Does gamified breath-biofeedback promote adherence, relaxation, and skill transfer in the wild?

This paper investigates whether gamification of deep breathing (DB) exercises promotes relaxation, skill transfer, and adherence to treatment in ambulatory settings. We designed a game-biofeedback (GBF) intervention where users perform DB exercises while playing a video game, and the game adapts according to the user's breathing rate using negative reinforcement instrumental conditioning. As a control, we developed an interactive paced-breathing treatment (PACE) where users follow a visual signal with their breathing and touch. In a user study, 30 participants were randomly assigned to GBF or PACE, and were allowed to practice at their leisure over the course of three days. Results show that the GBF group practiced their treatments significantly more often, achieved better skill transfer at post-test, and obtained a higher increase in self-reported positivity and relaxation during treatment. Our findings suggest that the use of negative reinforcement coupled with a fun casual game can be used as an alternative tool to promote relaxation and improve adherence to stress management interventions.