.5.4.239. Zhang JJ, Huang MJ, Yang R, Wang YQ, Tang XH, Han J, et al. Understanding the effects of hand design on embodiment in virtual reality. AI EDAM-ARTIFICIAL INTELLIGENCE FOR ENGINEERING DESIGN ANALYSIS AND MANUFACTURING. 2023;37. doi: 10.1017/S0890060423000045. Miner N, Abdollahi A, Myers C, Kosa M, Ghaednia H, Schwab JH, et al. Stairway to Heaven: A Gamified VR Journey for Breath Awareness. PROCEEDINGS OF THE 2024 CHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYTEMS, CHI 20242024. Winkler MH, Li Y, Pauli P, Muehlberger A. Modulation of smoking cue reactivity by social context-Implications for exposure therapy in virtual reality. FRONTIERS IN VIRTUAL REALITY. 2023;4. doi: 10.3389/frvir.2023.926679. Adhanom I, Halow S, Folmer E, MacNeilage P. VR Sickness Adaptation With Ramped Optic Flow Transfers From Abstract To Realistic Environments. FRONTIERS IN VIRTUAL REALITY. 2022;3. doi: 10.3389/frvir.2022.848001. Additional Declarations No competing interests reported. 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However, despite its evidence base, many individuals—particularly novices—struggle to maintain concentration due to both external distractions and internal mind-wandering [3]. Conventional delivery formats such as audio recordings or instructor-led classes can be perceived as monotonous or difficult to sustain, resulting in limited adherence and reduced therapeutic benefit [4].\u003c/p\u003e\n\u003cp\u003eVirtual reality (VR) technologies offer new opportunities to address these limitations. Through immersive, multisensory environments, VR can limit external distractions and provide attentional anchors, thereby creating conditions conducive to mindfulness practice [5]. Unlike two-dimensional media, VR affords presence and embodiment, potentially enabling users to more readily access meditative states [6]. For example, visual breathing guides, ambient soundscapes, or nature-based scenes can serve as salient cues to redirect wandering attention [7]. Early feasibility studies suggest that VR mindfulness is both acceptable and engaging across populations, including students, patients with chronic pain, and veterans with substance use disorders [8, 9].\u003c/p\u003e\n\u003cp\u003eBeyond feasibility, a critical question concerns how VR systems should be designed to optimally support mindfulness. Prior work emphasizes that design features such as visual aesthetics, sound composition, interactivity, and spatial minimalism can profoundly influence attentional outcomes [3, 10]. Naturalistic environments with low-saturation color palettes, stable horizons, and slow temporal pacing have been associated with calming effects and enhanced focus [11]. In contrast, cluttered or overly dynamic environments may overload attentional resources and disrupt meditative flow [12, 13]. Similarly, congruent multisensory elements (e.g., gentle scents, tactile feedback) can deepen presence, while incongruent cues risk distraction [14, 15]. These findings align with theories from environmental psychology and design research, underscoring the need for an interdisciplinary perspective that integrates psychology, human–computer interaction, and art/design disciplines.\u003c/p\u003e\n\u003cp\u003eDespite growing interest, systematic understanding remains limited. Existing reviews have addressed VR for mental health broadly, but few have specifically synthesized how sensory and visual design elements in VR mindfulness applications contribute to attentional regulation [1, 3]. Moreover, much of the evidence is fragmented across pilot trials, design prototypes, and feasibility studies with heterogeneous outcomes [16, 17]. This fragmentation hampers the ability of researchers and practitioners to identify consistent principles and design guidelines.\u003c/p\u003e\n\u003cp\u003eThe present review addresses this gap by conducting a PRISMA-based systematic review of VR-based mindfulness meditation interventions, with a dedicated focus on sensory design and attentional outcomes. We synthesized findings from 15 eligible studies, supplemented by 10 cross-disciplinary references from design and psychology [18, 19]. Our objectives were threefold:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eTo describe the range of VR design strategies employed in mindfulness applications, including visual environments, auditory and multisensory cues, embodiment, and biofeedback.\u003c/li\u003e\n\u003cli\u003eTo evaluate evidence linking these design strategies to attentional, emotional, and user experience outcomes.\u003c/li\u003e\n\u003cli\u003eTo identify interdisciplinary contributions from art and design that can inform future development of VR mindfulness systems.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eBy highlighting both effective practices and unresolved challenges, this review aims to guide researchers, clinicians, and designers in developing VR mindfulness environments that maximize attentional regulation and user benefit. Furthermore, by situating VR mindfulness at the intersection of technology, psychology, and design, we emphasize the role of aesthetic and sensory considerations as central, rather than peripheral, to therapeutic efficacy.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eThis review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A systematic search was conducted in Web of Science (Core Collection and allied indexes), PubMed, Scopus, IEEE Xplore, and ACM Digital Library, covering publications from January 2010 to January 2025. The search terms included combinations of: \u003cem\u003e\u0026ldquo;virtual reality\u0026rdquo; OR \u0026ldquo;VR\u0026rdquo;\u003c/em\u003e AND \u003cem\u003e\u0026ldquo;mindfulness\u0026rdquo; OR \u0026ldquo;mindfulness meditation\u0026rdquo;\u003c/em\u003e AND \u003cem\u003e\u0026ldquo;design\u0026rdquo; OR \u0026ldquo;visual aesthetics\u0026rdquo; OR \u0026ldquo;sensory\u0026rdquo;\u003c/em\u003e AND \u003cem\u003e\u0026ldquo;attention\u0026rdquo; OR \u0026ldquo;focus.\u0026rdquo;\u003c/em\u003e To reduce irrelevant results, exclusion terms included \u003cem\u003e\u0026ldquo;augmented reality,\u0026rdquo; \u0026ldquo;AR,\u0026rdquo; \u0026ldquo;mixed reality,\u0026rdquo; \u0026ldquo;MR,\u0026rdquo; \u0026ldquo;game,\u0026rdquo; \u0026ldquo;animal study,\u0026rdquo; and \u0026ldquo;technical development.\u0026rdquo;\u003c/em\u003e Boolean operators and truncations were tailored for each database. Additionally, reference lists of included studies were hand-searched for relevant sources [1, 3].\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eStudies were included if they: (1) explicitly described a VR-based intervention for mindfulness or meditation; (2) reported design features related to visual, sensory, or attentional strategies; and (3) included empirical evaluation, whether feasibility studies, pilot trials, or research protocols. Exclusion criteria were: (1) reviews, commentaries, and conference abstracts that did not contain original empirical data; (2) studies not involving VR or not focused on mindfulness; and (3) non-English publications. This approach allowed for the inclusion of early-stage empirical work, such as feasibility studies, pilot trials, and research protocols, which are valuable for understanding the field\u0026rsquo;s design landscape and future directions.\u003c/p\u003e\n\u003ch3\u003eStudy Selection and Screening\u003c/h3\u003e\n\u003cp\u003eTwo reviewers independently screened titles and abstracts for relevance. Full texts were then assessed according to inclusion and exclusion criteria. Discrepancies were resolved by consensus. The initial search yielded 48 records. After removing duplicates and applying exclusion criteria, 19 full texts were assessed. Four were excluded for being reviews or for being unrelated to the core topic, leaving 15 studies for final synthesis. Fig. 1 presents the PRISMA flow diagram of the search and selection process.\u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eKey information was extracted from each included study: authorship, year, population, VR system hardware, virtual environment characteristics (e.g., natural vs. abstract design, color palettes, motion pacing), sensory features (audio, olfactory, haptic), attentional guidance strategies (e.g., breathing cues, embodiment, biofeedback), study design, and outcomes related to mindfulness, attention, emotional well-being, and user experience. Extraction was validated by cross-checking with a structured spreadsheet prepared by the student research team.\u003c/p\u003e\n\u003ch3\u003eSynthesis Approach\u003c/h3\u003e\n\u003cp\u003eGiven heterogeneity across interventions and outcome measures, a narrative synthesis approach was used. Studies were grouped under thematic categories: (a) VR environment design and sensory features; (b) mindfulness and attentional outcomes; (c) emotional, stress-related, and clinical outcomes; and (d) user experience and acceptability. Within each theme, findings were compared, and recurring design principles were identified [5, 7]. Quantitative outcome data were reported descriptively; qualitative insights were incorporated where relevant to illustrate user experience and design implications.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eStudy Characteristics\u003c/p\u003e\u003cp\u003eA total of 15 studies were included, spanning diverse populations and settings. This review synthesizes various research types, including empirical studies, design prototypes, feasibility studies, and research protocols, to comprehensively reflect the design and methodological landscape of this field. Sample sizes ranged from healthy university students and adolescents to clinical groups, such as cancer survivors with chronic pain, hemodialysis patients, veterans with substance use disorders, and post-COVID rehabilitation cohorts [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Most studies were small-scale pilots or feasibility trials, with sample sizes between 15 and 60 participants. Interventions varied from single-session experiments to 6\u0026ndash;8 week programs. Hardware primarily included Oculus Rift/Quest or HTC Vive head-mounted displays, while some telemindfulness interventions used cloud-based VR systems compatible with mobile devices [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of Included Studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy Title\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAuthor \u0026amp; Year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003esubjects\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVR Environment \u0026amp; Sensory Features\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe potential of virtual reality to support adolescent mental well-being in schools: A UK co-design and proof-of-concept study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eS. Hugh-Jones, M. Ulor, T. Nugent, Hugh-Jones et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdolescents (UK, 15\u0026ndash;18); Emotional/Attention Needs ; Mainstream/Specialist Education.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eImmersive 360\u0026deg; Calm Scenes (Beach/Forest); Guided Audio (Optional Narrators/Ambient Sound); Minimal Interaction; Mindfulness Support.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026uarr; Post-Session Mood; \u0026uarr; Sustained Attention ; \u0026uarr; Content Recall/Practice Completion; Strong Presence; \u0026uarr; In-the-Moment Emotion Regulation; Stress Reduction (\"Step Out\").\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy protocol for improving mental health during pregnancy:a randomized controlled low-intensity m-health intervention by midwives at primary care centers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJimenez-Barragan et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePregnant Women (Spanish-Speaking, \u0026ge;\u0026thinsp;18); Mild Anxiety/Depression (EPDS 9\u0026ndash;12); Early Gestation (12\u0026ndash;14 weeks); Primary-Care Setting.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHome-Based VR (Oculus GO); 14-min Cordless App; Three 360\u0026deg; Relaxation Modules; Avatar Narrator; Paced Breathing/Muscle-Relaxation Cues; Ambient Sound; Controller-Free.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6-Week Daily Use;\u0026darr; Anxiety/Depression Symptoms (STAI, EPDS, SCL-90); High Usability; \u0026uarr; Focused Attention; \u0026uarr; Recall of Relaxation Steps; Strong Presence; Detachment from Daily Stressors.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHernandez et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdults (\u0026ge;\u0026thinsp;21); Maintenance Hemodialysis\u0026thinsp;\u0026ge;\u0026thinsp;3mos); Comorbid Depression (BDI-II\u0026thinsp;\u0026ge;\u0026thinsp;11); Chicago Dialysis Centers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMeta Quest Pro Headset; In-Session Use (During Dialysis); 3D/360\u0026deg; Worlds (Garden, Gallery, Beach); Head-Gaze Navigation; Interactive Tasks (Virtual Photos, Mini-Games, Quizzes); Bilingual Audio.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePilot Data; Significant \u0026darr; Depression (BDI-II, PROMIS);\u0026uarr; Life Satisfaction/Positive Affect/Optimism/Emotional Vitality;\u0026uarr; Attention to Content;\u0026uarr; Homework Recall; Strong Presence; Momentary Clinic Escape.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderstanding How Virtual Reality Can Support Mindfulness Practice: Mixed Methods Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSeabrook et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGeneral Population (N\u0026thinsp;=\u0026thinsp;37, mean age 38); Varying Mindfulness Experience; No Severe Mental Illness/VR Sickness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15-min App (Oculus Go); Controller-Free; Immersive 360\u0026deg; Forest Video; Spatial Nature Sounds; Guided Voiceover (Attentional Anchors); User-Selected Focus Points.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSignificant \u0026uarr; State Mindfulness/Positive Affect (Large Effect Size: d\u0026thinsp;=\u0026thinsp;1.80); \u0026uarr; Present-Moment Attention;\u0026uarr; Recall of Practice Steps; Pronounced Sense of Presence; Attentional Anchor (VE as tool); Thought Detachment (\"Step Away\").\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMindfulness-based relapse prevention combined with virtual reality cue exposure for methamphetamine use disorder: Study protocol for a randomized controlled trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChen et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMethamphetamine Users (N\u0026thinsp;=\u0026thinsp;180, 18\u0026ndash;55 yrs); Abstinent (\u0026ge;\u0026thinsp;3 mos); Rehab Center (Beijing).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHTC VIVE System; Room-Scale VR (3x4m); Single 60-min Session; Virtual Living-Room (Drug Cues: Foil/Paraphernalia); VR Cue Exposure ; Therapist-Guided Mindfulness ; Physiological Streaming (SC/HR/EEG).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026darr; Self-Reported Craving; \u0026darr; Attentional Bias (Emotional Stroop); \u0026uarr; Sustained Attention; Strong Presence (\"In the using scene\"); \u0026uarr; Recall of Coping Steps; \u0026uarr; Regulation of Drug-Related Memory; \u0026uarr; On-Task Focus.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients perceptions of virtual reality therapy in the management of chronic cancer pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGarrett et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdults (N\u0026thinsp;=\u0026thinsp;12, Canadian); Chronic Cancer Pain (\u0026gt;\u0026thinsp;3 mos, NRS\u0026thinsp;\u0026ge;\u0026thinsp;4); Mostly Post-Treatment; VR-Na\u0026iuml;ve.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHome Sessions (HTC Vive); 45-min Sessions; User-Choice Modules (Mindful Walk, Puzzles, Sci-Fi); 3D/360\u0026deg;; Navigation by Head-Turn/Controller; Seated/Standing.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTransient but Significant Pain Reduction;\u0026uarr; Attention; \u0026uarr; Memory for Coping Steps; Strong Sense of Presence (\"Forgot pain\"); Relaxation/Distraction Preferred; Minor Cybersickness/Eye-Strain Noted.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUsing Artificial Intelligence-informed Experience-Based Co-Design (AI-EBCD) to create a virtual reality-based mindfulness application to reduce diabetes distress: protocol for a mixed- methods feasibility study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhosal et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdults; Type 2 Diabetes (\u0026gt;\u0026thinsp;12 mos); Self-Reported Diabetes Distress; Smartphone Owner (Android).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15-min Unity VR App; Co-Designed (Generative AI/Users); Immersive Audiovisual Scenes; Interactive Breathing Cues; Personalized Content.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePilot Data; Significant \u0026darr; Diabetes Distress (DDS);\u0026uarr; Quality of Life (DSQoLS); \u0026uarr; Attention Regulation; \u0026uarr; Recall of Mindfulness Steps; Strong Presence; Focus Shift from Daily Stress.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention Regulation Framework: Designing Self-Regulated Mindfulness Technologies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNiksirat et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdults; Meditation Na\u0026iuml;ve; Novices/Unfamiliar with Mindfulness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMobile-Based VR; Non-Intrusive Detection-Feedback; Subtle Movement Input (Finger/Body Motion); Multimodal Sensory Cues (Audio-Visual/Haptic); Attention Regulation Focus.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026uarr; Attention (ANT scores); \u0026uarr; Memory (Theta/Alpha EEG \u0026uarr;); \u0026uarr; Presence (Self-Reported); \u0026darr; Stress Markers (\u0026uarr; HR Variability); \u0026darr; Mood Disturbances (POMS).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVirtual reality mindfulness training for veterans in residential substance use treatment: Pilot study of feasibility and acceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVan Doren et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVeterans (N\u0026thinsp;=\u0026thinsp;20, mostly male); Residential Substance Use Treatment; High Rates PTSD/Depression.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSelf-Guided VR Headset; 360\u0026deg; Nature Scenes; Ambient Sounds; Guided Audio Instructions; Passive Interaction (Gaze/Listening).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSignificant \u0026darr; Negative Affect/Anxiety; \u0026uarr; Positive Emotions/Calmness; \u0026uarr; State Mindfulness;\u0026uarr; Attention Focus; \u0026uarr; Sense of Presence.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDesign Considerations for Supporting Mindfulness in Virtual Reality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKelly et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGeneral Population (N\u0026thinsp;=\u0026thinsp;9); Varying VR/Mindfulness Experience (Novices/Practitioners).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVR App \"Place\"; Omnidirectional Forest Videos; Natural Sounds; Guided Voiceovers; Minimal Interaction (Head Gaze/Auto-Transitions); Mindfulness Support.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026uarr; State Mindfulness/Relaxation/Positive Affect; \u0026uarr; Attention Regulation;\u0026uarr; Memory Anchoring (Sensory Cues); Enhanced Sense of Presence; Non-Overwhelming User Experience.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePutting Oneself in the Body of Others: A Pilot Study on the Efficacy of an Embodied Virtual Reality System to Generate Self-Compassion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCebolla et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUniversity Students (N\u0026thinsp;=\u0026thinsp;16); Meditation Na\u0026iuml;ve; No Mental Disorders; RCT Design (VR vs. Audio).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTMTBA-VR System (Oculus Rift); Body-Swap Illusion; Third-Person View; Visual/Auditory/Proprioceptive Feedback; Self-Compassion Meditation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBoth Groups \u0026uarr; Self-Compassion/Mindfulness; VR \u0026uarr; Adherence (esp. for Low Imagery Ability); VR \u0026uarr; Attention; VR \u0026uarr; Memory Anchoring; VR \u0026uarr; Sense of Presence.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVirtual reality\u0026ndash;guided mindfulness for chronic pain in cancer survivors: protocol for the virtual mind study\u0026mdash;a single-group feasibility trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBaydoun et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdult Cancer Survivors (N\u0026thinsp;=\u0026thinsp;15); Chronic Cancer-Related Pain (\u0026gt;\u0026thinsp;3 mos); Moderate-Severe Pain Interference.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandalone Headset (Pico Neo 3 Pro, 4K); Head Tracking/Built-in Audio; Daily 10\u0026ndash;15 min Sessions; VR-Guided Mindfulness; Nature-Themed Environments.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026darr; Pain/Anxiety/Depression/Fatigue; \u0026uarr; Sleep/Quality of Life/Trait Mindfulness/Sense of Presence; Data Collection: Pain Ratings, VR Engagement, Attention Focus, Memory Anchoring, Immersive Effects.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA Cloud-Based Virtual Reality App for a Novel Telemindfulness Service: Rationale, Design and Feasibility Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCikajlo et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHospital Employees (\u0026uarr; Stress); Outpatients (TBI/Brain-Tumor) with Anxiety; 8-Week Trial (N\u0026thinsp;=\u0026thinsp;8 total).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSamsung GearVR; User-Selected 360\u0026deg; Scenes (Nature/Virtual Rooms); Natural Interaction (Head Movement/Voice); Real-Time Instructor Audio-Video; Music/Natural Sound Stream.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026uarr; Patient Life Satisfaction/MAAS Mindfulness;\u0026darr; High-Frequency Head Motion (Physiological Marker); Improved Attention/Memory Engagement (Inferred from Head Motion); Strong Presence; High Ease-of-Use.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReal - time virtual reality co - creation: collective intelligence and consciousness for student engagement and focused attention within online communities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWang, Sun [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTenth-Grade EFL Students (N\u0026thinsp;=\u0026thinsp;66, Taiwan); Quasi-Randomized Design; VR vs. 2D vs. Paper Groups.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCoSpaces Edu; 3D VR Co-Creation; Shared VR Scene; Drag-and-Drop Objects/Coding; Google-Cardboard Immersion (First-Person); Real-Time Co-Editing/Tap Navigation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSignificant \u0026uarr; Emotional Engagement (VR\u0026thinsp;\u0026gt;\u0026thinsp;2D\u0026thinsp;\u0026gt;\u0026thinsp;Paper); No Significant \u0026uarr; Behavioral/Cognitive Engagement/Focused Attention; VR \u0026uarr; Situational Interest/Memory Encoding (Temporary Boost); Suggests Need for Longer Intervention.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA multimodal group-based immersive virtual reality intervention for improving cognition and mental health in patients with post-COVID-19 condition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCano et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdults (N\u0026thinsp;=\u0026thinsp;31, mean age 50.3, 76.9% women); Post-COVID Cognitive Complaints; Elevated Depression/Anxiety (PHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;6, GAD-7\u0026thinsp;\u0026ge;\u0026thinsp;10); Quasi-Assigned (IVR vs. Usual Care); 15-Session.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIVR (Immersive Virtual Reality); Group Sessions; Headset-Free (MK360 360\u0026deg; Projection over 3 Walls/Ceiling); Multimodal Training; 10-min Mindfulness/30-min Interactive Cognitive Tasks (Park Walk/Emoticon Search); Real-Time Visuals/Sound/Therapist Cues; Shared Space Movement/Response.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLarge-Effect Improvements vs. Controls;\u0026uarr; Global Cognition;\u0026uarr; Attention (\u0026darr; CPT Omissions); \u0026uarr; Processing Speed;\u0026uarr; Episodic Memory; \u0026darr; Depressive Symptoms (\u0026darr; PHQ-9 6 pts); High Enjoyment/Perceived Improvement; Stable Fatigue; Strong Presence; Sustained Engagement (No Overload).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eVR Environment Design and Sensory Features\u003c/p\u003e\u003cp\u003eMost interventions employed nature-based environments\u0026mdash;forests, beaches, rivers, or mountains\u0026mdash;reflecting biophilic design principles known to promote calmness and restoration [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Visual features emphasized low-saturation colors, horizon stability, and minimal clutter [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Temporal pacing, such as slow drifting or breath-synchronized animations, reduced exogenous attentional capture [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Audio design consistently included ambient natural sounds and soft narration, with positive feedback regarding immersion [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Multisensory enhancements, such as olfactory pine scent [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] or tactile water spray [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], deepened presence and embodiment. Embodiment strategies, including body-swap illusions and biofeedback-driven environments, supported interoceptive awareness and attentional focus [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFocusing on the visual design, the visual design of nature-based settings was often highly detailed. Examples included 4K omnidirectional (360\u0026deg;) video of a real forest, captured at a 1.3-meter height to simulate a seated perspective [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], 360\u0026deg; calm scenes of beaches [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and 3D computer-generated worlds featuring mountain meadows, white sands, and spring creeks [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, environments were also purpose-built for non-relaxation goals. For substance use disorder, Chen et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] constructed a virtual living room containing drug paraphernalia (eg, foil) to specifically conduct virtual reality cue exposure (VRCE) therapy. For hemodialysis patients, Hernandez et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] designed interactive 3D/360\u0026deg; worlds (eg, garden, gallery) that included mini-games and quizzes to support a positive psychology curriculum.\u003c/p\u003e\u003cp\u003eBeyond the visual elements, auditory design was a critical component for immersion. Studies used ambient sounds recorded on-site [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] or provided user-selectable streams of music and natural sounds (eg, birds, wind, waves)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The narrator's voice and pacing were key design considerations. For example, Kelly et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], through iterative user testing, found that a slower pace and longer pauses in the narration were essential to allow users time for unguided practice.\u003c/p\u003e\u003cp\u003eFurthermore, multisensory and embodiment strategies were explored in depth. A prominent example is the study by Cebolla et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which used \"The Machine to be Another\" (TMTBA-VR) system. This setup induced a \"body swap illusion\" by feeding a performer's first-person visual perspective to the user's VR headset while they synchronized movements, allowing the user to feel embodied in another person's form and see themselves from a third-person perspective to enhance self-compassion. Other systems integrated biofeedback. Niksirat et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] developed a framework where subtle finger movements on a smartphone's touchscreen provide real-time audio-visual feedback to help \u003cem\u003eself-regulate\u003c/em\u003e attention, eliminating the need for external sensors. Visual breathing guides, such as the \"Breathing Sphere\" animation for adolescents, were also employed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], as were interactive breathing cues in co-designed apps [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMindfulness and Attentional Outcomes\u003c/p\u003e\u003cp\u003eAcross studies, immediate improvements in state mindfulness, present-moment focus, and reduced mind-wandering were observed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Adolescent participants reported that breathing-ball animations improved attention regulation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Post-COVID participants in group VR interventions demonstrated gains in attention and cognitive function [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, when VR tasks were complex or interactive, attentional benefits were reduced, indicating potential cognitive load issues [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe immediate enhancement of state mindfulness is a highly consistent finding. Seabrook et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] reported a large and statistically significant increase in State Mindfulness Scale scores (Cohen's d\u0026thinsp;=\u0026thinsp;1.80) after a single 15-minute session. Van Doren et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] also noted significant increases in state mindfulness among veterans, who qualitatively reported that the VR environment helped them \"zone in.\" Qualitative feedback from other studies supports this, with participants describing the immersive visuals and sounds as effective \"attentional anchors\" that helped them \"rein in\" a wandering mind more quickly than traditional practice [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eObjective measures of attention further support these self-reports. Cano et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] found that post-COVID patients in their group IVR intervention showed significant gains in attention, specifically a reduction in omission errors on the Continuous Performance Test (CPT). The framework proposed by Niksirat et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], which uses subtle finger movements for self-regulation, led to improved scores on the Attentional Network Test (ANT) and corresponding increases in theta/alpha EEG activity, which are associated with memory and attention. Similarly, Chen et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] found that their VRCE-plus-mindfulness group showed a reduction in attentional bias as measured by the Emotional Stroop test.\u003c/p\u003e\u003cp\u003eHowever, the cognitive demands of the VR interaction itself can be a limiting factor. Wang and Sun [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] compared VR co-creation (using CoSpaces) to 2D and paper methods. While VR significantly boosted \u003cem\u003eemotional\u003c/em\u003e engagement, it failed to show significant gains in cognitive engagement or focused attention. The researchers posited that the cognitive load of navigating the complex 3D authoring tool in a short period consumed the attentional resources that would have otherwise been directed at the task itself.\u003c/p\u003e\u003cp\u003eEmotional, Stress-Related, and Clinical Outcomes\u003c/p\u003e\u003cp\u003eVR mindfulness interventions showed consistent calming and affective benefits, with reductions in anxiety, stress, and pain reported across populations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Clinical contexts highlighted VR\u0026rsquo;s feasibility for oncology, hemodialysis, and chronic pain patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While results are promising, heterogeneity of measures and small samples limit generalizability.\u003c/p\u003e\u003cp\u003e Participants consistently reported strong calming benefits. Van Doren et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found that veterans, after a single session, experienced significant reductions in negative affect (including anxiety) and significant increases in positive emotions and calmness. This was mirrored by Seabrook et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], who also measured a significant increase in positive affect. In the study with adolescents, post-session mood ratings increased on average from 3.15 to 4.56 (out of 5) in mainstream schools, and from 2.78 to 4.17 in a specialist setting, demonstrating an immediate affective boost [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn specific clinical populations, these interventions demonstrated clear therapeutic potential. For cancer survivors with chronic pain, Garrett et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] reported that participants found \"transient but significant\" pain reduction after using VR modules, including a \"Mindful Walk.\" The protocol by Baydoun et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] is designed to formally test these outcomes, aiming for reductions in pain, anxiety, and depression. For post-COVID patients, Cano et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] found their multimodal IVR intervention produced a large-effect improvement in depressive symptoms (a 6-point drop on the PHQ-9). Similarly, protocols are in place to test the efficacy of VR interventions on reducing depression in hemodialysis patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and reducing anxiety and depression in pregnant women [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Ghosal et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] also aim to show a reduction in diabetes distress. For substance use, Chen et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported that VRCE combined with mindfulness reduced self-reported craving.\u003c/p\u003e\u003cp\u003eUser Experience and Acceptability\u003c/p\u003e\u003cp\u003eAcceptability was high across most studies, with participants describing VR as immersive, private, and engaging [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Cybersickness was infrequent and generally mild when design minimized motion and maintained frame stability. Session length optimization (5\u0026ndash;15 minutes per session) and cultural adaptation of narratives were noted as practical considerations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Overall, user experience findings reinforced the importance of simple design, congruent multisensory cues, and ergonomic usability for successful VR mindfulness adoption.\u003c/p\u003e\u003cp\u003eA key advantage highlighted by participants was VR's ability to reduce distractions. Veterans in residential substance use treatment noted that in traditional mindfulness groups, the presence of others was disruptive [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The VR headset provided a sense of privacy and safety, which was particularly valued by participants with PTSD, who reported feeling less hypervigilant and more able to relax in the \"bubble\" of the VR environment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The novelty and engaging nature of the technology were also frequently cited as positive factors that increased motivation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe most common negative feedback related to hardware discomfort. Cybersickness was reported, though infrequently, and was primarily associated with experiences that simulated movement, such as flying [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. More pervasive were complaints about the physical ergonomics of the headset, including its weight, the pressure it exerted on the face, and incompatibility with eyeglasses [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Technical limitations, such as mobile phones overheating in GearVR systems, also prompted designers to limit session durations to 30 minutes to ensure user comfort and system stability [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe need for personalization and co-design was a strong theme. Participants in the focus groups conducted by Kelly et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] revealed that users desire a variety of environments (eg, day vs. night scenes) and the ability to select one based on their current mood. This feedback aligns with findings from Garrett et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], where patients showed distinct preferences for \u003cem\u003eeither\u003c/em\u003e contemplative experiences (like the mindful walk) or cognitive-challenge games, but rarely both. This highlights that a \"one-size-fits-all\" design is suboptimal. Consequently, newer protocols are explicitly built around co-design, such as involving adolescents in the design process [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] or using generative AI to create personalized content with adults who have type 2 diabetes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSummary of Findings\u003c/p\u003e\u003cp\u003eVR sensory and design features influence mindfulness practice. Evidence consistently indicated that nature-based environments, stable visual horizons, ambient soundscapes, and congruent multisensory cues were effective in improving attentional focus and emotional regulation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Multisensory and embodiment features enhanced presence, but overly complex interactions risked cognitive overload. Importantly, the findings converge across adolescent, clinical, and healthy adult populations, underscoring the broad applicability of design-driven mindfulness interventions.\u003c/p\u003e\u003cp\u003eThis convergence was evident in both the chosen modalities and the reported outcomes. For instance, the effectiveness of nature-based environments was validated not only in high-fidelity 4K omnidirectional videos [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] but also in more stylized, computer-generated 3D worlds [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, the role of embodiment in enhancing presence was powerfully demonstrated by the \"body swap illusion\" technique, which leveraged multisensory feedback to deepen self-compassion [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Conversely, the risk of cognitive overload was explicitly confirmed by Wang and Sun [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], who found that while a complex 3D co-creation task (CoSpaces) increased emotional engagement, it failed to improve focused attention, suggesting attentional resources were consumed by the tool itself. These findings provide a more granular understanding of the trade-offs between immersion and cognitive load.\u003c/p\u003e\u003cp\u003eComparison with Existing Literature\u003c/p\u003e\u003cp\u003eWhen compared with traditional 2D or audio-guided modalities, VR-based interventions demonstrate distinct advantages. For instance, studies comparing computer-generated VR (CG-VR) with 2D high-definition video found that the increased sense of presence in CG-VR mediated significantly greater improvements in positive affect [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Similarly, VR-enhanced mindfulness has been shown to produce a greater increase in decentering\u0026mdash;a key metacognitive skill involving the ability to observe one's thoughts without entanglement\u0026mdash;than audio-only guidance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, the simple equation of immersion with effectiveness is challenged by a critical design dichotomy: photorealism versus abstraction. While realistic renderings can evoke a stronger sense of presence, they risk triggering real-world semantic associations that may distract from introspective focus. This paradox is partially resolved by evidence suggesting that visual coherence and quality may be more critical than realism itself. An internally consistent, stylized world could be more effective than an imperfectly realistic one, as it minimizes the risk of incongruent elements breaking the meditative state [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This shifts the design focus from a simple pursuit of realism to the creation of a cohesive virtual space that best supports attentional control.\u003c/p\u003e\u003cp\u003eThe findings from this review reinforce these distinct advantages over audio-only modalities. For example, Cebolla et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] directly compared their embodied VR system to an audio-only meditation and found that while both groups improved, the VR intervention significantly increased adherence, particularly for participants with low imagery ability. This suggests VR acts as a powerful scaffold for individuals who struggle to generate or sustain mental images, a common barrier in traditional practice. Furthermore, participants in multiple studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] explicitly stated that the primary benefit of VR over audio-only guides was its ability to eliminate external distractions and provide a persistent visual \"attentional anchor,\" which helped them \"rein in\" a wandering mind and fostered a greater sense of safety and privacy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInterdisciplinary Contributions\u003c/p\u003e\u003cp\u003eThis review highlights the critical importance of interdisciplinary integration, where principles from art, design, and psychology converge to inform effective VR mindfulness systems. Artistic and aesthetic strategies are not merely decorative but foundational to the therapeutic experience. For example, the use of spatial aesthetics inspired by Japanese gardens\u0026mdash;emphasizing negative space and asymmetrical layouts\u0026mdash;can create a contemplative and meditative virtual space, a principle also observed in the design of immersive virtual museums [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Color psychology also plays a crucial role; the deliberate use of low-saturation color palettes, particularly in the green-blue spectrum, aligns with theories suggesting certain color schemes can directly induce calmness and reduce physiological arousal [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Furthermore, insights from social psychology explain the enhanced effects of group-based VR interventions. The mechanism of rhythmic synchrony, where individuals perform actions in unison, can amplify compassion and prosocial emotions, strengthening therapeutic alliance and adherence [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Finally, the technical implementation of embodiment is deeply rooted in cognitive psychology, where the non-hierarchical integration of visual form, touch, and spatial cues is essential for generating a convincing sense of body ownership and agency [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Collectively, these contributions underscore that VR mindfulness is not simply a technological tool, but a practice situated at the rich intersection of art, social science, and human-computer interaction.\u003c/p\u003e\u003cp\u003eThe studies in this review provide concrete examples of this interdisciplinary convergence. From a Human-Computer Interaction (HCI) perspective, Niksirat et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] developed an 'Attention Regulation Framework' that translates cognitive theory into a tangible interaction model, using subtle finger movements on a touchscreen as a real-time proxy for attention. This work exemplifies how HCI design can create biofeedback loops without intrusive sensors. From clinical psychology, the work of Chen et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] merges traditional cue exposure therapy for addiction with bespoke VR environment design, creating a high-risk virtual scenario to practice mindfulness skills safely. Furthermore, the work by Cano et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] demonstrates an integration of neuropsychology and social psychology, using a shared, headset-free IVR space for group-based cognitive rehabilitation, showing that the social presence of a group can be combined with immersive technology to enhance outcomes.\u003c/p\u003e\u003cp\u003eDesign Implications for Practice\u003c/p\u003e\u003cp\u003e Based on the synthesized evidence, we propose a set of actionable design guidelines for practitioners and researchers. First, in visual design, prioritize simplicity and coherence over photorealism. This involves using low-saturation color palettes and minimalist spaces to reduce cognitive load [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], but more importantly, ensuring the internal consistency of the chosen aesthetic, whether abstract or stylized [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Second, multisensory integration must be congruent and purposeful. Olfactory and tactile cues should be carefully timed and matched to the visual environment to enhance presence without causing distraction, as inappropriate stimuli can disrupt the meditative state [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Third, interaction design should follow a principle of \"less is more.\" Iterative user feedback often reveals the need for longer pauses, slower pacing, and simpler interactions to be effective [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. For specific populations, such as those with substance use disorders, incorporating social elements into VR can increase ecological validity, but these must be introduced carefully to manage cue reactivity [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Finally, user agency and personalization are key. Providing choices in visual and auditory anchors allows users to select what is most effective for them, ultimately supporting engagement and adherence. These principles form a foundation for creating VR mindfulness experiences that are not only technologically immersive but also psychologically attuned and therapeutically effective.\u003c/p\u003e\u003cp\u003eThis review also highlights several specific, practical implications. First, the design of the guided narration is as critical as the visuals. Iterative user testing by Kelly et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] revealed that users strongly prefer slower-paced narration with extended pauses (eg, up to 70 seconds, as in Cano et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]), as this allows them to shift from passive listening to active, unguided practice. Second, hardware ergonomics cannot be an afterthought. Multiple studies reported that the weight of the headset, pressure on the face, and incompatibility with eyeglasses were significant barriers to immersion and comfort [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Future designs must prioritize lighter, more comfortable, and wireless hardware. Finally, the design process itself is an implication. The success of co-design approaches [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] suggests that involving the target population (eg, adolescents, patients with diabetes) from the outset is crucial for creating applications that are not only usable but also relevant, trusted, and engaging.\u003c/p\u003e\u003cp\u003eLimitations and Future Directions\u003c/p\u003e\u003cp\u003eDespite the promising findings, the current evidence base has notable limitations, including a predominance of small-scale pilot studies, heterogeneous outcome measures, and a lack of long-term follow-up data. These limitations highlight several critical directions for future research. First, there is a need for systematic component analysis to understand how specific design choices impact outcomes. For example, future studies should compare how different avatar designs\u0026mdash;from photorealistic to stylized or abstract\u0026mdash;influence the sense of embodiment and therapeutic outcomes such as self-compassion [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Second, research should move beyond static environments to explore dynamic, biofeedback-driven systems. Innovations such as gamified, breath-driven locomotion, where virtual movement is tied to respiratory rate, offer a pathway to externalize interoceptive states and create a more engaging, self-regulated experience [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Third, for clinical applications like substance use disorder, interventions must increase their ecological validity. Future VR cue-exposure paradigms should incorporate social contexts, such as peer pressure from virtual avatars, which are often more potent relapse triggers than object-based cues alone [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Finally, to improve accessibility, research on mitigating cybersickness is crucial. This includes exploring adaptation protocols, such as gradually increasing optic flow, which may help users build tolerance and engage more comfortably in VR experiences [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Addressing these areas will be essential for maturing VR mindfulness from a promising novelty into a robust, evidence-based therapeutic modality.\u003c/p\u003e\u003cp\u003eThe studies reviewed here point directly to these future directions. For example, the non-intrusive biofeedback method proposed by Niksirat et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], which uses simple finger movements, could be expanded using modern smartphone haptics to create a closed-loop, self-regulating experience without any visual interface. Similarly, the profound effects of the \"body swap illusion\" [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] are just the beginning. Future systems could combine this with generative AI to allow a user to interact with a virtual avatar of their past self or a future, healthier self, providing a powerful new paradigm for self-compassion and behavioral change.\u003c/p\u003e\u003cp\u003eLooking beyond these specific technical steps, the societal context in which this technology is emerging suggests a more profound and urgent role for VR. We are entering an era defined by the splintering of attention due to fragmented internet information, the disorienting impact of pervasive AI, and the potential for increased isolation within nascent metaverse platforms. This combination presents a significant risk for widespread psychological distress, anxiety, and a detachment from the present moment. In this future, immersive technologies like VR and Mixed Reality (MR) will not be mere novelties; they may become essential tools for psychological survival and healing. As these devices become as ubiquitous as smartphones, their unique ability to create a \"digital sanctuary\"\u0026mdash;a controlled, immersive, and restorative space\u0026mdash;will be critically important. The true future value of VR mindfulness, therefore, may be as a necessary, scalable counterbalance to the very technologies that will otherwise dominate the next computing era, offering a vital pathway back to attentional focus and emotional regulation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVR-based mindfulness interventions demonstrate strong potential in enhancing attentional regulation and emotional well-being. By synthesizing findings from 15 empirical studies, this review shows that carefully designed sensory and visual elements\u0026mdash;such as nature-inspired environments, ambient soundscapes, and embodiment strategies\u0026mdash;play decisive roles in supporting mindfulness practice. The interdisciplinary integration of psychology, design, and immersive technology highlights that aesthetic decisions are not secondary but essential to therapeutic impact. While limitations remain regarding methodological rigor, sample diversity, and long-term efficacy, the convergence of evidence supports VR as a promising complement to traditional mindfulness. Future research should refine design mechanisms, conduct rigorous large-scale evaluations, and develop culturally inclusive, scalable applications to establish VR mindfulness as a reliable and widely accessible therapeutic modality.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eNo funds, grants, or other support were received for conducting this study.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003ch3\u003eEthics approval\u003c/h3\u003e\n\u003cp\u003eThis article is a systematic review of previously published studies. No ethical approval was required because no new studies with human participants or animals were performed by any of the authors.\u003c/p\u003e\n\u003cp\u003eConsent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eConsent to publish\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eThis review is based on data extracted from previously published articles cited in the reference list. No new datasets were generated. Additional extraction sheets or coding templates used in this review are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eHuman and animal rights\u003c/p\u003e\n\u003cp\u003eThis article does not contain any studies with human participants or animals performed by any of the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSeabrook E, Kelly R, Foley F, Theiler S, Thomas N, Wadley G, et al. 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Understanding the effects of hand design on embodiment in virtual reality. AI EDAM-ARTIFICIAL INTELLIGENCE FOR ENGINEERING DESIGN ANALYSIS AND MANUFACTURING. 2023;37. doi: 10.1017/S0890060423000045.\u003c/li\u003e\n\u003cli\u003eMiner N, Abdollahi A, Myers C, Kosa M, Ghaednia H, Schwab JH, et al. Stairway to Heaven: A Gamified VR Journey for Breath Awareness. PROCEEDINGS OF THE 2024 CHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYTEMS, CHI 20242024.\u003c/li\u003e\n\u003cli\u003eWinkler MH, Li Y, Pauli P, Muehlberger A. Modulation of smoking cue reactivity by social context-Implications for exposure therapy in virtual reality. FRONTIERS IN VIRTUAL REALITY. 2023;4. doi: 10.3389/frvir.2023.926679.\u003c/li\u003e\n\u003cli\u003eAdhanom I, Halow S, Folmer E, MacNeilage P. VR Sickness Adaptation With Ramped Optic Flow Transfers From Abstract To Realistic Environments. FRONTIERS IN VIRTUAL REALITY. 2022;3. doi: 10.3389/frvir.2022.848001.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Virtual reality, Mindfulness meditation, Sensory design, Attentional regulation, Immersive technology, Interdisciplinary design","lastPublishedDoi":"10.21203/rs.3.rs-8305873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8305873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose of Review \u003c/strong\u003eMindfulness meditation is widely recognized for its benefits in stress reduction and attentional regulation, yet many practitioners face barriers of distraction and disengagement. Virtual reality (VR) provides immersive, multisensory environments that may enhance mindfulness by anchoring attention and reducing external interference. This systematic review synthesizes empirical studies examining VR-supported mindfulness interventions with a specific focus on sensory design, visual aesthetics, and attentional outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecent Findings \u003c/strong\u003eA synthesis of 15 empirical studies and supplemental references reveals that VR mindfulness programs commonly employ nature-based visuals, ambient soundscapes, breathing guides, and occasional multisensory or embodied features across diverse populations, including adolescents, clinical patients, and healthy adults. Evidence indicates that these design elements improve state mindfulness, emotional regulation, and user engagement, although challenges remain regarding long-term efficacy and cybersickness. Comparisons with traditional audio- or video-based mindfulness suggest that VR offers equal or greater short-term attentional benefits and stronger user appeal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSummary \u003c/strong\u003eThis review highlights interdisciplinary contributions from design, psychology, and immersive technology, providing practical guidelines for optimizing VR mindfulness environments. While VR demonstrates potential as a powerful tool for attentional regulation, future research should employ larger trials and component analyses to clarify effective design mechanisms and sustainable outcomes.\u003c/p\u003e","manuscriptTitle":"Virtual Reality-Based Mindfulness Meditation: A Systematic Review of Sensory Design and Attentional Control","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-10 10:44:09","doi":"10.21203/rs.3.rs-8305873/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0ee4951f-07f4-42bc-b08e-440a1562ab9f","owner":[],"postedDate":"December 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-10T13:54:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-10 10:44:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8305873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8305873","identity":"rs-8305873","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}