Meditation

Two reviewers (LB and MH) independently selected potentially eligible studies in two phases. At the first phase, selection was based on title and abstract, and at the second phase on the full-text article. All studies identified as potentially eligible by at least one of the reviewers during the first selection phase, were re-assessed at the second selection phase. During the second phase, disagreements between the reviewers were resolved by consensus. The inter-rater reliability (kappa) was 0.90.
The inclusion criteria were as follows:
• Examination of the effects of a positive psychology intervention. A positive psychology intervention (PPI) was defined in accordance with Sin and Lyubomirsky’s (2009) article as a psychological intervention (training, exercise, therapy) primarily aimed at raising positive feelings, positive cognitions or positive behavior as opposed to interventions aiming to reduce symptoms, problems or disorders. The intervention should have been explicitly developed in line with the theoretical tradition of positive psychology (usually reported in the introduction section of an article).
• Randomization of the study subjects (randomizing individuals, not groups) and the presence of a comparator condition (no intervention, placebo, care as usual).
• Publication in a peer-reviewed journal.
• At least one of the following are measured as outcomes: well-being (subjective well-being and/or psychological well-being) or depression (diagnosis or symptoms).
• Sufficient statistics are reported to enable the calculation of standardized effect sizes.
If necessary, authors were contacted for supplementary data. We excluded studies that involved physical exercises aimed at the improvement of well-being, as well as mindfulness or meditation interventions, forgiveness therapy, life-review and reminiscence interventions. Furthermore, well-being interventions in diseased populations not explicitly grounded in positive psychology theory (‘coping with disease courses’) were excluded. Apart from being beyond the scope of this meta-analysis, extensive meta-analyses have already been published for these types of intervention
[40 (link)-42 (link)]. This does not imply that these interventions do not have positive effects on well-being, a point which will be elaborated on in the discussion section of this paper.

A systematic search of mindfulness-based mobile apps accessible from Australia was conducted in June 2014. The search was conducted using the Google app search function as well as the search feature in the iTunes app store. The Google app search included mindfulness, vipassana, mindful, meditation, and present moment, and excluded hypnosis, hypnotize, weight, magazine, mindmap, mind map, mind-map, and binaural. “Mindfulness” was the only search term used in iTunes, as the search feature was more limited.
Preliminary screening removed irrelevant apps (music/relaxation, happiness, inspirational cards, games, clocks, etc), apps not in English, and those that were not readily accessible. Mindfulness apps that were secular, explicated mindfulness practice, and also had guided mindfulness training were included. Apps that only gave reminders, timers, or guided meditation tracks were excluded, as were apps that cost more than $10 (on the grounds that they were unlikely to be purchased by a large number of users). While guided meditation tracks are a part of mindfulness training, that by itself cannot be justified as mindfulness training as they lack education about mindfulness.
The apps were rated and reviewed in iOS 7 with an iPhone 5s. Each app was tested by at least one author for a minimum of 30 minutes in a real-world setting. The authors were involved in the development of the MARS [24 (link)] and had undertaken mindfulness training. Two of the authors had delivered mindfulness training as part of their clinical psychology practice.

Religiosity was assessed using Muslim BIAC (M.BIAC) scale (25 (link)). The original study of BIAC in English was conducted on female caregivers living in the Southeastern and Western USA. This study demonstrated that BIAC has solid psychometric properties with excellent internal consistency, test–retest reliability, and convergent validity (26 (link)).
The BIAC consists of 10 questions, with each rated on a scale ranging from 1 to 10, except the first question which is scored 1 or 10 depending on the response. The total scale score ranges from 10 to 100. Item 1 directly asked respondents to choose their highest priority in life, with common priorities among the response options ranging from their health to their family (including God). The remaining items assess attendance at religious services, religious social involvement besides attending religious services, decision to place life under God's requirements, percentage of annual income given two religious causes, time spent listening/viewing religious media, time spent reading religious books and scriptures, time spent in prayer or meditation, time spent in religious volunteering, and the degree to which life is being conformed to one's religious teachings (27 (link)). The Arabic version of BIAC was published in 2016 (28 (link)).
Rammouz et al. (25 (link)) studied the Moroccan Arabic version of the Muslim BIAC on a sample of 132 students at Ibn Zohr University, Agadir, Morocco. The Cronbach's alpha for internal reliability was 0.81, with the alpha for removed items ranging from 0.77 to 0.82. Test–retest reliability by intra-class correlation coefficient (ICC) was 0.87 (95% CI = 0.83–0.91). Discriminant validity indicated relatively weak correlations between depressive symptoms (r = −0.06) and perceived stress (r = 0.08) (25 (link)).

Research staff demonstrated use of the VR headsets with the patients in a telehealth meeting prior to the initial intervention. Once all baseline assessments were collected, patients completed a brief, self-selected 5-min VR intervention under remote supervision by study staff. Staff remained in the telehealth meeting with the patients during the VR intervention so they could monitor for any technology issues or device-related AEs.
The VR headset used in this trial is the Pico G2 4K device, which is an immersive, lightweight, stand-alone headset that comes with an orientation-tracked controller and does not require a smartphone or a PC to function. This headset can be used via “gaze mode” or “controller mode” where the user can make selections on the screen by either directing their gaze at a particular item or by pointing at it using the remote controller. Additionally, there is a breath shield attachment on the front of the headset that can detect breathing patterns of the user and will change the virtual environment experienced if a breath-based scenario is chosen. The VR software loaded on the headset was designed by AppliedVR™ for use within clinical populations and aims to target unpleasant symptoms and promote relaxation. There are a total of 41 scenarios on the VR headset that fall within 3 main categories: (1) Dynamic Breathing, (2) Guided Relaxation, and (3) Instant Escape, shown in Fig. 1. While there are several interactive games on the VR device, participants were instructed not to choose these during the initial VR intervention since they tend to be more stimulating than anxiolytic.Fig. 1

AppliedVR™ virtual scenarios on Pico G2 4K headset. The dynamic breathing scenarios, which make use of a breath shield attachment, guide the participant to take slow, deep breaths in order to slow the heart rate and induce relaxation as the environment seen changes based on the breathing pattern. Guided relaxation scenarios are meditative in nature and promote mindfulness and bringing attention to unhelpful thoughts and emotions that participants might be experiencing. Instant escape scenarios allow distraction through exploration of immersive environments, including ocean-based experiences, travel to various locations around the world, and interactive games

Following the initial VR intervention, patients had self-directed VR use for the 1 month period they were on study and could choose any scenario available on the headset. Study staff conducted weekly check-ins to help troubleshoot any technological questions, to ask about device-related AEs, and to ask how often they used VR during the previous week. Other members of the household, including caregivers, were permitted to use the VR headset and patients were asked to inform us if this occurred, though no data was collected from those individuals.