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Published on in Vol 26 (2024)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/51596, first published .
Effects of a Rice-Farming Simulation Video Game on Nature Relatedness, Nutritional Status, and Psychological State in Urban-Dwelling Adults During the COVID-19 Pandemic: Randomized Waitlist Controlled Trial

Effects of a Rice-Farming Simulation Video Game on Nature Relatedness, Nutritional Status, and Psychological State in Urban-Dwelling Adults During the COVID-19 Pandemic: Randomized Waitlist Controlled Trial

Effects of a Rice-Farming Simulation Video Game on Nature Relatedness, Nutritional Status, and Psychological State in Urban-Dwelling Adults During the COVID-19 Pandemic: Randomized Waitlist Controlled Trial

Authors of this article:

Seulki Lee1 Author Orcid Image ;   Chisung Yuh2 Author Orcid Image ;   Yu-Bin Shin1 Author Orcid Image ;   Heon-Jeong Lee1 Author Orcid Image ;   Young-Mee Lee2 Author Orcid Image ;   Jungsil Lee3 Author Orcid Image ;   Chul-Hyun Cho1, 4 Author Orcid Image
Article Authors Cited by (2) Tweetations (7) Metrics

    Original Paper

    1Department of Psychiatry, Korea University College of Medicine, Seoul, Republic of Korea

    2Department of Medical Education, Korea University College of Medicine, Seoul, Republic of Korea

    3Department of Environmental Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea

    4Department of Biomedical Informatics, Korea University College of Medicine, Seoul, Republic of Korea

    *these authors contributed equally

    Corresponding Author:

    Chul-Hyun Cho, MD, PhD

    Department of Psychiatry, Korea University College of Medicine

    73 Goryeodae-ro Seongbuk-gu

    Seoul, 02841

    Republic of Korea

    Phone: 82 0221993827

    Email: david0203@gmail.com


    Background: During the COVID-19 pandemic, urban inhabitants faced significant challenges in maintaining connections with nature, adhering to nutritional guidelines, and managing mental well-being.

    Objective: Recognizing the urgent need for innovative approaches, this study was designed to explore the potential benefits of a specific digital intervention, the rice-farming simulation game Sakuna: Of Rice and Ruin, for nature relatedness, nutritional behaviors, and psychological well-being.

    Methods: A total of 66 adults without any prior major psychiatric disorders residing in an urban area were recruited for the study. They were randomly assigned to 2 groups through block randomization: the immediate intervention group (IIG; 34/66, 52%) and the waitlist group (32/66, 48%). Participants in the IIG were instructed to play the game for at least 4 days per week for 3 weeks, with each session lasting from 30 minutes to 3 hours. Assessments were performed at baseline, week 1, and week 3. The Nature Relatedness Scale (NR) and Nutrition Quotient Scale were used to evaluate nature relatedness and nutritional state, respectively. Furthermore, psychological state was assessed using the World Health Organization Quality of Life–Brief Version (WHOQOL-BREF), Brief Fear of Negative Evaluation Scale, Social Avoidance and Distress Scale, Toronto Alexithymia Scale, State-Trait Anxiety Inventory, Center for Epidemiologic Studies Depression Scale Revised, and Korean Resilience Quotient.

    Results: This study’s results revealed significant time interactions between the IIG and waitlist group for both the total NR score (P=.001) and the score of the self subdomain of NR (P<.001), indicating an impact of the game on nature relatedness. No group×time interactions were found for the total Nutrition Quotient Scale and subdomain scores, although both groups showed increases from baseline. For psychological state, a significant group×time interaction was observed in the total WHOQOL-BREF score (P=.049), suggesting an impact of the game on quality of life. The psychological (P=.01), social (P=.003), and environmental (P=.04) subdomains of the WHOQOL-BREF showed only a significant time effect. Other psychological scales did not display any significant changes (all P>.05).

    Conclusions: Our findings suggest that the rice-farming game intervention might have positive effects on nature relatedness, nature-friendly dietary behaviors, quality of life, anxiety, depression, interpersonal relationships, and resilience among urban adults during the COVID-19 pandemic. The impact of pronature games in confined urban environments provides valuable evidence of how digital technologies can be used to enhance urban residents’ affinity for nature and psychological well-being. This understanding can be extended in the future to other digital platforms, such as metaverses.

    Trial Registration: Clinical Research Information Service (CRIS) KCT0007657; http://tinyurl.com/yck7zxp7

    J Med Internet Res 2024;26:e51596

    doi:10.2196/51596

    Keywords

    video game; digital intervention; nature relatedness; nutritional status; psychological state; COVID-19; urban-dwelling adults 


    Background

    Urbanization and industrialization have reshaped societies all over the world, with a substantial fraction of populations now residing in city centers [1]. Urban lifestyles, although convenient, may divorce individuals from nature and promote behaviors that can negatively impact both physical and mental health [1,2]. Recognizing the importance of nature for human well-being, it is important for research to be conducted using an integrated approach to examine the effects of urban living on health promotion behaviors, nature relatedness, nutritional status, and psychological states [3-5].

    Urban living can engender lifestyle habits that impede connection with nature and hinder balanced nutrition [6]. Many urban dwellers lack access to green spaces, leading to a significant detachment from nature and possibly unhealthy eating habits. The convenience and ubiquity of fast food in urban areas, coupled with limited access to fresh produce, may lead to diets that are high in fat, sugar, and calories. Combined with the sedentary habits required by city living, the lack of connection with nature and poor nutrition escalate the risks of obesity, diabetes, and other health issues [6-8].

    The stressors of urban living, social isolation, and alienation from nature can have severe psychological consequences. Restricted access to green spaces contributes to feelings of estrangement from nature, exacerbating stress, anxiety, and depression and undermining the overall well-being. Indeed, studies have shown that exposure to nature can enhance feelings of well-being and mitigate stress [9,10].

    The COVID-19 pandemic and the ensuing social distancing policies amplified urban dwellers’ physical and social isolation, increased negative dietary patterns, decreased outdoor physical activities, and escalated psychological distress [11-13]. A rapid rise in obesity and metabolic diseases were associated with such changes in dietary patterns in previously healthy young adults in South Korea during the COVID-19 pandemic [14]. Moreover, mental health, which is highly correlated with obesity and metabolic health, became a serious issue during the pandemic for similar reasons, such as individual isolation measures in closed spaces and detachment from the surrounding community and nature [14]. Because future pandemics are a real possibility, urban dwellers’ susceptibility necessitates the development of strategies to promote their physical and psychological well-being [15,16]. These efforts are not only important for pandemic preparedness but also vital interventions in the modern, urban-centric society.

    The video game industry, which saw an expansion during the era of social distancing, presents an opportunity to address urban dwellers’ disconnection from nature and associated health issues [17]. The World Health Organization has suggested that video games may have positive effects for alleviating stress and social isolation [18]. Recently, games and game-like software have been deployed in clinical contexts for health promotion and disease treatment, as well as to promote psychological well-being, highlighting their potential as digital therapeutics [19].

    Gamification has become increasingly prevalent in health interventions, capitalizing on the persuasive capabilities of technology to effectuate positive behavior changes [20]. By implementing game mechanics, including points and levels, in nongame contexts, this strategy increases participation and encourages behavior modification [21]. A substantial proportion of the examined studies yielded inconclusive results, indicating that although gamification may be beneficial, its effects are not universally favorable and may differ depending on the context and quality of implementation. Although the literature frequently discusses short-term engagement, the results regarding long-term impact and intrinsic motivation are inconsistent, necessitating further investigation into the ways in which extrinsic motivators can evolve into sustained intrinsic motivation [21].

    Sakuna: Of Rice and Ruin, a rice-farming action role-playing game, provides a unique blend of entertainment and cultural education [22]. Players assume the role of Sakuna, a harvest goddess who has been banished to an island where she must battle demons and cultivate rice. The game introduces players to the intricacies of traditional rice farming and ties these agricultural practices directly to the character’s progression. We believe that this immersive experience could enhance players’ connection with nature, even in a game-based setting, and provide psychological benefits through exposure to slow and methodical tasks.

    As mentioned earlier, healthier food choices, such as traditional homemade rice-based meals in South Korea, could lead to a decrease in obesity and metabolic and mental health issues [14]. Rice is the staple food for more than half of the world’s population, and its cultivation plays an important role in Asian culture. In South Korea and Japan, rice is deeply associated with cultural identity, memories of family, and the community [23]. Healthy homemade meals are mostly perceived to be rice-based meals, which tend to be more balanced, higher in nutrients, and lower in calories than Western foods; several studies have been published on the association of rice-centered Japanese diet with the quality of life, sleep, impulsivity, depressive symptoms, and biochemical changes [24,25].

    This Study

    Therefore, we hypothesized that engaging in this rice-farming game would lead to a positive perception of nature and a rice-based balanced diet, which could subsequently affect actual food choices. Improved nature relatedness could positively influence psychological well-being and mood, which, in turn, could also help in choosing a healthier diet in real life. This study aims to explore the potential impacts of playing Sakuna: Of Rice and Ruin on nature relatedness, nutritional status, and psychological well-being among urban dwellers during the COVID-19 pandemic, especially during the period of social distancing. We investigated the game’s ability to provide a meaningful and accessible connection with nature and improve nutritional behavior and its potential influence on players’ mental health, focusing on the game’s realism and immersive content.


    Participants

    Our study used a recruitment strategy involving web-based bulletin boards of social network services and gaming communities in South Korea. The web-based recruitment process included posting institutional review board–approved announcements on our laboratory’s official website and sharing the link to this page on YouTube (Google LLC), Naver (Naver Corp), Twitch (Amazon, Inc), and 8 other game-related web-based platforms. From those who applied, we included only young adults aged 19 to 40 years with a minimum residency period of 6 months in the urban area at the time of study enrollment. The exclusion criteria included individuals diagnosed with major psychiatric disorders, game addiction, mental retardation, traumatic brain injury, or epilepsy or those who had used the game Sakuna: Of Rice and Ruin within the last 6 months.

    Once potential participants were identified, they were sent a brief video explaining research consent requirements via email. Subsequently, an electronic signature of the web-based informed consent form was obtained from all participants. Of the 71 individuals screened, 68 (96%) agreed to participate and provided their informed consent. We used block randomization to assign participants equally to the immediate intervention group (IIG) and waitlist group (WLG), each of which initially included 34 members. However, 2 (6%) out of 34 individuals from the WLG could not be contacted before the start of the study. Therefore, a final total of 32 participants were in the WLG, resulting in 66 participants overall.

    The study required participants to engage in the Sakuna: Of Rice and Ruin game under specific conditions. Participants were asked to use the game’s PC version if possible, although the use of the Nintendo Switch (Nintendo Co, Ltd) and PlayStation (Sony Interactive Entertainment) versions was also permitted. The game had a total running time of 35 hours, and participants were expected to play the game for at least 4 days per week for 3 weeks, with each session lasting from 30 minutes to 3 hours in length. We set a maximum daily playtime of 5 hours to prevent potential game addiction, with a strongly recommended 10-minute break time. An additional week was granted to any participant who was unable to complete the game within the initial 3 weeks.

    Participants were required to purchase the game independently for the purpose of the study, thus ensuring that each held individual copyright. The researchers did not provide the game to the participants. In addition, the study design involved real-time remote monitoring of gaming activities. The research team observed participants’ in-game progress through instant messaging platforms, where participants were instructed to share snapshots of the game’s start, pause, and finish screens as well as any achievements obtained, to track their engagement with the game.

    For the IIG, the gaming intervention took place in April 2021; the first assessment occurred before the game-playing phase, and subsequent evaluations occurred at the end of weeks 1 and 3. The WLG continued their usual daily activities for the first 2 weeks, starting the game only after this period. They also underwent assessments before the gaming phase and at the end of weeks 1 and 3. All the assessments were conducted via a web-based survey site. Figure 1 presents the schematic research flow with evaluations and procedures.

    ‎
    Figure 1. Schematic research flow. Comparison of the waitlist group and immediate intervention group (white), and game intervention in the entire sample (gray).

    A Rice-Farming Video Game Digital Intervention (Sakuna: Of Rice and Ruin)

    Overview

    Sakuna: Of Rice and Ruin (Marvelous Inc) is an action role-playing simulation game that provides a distinctive blend of agriculture and action gameplay, thus offering a unique gaming experience. The game is divided into 2 primary sections: an agricultural simulator, in which players must cultivate rice, and an action segment, in which players must combat demonic creatures using farming tools (Figure 2). The agrarian component spans several in-game seasons and involves multiple stages. These multiple stages range from tilling the soil and transplanting rice to adding fertilizer to managing water levels to weeding to eventually harvesting and threshing rice (Multimedia Appendices 1 and 2).

    Each successful rice harvest permanently enhances the character’s abilities. The quality of the harvest can be improved through meticulous crop management. Players who complete each task access new skills that expedite and enhance the cultivation process. The action element of the game features combat against demonic animals, for which rice harvests bolster players’ strength. Set in nature and modeled around real-world farming practices, it is reasonable to assume that the game may be influenced by the user’s connection with nature, nutritional status, and psychosocial state.

    In addition to rice farming, the game emphasizes the importance of traditional family dinners and a well-balanced diet. Sakuna, with her human friends, such as family, makes her own healthy daily dinner from the available natural ingredients (gathered, hunted, harvested, or stored), which are relatively low in calories but rich in nutrients. The available sources for the menu include various grains, 10 types of meat, 11 types of seafood and freshwater fish, 18 types of vegetables and fruits, and 15 types of natural sauce and plants. Sharing meals with family and having dinner conversations in the virtual world could make the player feel at home in the game. When Sakuna becomes picky about food, her friends encourage her to try a balanced meal. The player should consider a realistic and sustainable meal choice, as there are expiration periods for the natural food ingredients; expired foods cannot be consumed and should be turned into fertilizers. Furthermore, the menu choice is directly linked to Sakuna’s power and ability to explore the next morning. Eating a well-balanced meal increases Sakuna’s natural healing potential; missing a meal or major nutrients reduces the healing potential to zero, making it difficult to further explore or play an action. A summary of the game components is presented in Multimedia Appendix 3.

    The game and its associated elements may contribute to the dietary effects outlined in Textbox 1.

    Dietary outcomes might also be shaped by the profound psychological impacts of the game. The major hypothesis of this study was that as the participants were immersed in a virtual green environment with natural background music, their nature relatedness would improve, which could lead to reduced stress, improved mood and resilience, and enhanced mindfulness. These positive psychological effects could subsequently improve the participants’ dietary choices, such as by bringing about a reduction in stress eating (thus reducing the consumption of fast foods) and promoting mindful eating. In addition, increased nature relatedness might lead participants to feel a connection with food sources and to place greater value on them, with shifts toward natural food preferences and proenvironmental behaviors, such as sustainable food choices. However, these could not be fully determined by this study alone; further research is necessary to determine a clearer association between game elements and their effects.

    Using Sakuna: Of Rice and Ruin, we evaluated our study participants’ affinity to nature, mental health, and nutritional eating patterns. In particular, we focused on their enhanced awareness of rice cultivation and rural areas, their mental health, and their health behaviors in a context that required the application of their knowledge of rice farming.

    ‎
    Figure 2. Key scenes from the Sakuna: Of Rice and Ruin game (images used with permission from Edelweiss, the video game developers).
    Textbox 1. Dietary effects of the game.
    • Increased appreciation for a well-balanced diet (with grains, plants, and good protein sources): with an emphasis on balanced nutrition contributing to the character’s power and natural healing potential, participants may develop a positive perception of well-balanced homemade food and wholesome nutrition with minimal processing. Experiencing the process of rice farming may deepen players’ understanding and appreciation of the labor and resources required to produce rice and whole grains. In the postgame interview, some of the participants responded that after experiencing the milling process, they realized how precious the grains were and evenpurchasedthe specific types of whole grains in their real life.
    • Shift toward natural or homemade food and reduced fast food consumption: the simulation of traditional home cooking and eating natural foods in the game could influence the player to shift toward natural food selection or homemade meals rather than processed or fast foods. Some participants mentioned that after playing this game, they felt more fun in cooking and tried home cooking more frequently, which reduced the consumption of outside foods. A participant said, “I tried cooking at home the traditional dish I had in Sakuna because it looked so good.”
    • Sociocultural reinforcement of healthy food choices: Through daily interaction with nonplayer characters (friends at family dinners and the community), participants are reinforced of the importance of well-balanced diets and traditional Japanese-style homemade meals. Although the sociocultural effect significantly influences Sakuna’s dietary practice in the virtual world, it could also influence participants’ dietary practices in real life.
    • Sustainable dietary behavior: Owing to the expiration periods of natural ingredients and foods, participants should make a realistic choice of ingredients, considering both their freshness and nutritional values. Repeatedly experiencing the process of creating natural fertilizers from remnant foods can influence participants into making their dietary behaviors sustainable.
    Assessment of Nature Relatedness and Nutritional Status

    The Nature Relatedness Scale (NR) and Nutrition Quotient Scale (NQ) were used to assess nature relatedness and nutritional status, respectively. The NR measures and evaluates an individual’s connection with nature, their worldview with respect to nature, and their physical familiarity with nature across 3 subscales: self, perspective, and experience [26]. The reliability coefficients for the NR in the baseline and end evaluations were 0.693 and 0.569, respectively. The NQ measures and evaluates the quality and nutritional value of individuals’ meals. It assesses several aspects of a person’s dietary habits across 4 subscales: balance, diversity, moderation, and dietary behavior [27]. Balance is the frequency of intake of fruits, eggs, dairy products, beans or bean products, fish, and breakfast. Diversity indicates the level of deviated food habits and the frequency of vegetable and water intake. Moderation is the frequency of having sweet and greasy bread, processed beverages, instant noodles, sugar-sweetened beverages, late-night snacks, and street foods. Dietary behavior includes checking nutrition labels, performing exercises for more than 30 minutes, and washing hands before meals.

    Assessment of Psychological State

    We used multiple scales and inventories to evaluate the psychological states of participants (Textbox 2).

    Textbox 2. Instruments used to assess the psychological states of participants.

    The World Health Organization’s Quality of Life–Brief Version (WHOQOL-BREF)

    • The overall quality of life and well-being were assessed across 4 subscales: physical health, psychological health, social relations, and environment [28]. The reliability coefficients for the WHOQOL-BREF scale in the baseline and end evaluations were 0.895 and 0.925, respectively.

    The Brief Fear of Negative Evaluation Scale (BFNE)

    • This scale measures the fear of being negatively judged by others, where higher scores indicate greater fear [29]. The reliability coefficients for the BFNE scale in the baseline and end evaluations were 0.725 and 0.659, respectively.

    The Social Avoidance and Distress Scale (SADS)

    • This self-report tool assesses social anxiety and the tendency to avoid uncomfortable social situations [30]. The reliability coefficients for the SADS in the baseline and end evaluations were 0.940 and 0.958, respectively.

    The Toronto Alexithymia Scale (TAS)

    • This self-report measure assesses alexithymia, a personality trait characterized by difficulties in recognizing and expressing emotions [31]. The reliability coefficients for the TAS in the baseline and end evaluations were 0.940 and 0.884, respectively.

    The State-Trait Anxiety Inventory (STAI)

    • This inventory measures state and trait anxiety in both research and clinical practice contexts [32]. The reliability coefficients for the STAI–State in the baseline and end evaluations were 0.933 and 0.950, respectively. The reliability coefficients for the STAI–Trait in the baseline and end evaluations were 0.938 and 0.950, respectively.

    The Center for Epidemiologic Studies Depression Scale Revised (CESD-R)

    • This scale comprises 20 questions about various symptoms of depression as they may have appeared over the previous week [33]. The reliability coefficients for the CESD-R in the baseline and end evaluations were 0.915 and 0.912, respectively.

    The Korean Resilience Quotient (KRQ)

    • This measure assesses resilience across 3 areas: self-regulation ability, interpersonal relationships, and positivity [34]. The reliability coefficients for the KRQ scale in the baseline and end evaluations were 0.946 and 0.959, respectively.

    The General Self-Efficacy Scale (GSE)

    • This scale measures individuals’ beliefs in their own abilities and assesses their confidence across various problem situations [35]. The reliability coefficients for the GSE in the baseline and end evaluations were 0.888 and 0.918, respectively.

    The Spiritual Well-Being Scale (SWBS)

    • This self-report measure assesses spiritual well-being, which refers to individuals’ sense of purpose, connection to something greater than themselves, and inner peace [36]. The reliability coefficients for the SWBS in the baseline and end evaluations were 0.895 and 0.905, respectively.

    Statistical Analyses

    Data analysis was performed using SPSS (version 24, IMB Corp), incorporating a range of statistical tests, such as 2-tailed t tests, chi-square tests, and repeated-measures ANOVA. Repeated-measures ANOVA was specifically used to compare 2 groups of repeated observations captured at baseline, after 1 week of gameplay, and after 3 weeks of gameplay in the IIG and at the corresponding time points in the WLG. Given that the digital game intervention was eventually implemented in both groups, the 2 groups were amalgamated into a single sample (sample of the actual same gameplay at each time point in the IIG arm and after the wait in the WLG arm) to analyze intervention-induced changes. A P value of less than .05 was established as the threshold for statistical significance in all analyses. As a total of 10 psychological scales were applied to the analysis, multiple correction was performed. Bonferroni correction was performed for 7 scales (World Health Organization Quality of Life–Brief Version [WHOQOL-BREF], Brief Fear of Negative Evaluation Scale, Social Avoidance and Distress Scale, Toronto Alexithymia Scale, State-Trait Anxiety Inventory [STAI]–State, STAI–Trait, and Center for Epidemiologic Studies Depression Scale Revised) that were measured twice during the study period and for 3 scales (Korean Resilience Quotient, General Self-Efficacy Scale, and Spiritual Well-Being Scale) that were measured thrice during the study period.

    Ethical Considerations

    This study underwent a thorough ethical review and was approved by the Chungnam National University Sejong Hospital Institutional Review Board (reference 2021-01-012) and the Clinical Research Information Service (CRIS; reference KCT0007657). Written informed consent was obtained from all parents of the participating children, and informed consent was obtained from all participating children. The study data were anonymized and unidentified. Participants received compensation of KRW ₩70,000 (US $50) for their involvement in the study.


    Overview

    Table 1 presents the characteristics of all 66 participants. There were no significant differences between the IIG (n=34) and the WLG (n=32) in terms of age, sex, socioeconomic status, residence type, or marital status (all P>.05).

    Table 1. Comparison of participant characteristics.
    CharacteristicsTotal (n=66)GroupsStatisticsP values


    		IIGa (n=34)WLGb (n=32)

    Age (y), mean (SD)27 (5.07)28 (5.04)27 (5.10)t64=0.7.98
    Age group (y), n (%)χ21=0.4.53

    		19-2945 (68)22 (65)23 (72)


    		30-4021 (32)12 (35)9 (28)

    Sex, n (%)χ21=0.01.98

    		Male56 (85)29 (85)27 (84)


    		Female10 (15)5 (15)5 (16)

    Socioeconomic status, n (%)χ23=6.6.09

    		Wealthy26 (39)12 (35)14 (44)


    		Moderate26 (39)18 (53)8 (25)


    		Temporary11 (17)3 (9)8 (25)


    		Poor3 (5)1 (3)2 (6)

    Residence type, n (%)χ22=1.4.50

    		Living alone15 (23)9 (27)6 (19)


    		Living with another person10 (15)6 (18)4 (12)


    		Living with ≥2 persons40 (61)18 (55)22 (69)

    Marital status, n (%)χ21=0.7.79

    		Unmarried57 (86)29 (85)28 (87)


    		Married9 (14)5 (15)4 (13)

    aIIG: immediate intervention group.

    bWLG: waitlist group.

    Impacts of the Game on Nature Relatedness and Nutritional Status in the IIG and WLG

    Analysis of the impact of the game on nature relatedness and nutritional status (as shown in Table 2 and Multimedia Appendix 4) revealed significant group×time interactions for both the total NR score (F1,60=13.418; P=.001) and the self subscale of the NR (F1,62=16.977; P<.001). The total NQ score (F2,116=6.209; P=.003) and moderation (F2,118=3.954; P=.02) and dietary behavior (F2,124=12.619; P<.001) subscale scores generally increased from baseline in both groups, but no group×time interactions were found.

    Table 2. Comparison of the impact of the game on nature relatedness and nutritional status between the immediate invention group (IIG) and waitlist group (WLG).
    Measures and groupBaseline, mean (SD)1 week after starting the game or 1 week after waiting for the game, mean (SD)3 weeks after starting the game or 2 weeks after waiting for the game, mean (SD)Group×time interaction, F test (df)P valuesTime effect, F test (df)P values
    NRa

    		Total NR13.418 (1, 60).00110.053 (1, 60).002


    		IIG56.59 (6.95)N/Ab61.22 (6.00)





    		WLG58.07 (7.25)N/A57.73 (7.31)




    		Self16.977 (1, 62)<.00118.185 (1, 62)<.001


    		IIG24.74 (6.36)N/A28.62 (5.51)





    		WLG26.07 (5.15)N/A26.13 (5.48)




    		Perspective0.297 (1, 63).590.051 (1, 63).82


    		IIG15.45 (3.77)N/A15.55 (3.36)





    		WLG16.56 (3.00)N/A16.34 (3.13)




    		Experience2.453 (1, 63).120.682 (1, 63).41


    		IIG15.79 (2.47)N/A16.39 (2.05)





    		WLG15.56 (2.82)N/A15.38 (2.37)



    NQc




    		Total NQ1.461 (2, 116).2482.038 (2, 116).003


    		IIG48.00 (11.59)49.78 (10.62)51.46 (11.50)





    		WLG50.15 (10.65)51.07 (8.50)51.36 (9.14)




    		Balance0.486 (2, 126).621.798 (2, 126).17


    		IIG28.64 (15.53)28.85 (14.24)29.81 (15.43)





    		WLG31.92 (14.92)30.68 (13.24)33.81 (17.77)




    		Diversity1.319 (2, 126).271.670 (2, 126).19


    		IIG46.75 (19.36)50.58 (18.88)51.29 (16.86)





    		WLG49.60 (15.97)50.57 (13.58)49.45 (13.58)




    		Moderation0.950 (2, 118).393.954 (2, 118).02


    		IIG69.65 (12.18)69.80 (12.35)73.54 (12.97)





    		WLG68.31 (11.93)69.06 (11.28)70.01 (13.69)




    		Dietary behavior1.733 (2, 124).1812.619 (2, 124)<.001


    		IIG40.91 (17.46)45.68 (13.84)47.76 (16.60)





    		WLG44.91 (19.78)48.24 (17.91)47.91 (19.52)



    aNR: Nature Relatedness Scale.

    bN/A: not applicable.

    cNQ: Nutrition Quotient Scale.

    Impact of the Game on Psychological State in the IIG and WLG

    Analysis of the impact of the game on psychological state with Bonferroni correction (Table 3 and Multimedia Appendix 4) showed a significant group×time interaction concerning the total WHOQOL-BREF score (F1,62=7.652; P=.049). Scores for the psychological (F1,64=6.530; P=.01), social (F1,63=9.677; P=.003), and environmental (F1,63=4.250; P=.04) subscales showed a significant time effect at week 3 compared with baseline, but no significant group×time interaction was observed. No significant time effects or group×time interactions were found for the other psychological scales (all P>.05).

    Table 3. Comparison of the impact of the game on psychological state between the immediate intervention group (IIG) and waitlist group (WLG).
    Measures and groupBaseline, mean (SD)1 week after starting the game or 1 week after waiting for the game, mean (SD)3 weeks after starting the game or 2 weeks after waiting for the game, mean (SD)Group×time interaction, F test (df)P valuesTime effect, F test (df)P values
    WHOQOL-BREFa

    		Total score7.652 (1, 62).049c8.862 (1, 62).02c


    		IIG87.79 (11.84)N/Ab93.06 (13.08)





    		WLG89.65 (12.90)N/A89.84 (12.30)




    		Physical3.649 (1, 63).061.433 (1, 63).24


    		IIG24.29 (3.98)N/A25.56 (4.51)





    		WLG24.65 (5.05)N/A24.35 (4.37)




    		Psychological3.192 (1, 64).086.530 (1, 64).01


    		IIG19.44 (3.82)N/A20.68 (4.25)





    		WLG19.56 (4.19)N/A19.78 (3.78)




    		Social3.140 (1, 63).089.677 (1, 63).003


    		IIG9.68 (1.97)N/A10.62 (1.81)





    		WLG9.61 (2.19)N/A9.87 (2.16)




    		Environment3.877 (1, 63).054.250 (1, 63).04


    		IIG27.55 (3.65)N/A28.91 (3.75)





    		WLG28.88 (4.16)N/A28.91 (3.97)



    BFNEd1.065 (1, 62).14c0.630 (1, 62).01c

    		IIG27.91 (7.89)N/A27.76 (6.74)




    		WLG29.32 (4.92)N/A30.48 (5.27)



    SADSe0.730 (1, 58).77c4.173 (1, 58).32c

    		IIG84.13 (19.72)N/A81.35 (20.48)




    		WLG86.21 (15.39)N/A85.07 (16.60)



    TASf0.065 (1, 61).60c1.423 (1, 61).67c

    		IIG46.50 (9.63)N/A45.16 (11.01)




    		WLG45.68 (10.34)N/A44.81 (9.25)



    STAI-Sg0.427 (1, 62).61c0.054 (1, 62)0.71c

    		IIG39.00 (8.75)N/A38.41 (9.85)




    		WLG40.84 (10.94)N/A41.13 (9.99)



    STAI-Th2.514 (1, 59).83c5.299 (1, 59).18c

    		IIG41.80 (10.16)N/A39.00 (11.18)




    		WLG42.03 (10.19)N/A41.52 (10.93)



    CESDi0.370 (1, 61).82c5.617 (1, 61).15c

    		IIG9.69 (9.88)N/A6.91 (6.99)




    		WLG10.55 (9.01)N/A8.90 (9.89)



    KRQj3.804 (2, 106).17k0.381 (2, 106).62k

    		IIG178.58 (27.56)184.50 (28.23)183.50 (31.97)




    		WLG184.00 (23.52)182.90 (23.65)183.00 (24.61)



    GESl0.231 (2, 110).38k0.251 (2, 110).45k

    		IIG80.10 (13.61)79.03 (20.34)80.48 (19.03)




    		WLG82.39 (13.64)81.68 (13.39)81.46 (13.41)



    SWBSm0.307 (2, 114).21k0.432 (2, 114).95k

    		IIG67.04 (16.00)67.39 (18.19)68.46 (18.14)




    		WLG64.45 (16.46)65.29 (15.14)64.84 (14.24)



    aWHOQOL-BREF: World Health Organization’s Quality of Life–Brief Version.

    bN/A: not applicable.

    cBonferroni multiple corrections (P value×7) for a total of 7 psychological scales (World Health Organization’s Quality of Life–BREF, Brief Fear of Negative Evaluation Scale, Social Avoidance and Distress Scale, Toronto Alexithymia Scale, State-Trait Anxiety Inventory–State, Sate-Trait Anxiety Inventory–Trait, and Center for Epidemiologic Studies Depression Scale).

    dBFNE: Brief Fear of Negative Evaluation Scale.

    eSADS: Social Avoidance and Distress Scale.

    fTAS: Toronto Alexithymia Scale.

    gSTAI-S: State-Trait Anxiety Inventory–State.

    hSTAI-T: State-Trait Anxiety Inventory–Trait.

    iCESD: Center for Epidemiologic Studies Depression Scale.

    jKRQ: Korean Resilience Quotient.

    kBonferroni multiple corrections (P value×3) for a total of 3 psychological scales (Korean Resilience Quotient, General Self-Efficacy Scale, and Spiritual Well-Being Scale).

    lGES: General Self-Efficacy Scale.

    mSWBS: Spiritual Well-Being Scale.

    Impact of the Game on Nature Relatedness, Nutrition Status, and Psychological State Across the Entire Sample

    As both IIG and WLG ultimately played the game, we performed additional analyses on the changes in each scale from before to after the game for the entire sample of these 2 groups combined. Multimedia Appendices 5 and 6 present the overall changes in nature relatedness, nutritional status, and psychological state for all participants before and after gameplay. There were statistically significant increases in the total NR score (t62=−4.150; P<.001) and total NQ score (F2,114=4.775; P=.01) after the 3-week game period. The total WHOQOL-BREF score also significantly increased after gameplay (t63=−4.027; P<.007). The STAI–Trait score (t59=3.765; P<.007) statistically significantly decreased following gameplay compared with baseline. No statistically significant differences were found for any of the other psychological scales (all P>.05).


    Principal Findings

    Our study explored the impacts of a nature-friendly, rice-farming action video game on urban dwellers during the social distancing period of the COVID-19 pandemic, specifically examining changes in nature relatedness, nutritional behavior, and psychological state [37] The digital game intervention used in this study, similar to the concept of drug repositioning or the discovery of therapeutic factors from existing substances, sought to repurpose a recreational activity to take advantage of its therapeutic benefits [38]. This approach is gaining importance in the age of digital therapies and the emerging metaverse, where synergistic interactions between virtual and real-world experiences can potentially enhance mental health, promote healthy nutrition, and foster a deeper connection with nature [39,40].

    As hypothesized, the results revealed significant changes after 3 weeks of gameplay in the total NR score and the self subscale of the NR in the IIG compared with the WLG. This indicates that the game intervention bolstered participants’ connection with nature, especially by influencing their personal relationships. For urban dwellers, who are increasingly disconnected from nature, this indicates a promising strategy for nurturing an affinity with the natural environment [5]. The enhancement in nature relatedness could have clinical applications, particularly in the context of eco-friendly therapeutic approaches, which are emerging as effective components of mental health treatment [41]. By fostering a connection with nature, such game interventions may provide a complementary tool for treating affective disorders and stress-related conditions. They can also be incorporated into mindfulness-based therapies to augment the therapeutic experience, especially for those with limited access to natural settings [42]. These implications suggest a valuable role for nature-centric games in the broader spectrum of mental health care approaches.

    These findings are particularly relevant in light of the ongoing COVID-19 pandemic, which has necessitated social distancing and led to an increase in indoor activities, such as video gaming [17]. Video games, accessible through various platforms, including computers, consoles, and mobile devices, have been recommended by the World Health Organization as a means of alleviating stress [43,44]. In this context, our results suggest that video games have the potential to enhance nature connectivity, which is encouraging. This opens up possibilities for the development of the so-called serious games designed with therapeutic objectives [43].

    The study also found significant changes in the total WHOQOL-BREF scores in the IIG compared with the WLG, indicating potential positive impacts on psychological state. These findings suggest that nature-friendly video games have an impact on the quality of life in general, in addition to improving specific psychological and nutritional aspects [38]. However, it was not possible to conclusively attribute these changes to specific factors in the video game, such as the joy derived from the gameplay or the cathartic impact of the narrative of the game.

    The observed improvements in the WHOQOL-BREF scores may have therapeutic implications for individuals with diminished quality of life due to chronic conditions or individuals undergoing rehabilitation [45]. Aspects of the game that enhance psychological well-being could be particularly beneficial in clinical settings, offering a noninvasive means to support traditional therapies. Such games could be explored as a method to deliver positive psychological interventions, potentially aiding in the management of conditions such as chronic pain or fatigue, where patient engagement in enjoyable activities has been shown to contribute to the overall well-being.

    For additional analysis, we investigated the pregame and postgame results for all participants. The findings showed significant changes in the total NR score, scores of the self and experience subscales of the NR, the total NQ score, and score of the dietary behavior subscale. In psychological terms, not only did the total WHOQOL-BREF score and scores of all of its subscales show significant changes, but the Social Avoidance and Distress Scale, Toronto Alexithymia Scale, STAI, and Center for Epidemiologic Studies Depression Scale Revised scores also showed significant changes. Although the pre-post comparison of all participants was limited to the same group without comparison, the broad positive changes in nature relatedness, nutritional status, and psychological states observed when the sample size was increased can be considered a basis for extrapolating the therapeutic and educational effects of a game intervention with targeted content and features. If future studies can ensure sufficient group-specific sample sizes, we can expect these findings to be further emphasized. In addition, the observation of dietary behavior changes through a nature-friendly serious game in this study raises the possibility of using such games as part of digital therapies for improving and managing dietary habits among urban dwellers.

    Our study used the commercial game Sakuna: Of Rice and Ruin, which was launched by the South Korean branch of Nintendo in November 2020. The participants were randomized into the IIG and WLG conditions to evaluate the effects of the video game intervention. From the protective effects of nature on mental health [46], it can be assumed that an increased connection with nature through gaming may have some association with improved mental health and quality of life. Although our study showed significant results in terms of the NR, a case-control study examining the impact of specific game elements on nature connectivity could offer more precise insights. Furthermore, well-designed studies are necessary to ascertain which game factors facilitated the observed changes in the NR.

    Previous studies have presented mixed results, suggesting that future research should prioritize understanding the long-term effects of gamification and the elements contributing to its efficacy [21]. It is crucial to identify the active ingredients that drive sustained behavioral changes and how they interact with individual differences, including personality traits and demographics [47]. Moreover, comprehensive longitudinal studies are essential to investigate gamification's long-term impact [20]. Although gamification shows promise in enhancing health and educational outcomes, its long-term effectiveness and core components require further exploration.

    Strengths and Limitations

    This study has several strengths. First, it uses a commercial game for therapeutic and educational purposes. Using Sakuna: Of Rice and Ruin, we offered a real-world context for the exploration of the potential impact of video games on nature connectivity, dietary behavior, and psychological states. Similar to exploring the development of new drugs using natural plants or existing drugs, exploring therapeutic or educational elements in existing commercial games will be necessary in the coming digital age. This study has significant strengths in that regard. Second, the study design, which incorporated the random allocation of participants into either the IIG or the WLG, helped reduce the risk of selection bias, thereby improving the reliability of the findings. Third, the comprehensive evaluation of a broad range of outcomes, including changes in nature relatedness, nutritional status, quality of life, and various psychological measures, provided a multifaceted perspective on the potential benefits of video game interventions.

    This study has some limitations. First, although the period in which we conducted our study was unique, with the COVID-19 pandemic spreading in South Korea and social distancing being mandated as a national policy, this study primarily targeted the general public, and the participants were not a patient group. Most psychological scales used in this study were designed for psychological and pathological conditions; because we targeted a general population, and not a clinical group, the baseline values of the psychological scale were not high. This posed limitations for the evaluation of the game’s psychological improvement effects compared with a patient group. Future studies would benefit from examining the effects on patient groups with psychological or physical issues or high-risk groups. Second, this study did not clearly identify the specific elements of the video game that contributed to the observed behavioral and emotional changes. Further research is needed to determine which elements of the game are the most influential in producing significant effects. Finally, the sample size in this study was relatively small to determine statistical significance. To increase the reliability and statistical power of the findings, it is necessary to conduct another study with a larger sample size. Along these lines, it is also necessary to confirm the evidence produced through additional independent studies to ensure reproducibility.

    Conclusion

    Our study provides empirical evidence to suggest that nature-based video games, specifically Sakuna: Of Rice and Ruin, may enhance nature relatedness and positively influence nutritional and psychological states in an urban population. In light of our findings and the growing popularity of video games, particularly in the context of an increased tendency to stay at home owing to the COVID-19 pandemic, serious consideration should be given to the integration of digital games into strategies for promoting healthy behaviors and mental well-being. This is especially relevant as we navigate the challenges of our increasingly urbanized and digitized society. In conclusion, our study suggests that digital games, specifically those with a nature-based theme, can have a positive impact on users’ connection with nature, nutritional habits, and psychological health. Further studies are needed to corroborate these findings, identify the various influences of specific game elements, and determine the long-term effectiveness of these games as a form of digital therapy. Furthermore, it is necessary to optimize these specific game tools and integrate them into a real-world ecosystem to maximize their therapeutic potential.

    Acknowledgments

    This work was supported by National Research Foundation of Korea (NRF) grants funded by the Ministry of Science and Information and Communications Technology (MSIT), Government of Korea (NRF-2020R1C1C1007463 and NRF-2021R1A5A8032895); Information and Communications Technology and Future Planning for Convergent Research in the Development Program for R&D Convergence Over Science and Technology Liberal Arts (NRF-2022M3C1B6080866); and an Institute of Information and Communications Technology Planning and Evaluation (IITP) grant funded by the Korean government (MSIT; RS-2023-00224823).

    Data Availability

    The data supporting the findings of this study are available upon request from the corresponding author. The data are not publicly available because of privacy concerns.

    Authors' Contributions

    CHC and JL are cocorresponding authors of this paper and are responsible for data and materials, manuscript submission, peer review, publication process, authorship details, and ethics committee approval. JL and CHC conceived and designed the study. SL, CY, YBS, JL, and CHC performed the analyses. SL, CY, JL, and CHC wrote the first draft of the manuscript. SL, CY, YBS, JL, and CHC collected the data. SL, CY, HJL, YML, JL, and CHC edited all versions of the manuscript. All authors were involved in interpreting the results and read, commented on, and approved the final version of the manuscript.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    Scenes captured from the game Sakuna: Of Rice and Ruin (images used with permission from Edelweiss, the video game developers).

    DOCX File , 6310 KB
    Multimedia Appendix 2

    Summary of game characteristics.

    DOCX File , 16 KB
    Multimedia Appendix 3

    Summary of game components.

    DOCX File , 16 KB
    Multimedia Appendix 4

    Significant findings regarding the impact of the game in the immediate invention group and waitlist group.

    DOCX File , 36 KB
    Multimedia Appendix 5

    Impact of the computer game on nature relatedness, nutritional status, and psychological state in the entire sample.

    DOCX File , 21 KB
    Multimedia Appendix 6

    Significant findings regarding the impact of the game in the entire sample.

    DOCX File , 48 KB
    Multimedia Appendix 7

    CONSORT-eHEALTH checklist (V 1.6.1).

    PDF File (Adobe PDF File), 15077 KB
    1. Harpham T. Urbanization and mental health in developing countries: a research role for social scientists, public health professionals and social psychiatrists. Soc Sci Med. Jul 1994;39(2):233-245. [CrossRef] [Medline]
    2. Moore M, Gould P, Keary BS. Global urbanization and impact on health. Int J Hyg Environ Health. Aug 2003;206(4-5):269-278. [CrossRef] [Medline]
    3. Dean JH, Shanahan DF, Bush R, Gaston KJ, Lin BB, Barber E, et al. Is nature relatedness associated with better mental and physical health? Int J Environ Res Public Health. Jun 29, 2018;15(7):1371. [FREE Full text] [CrossRef] [Medline]
    4. Walsh R. Lifestyle and mental health. Am Psychol. Oct 2011;66(7):579-592. [CrossRef] [Medline]
    5. Martyn P, Brymer E. The relationship between nature relatedness and anxiety. J Health Psychol. Jul 04, 2016;21(7):1436-1445. [CrossRef] [Medline]
    6. Popkin BM. Urbanization, lifestyle changes and the nutrition transition. World Development. Nov 1999;27(11):1905-1916. [CrossRef]
    7. Yach D, Stuckler D, Brownell KD. Epidemiologic and economic consequences of the global epidemics of obesity and diabetes. Nat Med. Jan 01, 2006;12(1):62-66. [CrossRef] [Medline]
    8. Basu S, Stuckler D, McKee M, Galea G. Nutritional determinants of worldwide diabetes: an econometric study of food markets and diabetes prevalence in 173 countries. Public Health Nutr. Jun 13, 2012;16(1):179-186. [CrossRef]
    9. Ulrich RS. Visual landscapes and psychological well‐being. Landscape Res. Feb 24, 2007;4(1):17-23. [CrossRef]
    10. Groenewegen PP, van den Berg AE, de Vries S, Verheij RA. Vitamin G: effects of green space on health, well-being, and social safety. BMC Public Health. Jun 07, 2006;6(1):149. [FREE Full text] [CrossRef] [Medline]
    11. Hwang TJ, Rabheru K, Peisah C, Reichman W, Ikeda M. Loneliness and social isolation during the COVID-19 pandemic. Int Psychogeriatr. May 26, 2020;32(10):1217-1220. [CrossRef]
    12. Williams SN, Armitage CJ, Tampe T, Dienes K. Public perceptions and experiences of social distancing and social isolation during the COVID-19 pandemic: a UK-based focus group study. BMJ Open. Jul 20, 2020;10(7):e039334. [FREE Full text] [CrossRef] [Medline]
    13. Hoffart A, Johnson SU, Ebrahimi OV. Loneliness and social distancing during the COVID-19 pandemic: risk factors and associations with psychopathology. Front Psychiatry. Nov 20, 2020;11:589127. [FREE Full text] [CrossRef] [Medline]
    14. Lim S, Sohn M. How to cope with emerging viral diseases: lessons from South Korea's strategy for COVID-19, and collateral damage to cardiometabolic health. Lancet Reg Health West Pac. Jan 2023;30:100581. [FREE Full text] [CrossRef] [Medline]
    15. Michie S, West R. Sustained behavior change is key to preventing and tackling future pandemics. Nat Med. May 10, 2021;27(5):749-752. [CrossRef] [Medline]
    16. The Lancet Respiratory Medicine. Future pandemics: failing to prepare means preparing to fail. Lancet Respir Med. Mar 2022;10(3):221-222. [CrossRef]
    17. Barr M, Copeland-Stewart A. Playing video games during the COVID-19 pandemic and effects on players’ well-being. Games Culture. May 06, 2021;17(1):122-139. [CrossRef]
    18. Online games encourage players to stay mentally and physically healthy at home. World Health Organization. Nov 16, 2021. URL: https:/​/www.​who.int/​news/​item/​16-11-2021-online-games-encourage-players-to-stay-mentally-and-physically-healthy-at-home [accessed 2023-06-23]
    19. Ellis LA, Lee MD, Ijaz K, Smith J, Braithwaite J, Yin K. COVID-19 as 'game changer' for the physical activity and mental well-being of augmented reality game players during the pandemic: mixed methods survey study. J Med Internet Res. Dec 22, 2020;22(12):e25117. [FREE Full text] [CrossRef] [Medline]
    20. Cugelman B. Gamification: what it is and why it matters to digital health behavior change developers. JMIR Serious Games. Dec 12, 2013;1(1):e3. [FREE Full text] [CrossRef] [Medline]
    21. Johnson D, Deterding S, Kuhn KA, Staneva A, Stoyanov S, Hides L. Gamification for health and wellbeing: a systematic review of the literature. Internet Interv. Nov 2016;6:89-106. [FREE Full text] [CrossRef] [Medline]
    22. Sakuna: Of Rice and Ruin. Wikipedia. URL: https://en.wikipedia.org/wiki/Sakuna:_Of_Rice_and_Ruin [accessed 2023-06-23]
    23. Ohnuki-Tierney E. Rice as Self: Japanese Identities through Time. Princeton, NJ. Princeton University Press; 1993.
    24. Koga M, Toyomaki A, Kiso Y, Kusumi I. Impact of a rice-centered diet on the quality of sleep in association with reduced oxidative stress: a randomized, open, parallel-group clinical trial. Nutrients. Sep 24, 2020;12(10):2926. [FREE Full text] [CrossRef] [Medline]
    25. Kim HS, Jung SJ, Mun EG, Kim MS, Cho SM, Cha YS. Effects of a rice-based diet in Korean adolescents who habitually skip breakfast: a randomized, parallel group clinical trial. Nutrients. Mar 05, 2021;13(3):853. [FREE Full text] [CrossRef] [Medline]
    26. Steg L, Perlaviciute G, van der Werff E, Lurvink J. The significance of hedonic values for environmentally relevant attitudes, preferences, and actions. Environ Behav. Sep 10, 2012;46(2):163-192. [CrossRef]
    27. Kang MH, Lee JS, Kim HY, Kwon S, Choi YS, Chung HR, et al. Selecting items of a food behavior checklist for the development of nutrition quotient (NQ) for children. Korean J Nutr. 2012;45(4):372. [CrossRef]
    28. The WHOQOL Group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. May 01, 1998;28(3):551-558. [CrossRef] [Medline]
    29. Carleton RN, McCreary DR, Norton PJ, Asmundson GJ. Brief Fear of Negative Evaluation Scale-revised. Depress Anxiety. 2006;23(5):297-303. [CrossRef] [Medline]
    30. Turner SM, McCanna M, Beidel DC. Validity of the social avoidance and distress and fear of negative evaluation scales. Behav Res Ther. 1987;25(2):113-115. [CrossRef] [Medline]
    31. Bagby RM, Parker JD, Taylor GJ. The twenty-item Toronto Alexithymia scale—I. Item selection and cross-validation of the factor structure. J Psychosomatic Res. Jan 1994;38(1):23-32. [CrossRef]
    32. Spielberger CD, Gonzalez-Reigosa F, Martinez-Urrutia A, Natalicio LF, Natalicio DS. The State-Trait Anxiety Inventory. Revista Interamericana De Psicología. 2017;5(3 & 4) [CrossRef]
    33. Van Dam NT, Earleywine M. Validation of the Center for Epidemiologic Studies Depression Scale--Revised (CESD-R): pragmatic depression assessment in the general population. Psychiatry Res. Mar 30, 2011;186(1):128-132. [CrossRef] [Medline]
    34. Shin WY, Kim MG, Kim JH. Developing measures of resilience for korean adolescents and testing cross, convergent and discriminant validity. Stud Korean Youth. 2009;20:105-131.
    35. Tipton RM, Worthington EL. The measurement of generalized self-efficacy: a study of construct validity. J Pers Assess. Oct 1984;48(5):545-548. [CrossRef] [Medline]
    36. Paloutzian RF, Ellison CW. Manual for the spiritual well-being scale. Westmont College. 1991. URL: https://westmont.edu/sites/default/files/users/user401/SWBS%20Manual%202.0_0.pdf [accessed 2023-12-19]
    37. Grabowska-Chenczke O, Wajchman-Świtalska S, Woźniak M. Psychological well-being and nature relatedness. Forests. Jul 02, 2022;13(7):1048. [CrossRef]
    38. Ferrari M, McIlwaine SV, Reynolds JA, Archie S, Boydell K, Lal S, et al. Digital game interventions for youth mental health services (Gaming My Way to Recovery): protocol for a scoping review. JMIR Res Protoc. Jun 24, 2020;9(6):e13834. [FREE Full text] [CrossRef] [Medline]
    39. Qiu CS, Majeed A, Khan S, Watson M. Transforming health through the metaverse. J R Soc Med. Dec 2022;115(12):484-486. [FREE Full text] [CrossRef] [Medline]
    40. Wiederhold BK. Metaverse games: game changer for healthcare? Cyberpsychol Behav Soc Netw. May 01, 2022;25(5):267-269. [CrossRef] [Medline]
    41. Chaudhury P, Banerjee D. "Recovering with nature": a review of ecotherapy and implications for the COVID-19 pandemic. Front Public Health. Dec 10, 2020;8:604440. [FREE Full text] [CrossRef] [Medline]
    42. Luykx JJ, Voetterl HT. Toward ecologically sustainable mental health care-a call for action from within psychiatry. JAMA Psychiatry. Jun 01, 2022;79(6):524-525. [CrossRef] [Medline]
    43. Abd-Alrazaq A, Alajlani M, Alhuwail D, Schneider J, Akhu-Zaheya L, Ahmed A, et al. The effectiveness of serious games in alleviating anxiety: systematic review and meta-analysis. JMIR Serious Games. Feb 14, 2022;10(1):e29137. [FREE Full text] [CrossRef] [Medline]
    44. Can video games make us healthier? World Health Organization. Dec 8, 2021. URL: https://www.who.int/europe/news/item/08-12-2021-can-video-games-make-us-healthier [accessed 2023-06-23]
    45. Richardson CR, Franklin B, Moy ML, Jackson EA. Advances in rehabilitation for chronic diseases: improving health outcomes and function. BMJ. Jun 17, 2019;365:l2191. [CrossRef] [Medline]
    46. Liu H, Ren H, Remme RP, Nong H, Sui C. The effect of urban nature exposure on mental health—a case study of Guangzhou. J Clean Prod. Jul 2021;304:127100. [FREE Full text] [CrossRef]
    47. Smiderle R, Rigo SJ, Marques LB, Peçanha de Miranda Coelho JA, Jaques PA. The impact of gamification on students’ learning, engagement and behavior based on their personality traits. Smart Learn Environ. Jan 09, 2020;7(1) [CrossRef]

    ‎
    CRIS: Clinical Research Information Service
    IIG: immediate intervention group
    NQ: Nutrition Quotient Scale
    NR: Nature Relatedness Scale
    STAI: State-Trait Anxiety Inventory
    WHOQOL-BREF: World Health Organization Quality of Life–Brief Version
    WLG: waitlist group

    Edited by G Eysenbach; submitted 07.08.23; peer-reviewed by K Lee, T Baranowski; comments to author 31.08.23; revised version received 23.11.23; accepted 30.11.23; published 22.01.24.

    Copyright

    ©Seulki Lee, Chisung Yuh, Yu-Bin Shin, Heon-Jeong Lee, Young-Mee Lee, Jungsil Lee, Chul-Hyun Cho. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.01.2024.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.