November 9, 2024
Investigating the mediating role of ethical issues and healthcare between the metaverse and mental health in Pakistan, China, and Saudi Arabia

Theories

The framework of the study is based on the integration of the Human-Computer Interaction Principles (HCI), Social Cognitive Theory (SCT), Technological Determinism Theory (TDT), and Digital Well-being frameworks (DW). These theories establish a foundation for an empirical investigation to examine the complex interactions among the Metaverse, ethical issues, access to healthcare, and MH. They were used to determine the Metaverse’s effect on MH while considering healthcare and ethical issues as mediators.

Social cognitive theory

Albert Bandura presented the SCT. It explores how people learn from their society and environments (Bandura, 1986). It highlights the essential function that cognitive processes, self-efficacy beliefs, and observational learning influence a person’s behavior. It argues that people learn through experiences and by observing and copying others and highlights the dynamic interaction between an individual’s character, surroundings, and behavior. In sum, SCT offers a thorough framework for comprehending how people learn and use knowledge and behavior in everyday life, which makes it significant across numerous scientific fields (Bandura, 2002). In the context of this study, it can be used to investigate how ethical concerns and medical therapies mediate the effects of the Metaverse experiences on MH.

Technological determinism theory

This idea explores how technology affects both society and people. It asserts that technology fundamentally and inevitably influences the development of human culture, history, and society. This idea also argues that social development and changes in how individuals think, organize, and interact are driven by technological advances (Héder, 2021). Moreover, it says that technology has a transformative strength that shapes the structures of society and individuals’ behavior in predictable manners (Jan et al. 2020). This opinion frequently minimizes the importance of social and cultural influences, accusing technological advancements and their inherent characteristics for the changes. Some scholars have disagreed on the usefulness of TDT as an approach to understanding how technology affects society, while some believe it is (Bibri, 2022). Others believe it oversimplifies the complicated relationship between technology and society (Bojic, 2022). In the context of this study, it provides useful insights to examine the role of the Metaverse in shaping healthcare and MH.

Human-computer interaction principles

It provides a comprehensive framework for developing and evaluating technology systems and interfaces (Alkatheiri, 2022). HCI is primarily user-centered, highlighting accessibility and usability through a user-centered design. It fosters simplicity, learnability, and consistency while offering clear feedback with error management (Hustak and Krejcar, 2016). The importance of ethics in HCI has grown, with a focus on security and privacy due to the wider societal effects of technology (Nie et al. 2023). Further, technology needs to be tested and evaluated regularly to fulfill its purpose, improve user satisfaction and interaction, and express the collaborative link between technological advancement and human interaction (Saltarella et al. 2023). In the context of this research, the Metaverse technology can be used to investigate the usability and design of the Metaverse platforms and how they affect MH.

Digital well-being frameworks

The DW frameworks evaluate how digital technology affects well-being and function as roadmaps to assist people in navigating the complicated realm of digital technology, focusing on balanced, healthy, and vigilant connections (Gennari et al. 2023). The basic concepts of these models cover anything from encouraging self-awareness and healthy time management to teaching consumers about online security, privacy, and digital literacy (Tinmaz et al. 2023). These frameworks promote practices prioritizing MH while using technology (Smith et al. 2023). People can establish a more harmonic connection with digital tools and platforms. They can improve the quality of their life in today’s digital world by incorporating these frameworks into their individual and institutional strategies (Hamdoun et al. 2023; Li, 2023). In the context of this study, these frameworks can be used to measure the relationship between the Metaverse and MH.

The research applies HCI to examine the layout and usefulness of simulated environments of the Metaverse to find out the Metaverse’s influence on MH. HCI guides investigating the influence of human interactions and experiences in the virtual world on MH. For instance, user interfaces and immersion in the Metaverse will either positively or negatively affect MH. Furthermore, it is not easy to comprehend the relationship between the Metaverse, ethics, and MH. The study uses SCT to comprehend more about the ethics and behaviors in virtual spaces and how they may impact the MH of people. This theory facilitates us to comprehend the perception of people regarding ethical conduct and its impact on MH in the Metaverse. For example, we examine whether experiencing or taking part in immoral activities leads to anxiety, guilt, etc., in the Metaverse or not.

In addition, it is a complicated subject to discuss how the Metaverse impacts MH. Here, we apply the TDT to investigate how the technological entity that is the Metaverse may impact ethical issues and MH. TDT enables us to see if the technical characteristics of the Metaverse intrinsically influence ethics and, consequently, MH. For example, we examine if people act differently due to the immersive aspect of the Metaverse and if these actions affect their mental wellness. Similarly, the research uses DW to explore how the Metaverse facilitates healthcare access. DW frameworks provide a systematic approach to examining how well-being is affected by technological advancements. Using such frameworks, we investigate whether the Metaverse could be used as a platform for providing and supporting healthcare. For instance, considering the possible ethical issues raised by this special healthcare option, we examine if virtual healthcare provided via the Metaverse improves access to healthcare and patient MH. With the help of these theories, the study seeks to present a thorough understanding of the interplay of the Metaverse, healthcare, ethics, and MH in the currently evolving virtual landscape.

The Metaverse

The Metaverse is a digital world, an interconnected and interactive virtual reality where users may interact and navigate in real-time. With many distinctive features, including user content, a distinct digital economy, and smooth multi-platform accessibility, it differs from conventional online environments (Wang et al. 2023). Leading companies like Google and Meta have made significant investments in its development and consider it the next frontier for the web, where people can work, socialize, and play (Mosco, 2023). It also brings complex challenges, such as digital ownership rights, monopolistic control, accessibility, security, and privacy (Ooi et al. 2023). Overcoming these problems is essential as the Metaverse reshapes our lives and how we engage with the virtual world.

The development of the Metaverse accompanies a wide range of implications. Undoubtedly, it provides opportunities for improved social connectedness, new commercial opportunities, healthcare, and advanced learning possibilities. Nevertheless, it also prompts issues related to privacy, access (Letafati and Otoum, 2023), equal benefits, and the possibility of monopolistic domination of a few companies. Areas that need extra attention include intellectual property problems, challenges concerning content control, and the effect on in-person relationships (Wylde et al. 2023). These implications must be managed in the light of equality, ethics, and regulation while encouraging creativity and connectivity across the changing digital environment to fully utilize its potential for the common good (Arief et al. 2023).

The Metaverse will change our lives, working styles, and interactions by offering a virtual environment, enabling deep social connections, creative business options, and novel health and educational opportunities (Banaeian et al. 2023; Reibstein and Iyengar, 2023). It might revolutionize all walks of life and provide people with an environment for innovation, entrepreneurship, and cooperation (Calandra et al. 2023; Schiller et al. 2023). This makes it both beneficial and challenging. Its usefulness depends on managing major concerns like privacy, security, and accessibility and on the investing firms to develop and maintain the Metaverse that is accessible, ethical, and useful for society.

The Metaverse and mental health

MH is a person’s ability to perceive, think, and behave in ways that enhance their living quality while respecting their personal, cultural, and social boundaries (Manwell et al. 2015). Emotional, social, and psychological well-being are the parts of MH that influence human perception, behavior, and cognition. A person’s MH determines how to handle stress, relationships, and the process of decision-making (Galluccio, 2019). Sleep disturbance, fatigue, and thoughts of harming oneself or others are early indicators of MH issues (Pappa et al. 2021). Mental disorders influence and change a person’s cognitive functioning, behavior, and emotional reactions linked with distress or other impaired functioning (Goldman and Grob, 2006). It has a relationship with diet, stress, exercise, abuse, drugs, social interactions, and connections (Manger, 2019). Professionals like therapists, psychologists, psychiatrists, family physicians, etc., assist in MH treatment in various forms like counseling, therapy, etc. (Sass et al. 2022). Depression, anxiety, phobias, eating disorders, schizophrenia, obsessive-compulsive disorder, and personality disorders are major MH conditions that can cause psychosis, self-harm, panic attacks, suicidal thoughts, etc. (Solmi et al. 2022). A complex interaction of different factors causes any MH issue, and it is very difficult to identify as they may differ from person to person. Some of the common factors are abuse, lack of sleep, loneliness or social isolation, discrimination, social disadvantage, stress, drugs, violence, bullying, trauma, etc. Physical and environmental factors also affect behavior, such as injuries and neurological conditions (Limone and Toto, 2022).

It is unclear that technology always creates MH issues, and researchers are divided on this. For example, if technology leads to problems associated with behavior, attention, and self-regulation, it also minimizes depression and anxiety (Weinstein et al. 2021). Users with low socio-economic status are at higher risk of MH issues than those with high socio-economic status. Another reason for MH issues is the duration of using technology (Strutt et al. 2022). Those who spend more time using digital technology are more likely to suffer from fighting, lying, and other behavioral problems. It also leads to issues like “paying attention and exhibiting attention deficit-hyperactivity disorder symptoms.” Similarly, self-regulation problems are also evident in frequent users (Liston et al. 2011). Digital technology also decreases the bonding between family members and society (Newman et al. 2019). People who spend more time using digital devices have less time for social activities, sports, or time with family members or relatives. This increases the chances of mental disorders in the form of behavior, psychosis, self-harm, panic attacks, and suicidal thoughts (Fegert et al. 2020). Perhaps the most severe challenge of using digital technology is that people can easily access and see the lifestyles of others, the different kinds of thoughts, and face bullying and harassment, etc., that often leads to feelings of discrimination or abuse (Ali and Shahbuddin, 2022). These are some of the problems digital technology brings to our lives, causing MH issues. On the other hand, many MH problems can be solved using digital technology (Areàn et al. 2016). For example, it minimizes the issues of isolation, depression, and anxiety and offers advanced treatment for various mental disorders.

The Metaverse brings both opportunity and risk for MH (Usmani et al. 2022). It provides avenues for social interaction, medical care, and artistic endeavors, enhancing MH (Cerasa et al. 2022). Virtual environments can minimize feelings of loneliness, offer support for those experiencing MH issues, and provide new methods of treatment (Ifdil et al. 2023). Despite this, it also brings worries regarding the possibility of addiction, separation from the real world, and the blurring of real and digital borders, which will increase MH issues (Situmorang, 2023). Achieving the right balance between utilizing the Metaverse’s potential for treatment and minimizing its challenges is essential for an individual’s MH (Curtis and Brolan, 2023).

Metaverse in healthcare

The Metaverse consists of two words: meta, which means “beyond,” and the universe (Hollensen et al. 2023). It connects social media, AR, and VR technologies via high-speed internet (Ullah et al. 2018). It is a digital universe merging virtual and physical reality (Bibri, 2022). Advanced technologies like AR, VR, artificial intelligence, blockchain, cloud computing, and 5 G and 6 G internet are its building blocks (Wang and Zhao, 2022). The Metaverse refers to a collaborative, interactive, and immersive digital environment where people interact as online crowds (Dwivedi et al. 2022) to support work, play, and socialize (Askr et al. 2023; Wolf et al. 2013). It is a fact that our lives are becoming a mix of virtual and physical worlds (Meta, 2022). Some scientists believe the present social media and digital communication technologies are its primary form, while some say it is yet to come (Salar et al. 2023). In the Metaverse, people will enter through AR glasses or VR headsets, symbolizing avatars to interact with others and participate in various activities (Njoku et al. 2023). People in the Metaverse will experience a strange sense of presence and feel themselves in an environment without any technological perception that generates it (Oh et al. 2023). People will feel they perform tasks like they do in a real environment. The simulative progressions presented by VR, AR, and MR offer a potential basis for recognizing the Metaverse experience as a real-world experience (Smith et al. 2019). It is important to note that VR, AR, or MR embodied simulations will share human brain functions. The brain produces its body simulation to predict and represent actions and emotions. (Parsons et al. 2020). In the same way, humans will experience the sensory consequences of various scenarios in virtual spaces as in the real world (Riva and Wiederhold, 2022).

This shows that the Metaverse and human brains are working side by side, and their existence is made possible by the normal functions of the human brain (Islam Mozumder et al. 2023). The perceptions and feelings a human brain experiences in the real world are similar to those of a virtual one (De Borst and de Gelder, 2015). It can also have a significant psychological and behavioral impact on human beings (Ningning and Wenguang, 2023). Similarly, the brain’s functions are strongly associated with MH and well-being. There are many risks associated with human behavior, psychological experience, and well-being from the Metaverse. Conversely, it has profound applications in rehabilitation, telemedicine operations, psychotherapy, etc. (Mozumder et al. 2023). It can further assist the healthcare system in enhancing personalized care at a lower cost, regardless of the patient’s location. Telepresence, blockchain, and digital twining could also provide amazing possibilities and opportunities for MH care in the Metaverse (Shetty et al. 2022). Some MH applications are Mood Fit, Better Help, Mood Mission, Sanvello, Calm, Happify, Depression CBT Self-Help Guide, Shine, e-Moods, Bearable, Todoist, PTSD Coach, etc. Many hospital chains and fitness centers are adopting technologies beyond digital ones for the MH (Bansal et al. 2022). It is evident from the statistics that the global Metaverse market for healthcare was $5.06 billion in 2021 and is expected to reach $71.97 billion by 2030.

The Metaverse will significantly change healthcare access by eliminating geographical constraints and providing new approaches for distant healthcare (Ifdil et al. 2023; Chengoden et al. 2023). It will facilitate telemedicine sessions (Wiederhold, 2022), allowing patients to interact with health professionals from their homes, and will be especially useful for people living in underserved or distant locations. Furthermore, virtual medical training can help healthcare workers improve their expertise and abilities (Tan et al. 2022). Besides its benefits, issues like data security and privacy will emerge, and personal health data will be at risk of cyber assaults (Benjamins et al. 2023). Therefore, reducing the potential risks associated with adopting the Metaverse in healthcare is necessary. A proper balance between using the Metaverse’s potential to enhance healthcare access and securing medical information is necessary (Solaiman, 2023).

Ethical issue(s) of the Metaverse in healthcare

Adopting the Metaverse brings many ethical challenges that must be taken seriously (Kaddoura and Al Husseiny, 2023). The primary concern is digital privacy, which arises when people get involved in these virtual worlds, leaving a lot of private data behind (Smith et al. 2023). Secondly, the risk of being overly involved in digital environments (Chen, 2022). It also includes the legitimacy of virtual encounters, the risk of fraud, and the dissolving of fiction and reality (De Felice et al. 2023). There are also concerns about digital spying, surveillance capitalism, and the absolute power of a few technological giants in controlling the Metaverse (Qamar et al. 2023). Resolving these ethical issues is critical to ensure that the Metaverse is an environment that serves humanity rather than endangers our values and MH (Kshetri, 2022).

Undoubtedly, the Metaverse will benefit healthcare and provide tremendous solutions to various problems. Yet, it will also invite the issue of medical ethics (Leroy et al. 2022). Most ethical issues like safety, privacy, social, accessibility, identity control, and freedom of expression are also some of its concerns. Also, new technology brings new concerns (Quach et al. 2022). For example, deep fakes and manipulations might also be serious ethical concerns (Zhao et al. 2022). Data security is one of the most serious concerns in any healthcare system. It is very unethical if data regarding patients, etc., is shared or leaked with any unauthorized party. This could be its potential ethical threat to healthcare (Zeng et al. 2022). Harassment, bullying, and other impolite behavior are other serious concerns in the Metaverse (Wiederhold, 2022). Many people will disregard others and will also violate their freedom (Wang and Zhao, 2022). Mental and biological privacy will also be threatening when someone reads our minds, models our identity, and controls our behavior. Safety is another potential threat, as technology and devices can be attacked by hackers (Wiederhold, 2022). Another serious ethical concern is its unequal access. Many poor and developing nations cannot afford the technology, and the digital divide will increase (Kaur, 2022).

Perhaps the most important ethical issue in the Metaverse is the manipulation of reality. Pictures, videos, etc., can be used as deep fake videos. In other words, old videos can be deceived using the latest digital Metaverse technology in a forged reality. The question is, how will such videos impact the MH of the one associated with it? In addition, the Metaverse will also change the living habits of humans. Their social life will be highly impacted as they live in a joint real-virtual world. Their relationships will also be disturbed, and a negative change is expected in their behavior (Dwivedi et al. 2022). In short, it is a fact that the Metaverse in healthcare will bridge the real and virtual worlds and provide solutions to many of today’s healthcare problems, but it also brings some ethical issues like information security, privacy, harassment, bullying, manipulation, unequal access, etc. (Kaur, 2022).

Mental health

MH encompasses an individual’s social, psychological, and emotional state (WHO, 2023). It involves mental disorders, managing stress, upholding healthy relationships, dealing with challenges in life, and staying happy and contented (Hattie et al. 2004). From infancy to maturity, good MH is essential since it affects a person’s ability to function well and live a satisfied life (van den et al. 2023). Factors contributing to MH are emotional well-being, psychological resilience, effective management of stress and anxiety, and quality relationships. Cultural and social factors, including societal norms, cultural values, and financial status, also help or hurt MH (Manger, 2019). Events in life can also have a significant effect on MH. MH is also influenced by deoxyribonucleic acid and other biological factors, such as brain chemistry and inheritance (Patalay and Demkowicz, 2023).

Promoting MH is essential for avoiding mental illnesses and improving quality of life (van den et al. 2023). There are various initiatives people take to improve their MH. Maintaining excellent MH requires keeping a healthy weight, eating a balanced diet, getting adequate sleep, and reducing (Arslan, 2023; LaBelle, 2019). Seeking medical care is necessary for successful MH treatment. Enhancing awareness and lowering the stigma associated with MH problems foster a more welcoming and encouraging community. It significantly impacts one’s life, especially on a person’s ability to work, establish and maintain relationships, and make decisions. It also leads to physical health issues like chronic illnesses, reduced immune systems, and cardiovascular disease. On the good side, it contributes to resilience and productivity and promotes happy relationships and successful living (Foster et al. 2023).

Theoretical mechanism

A theoretical framework integrating concepts from SCT, TDT, HCI Principles, and DW Frameworks can potentially be used to understand the influence of the Metaverse on MH, with moral issues and healthcare as mediators. According to SCT, social interactions are the sources of behavior adoption, and interactions in virtual settings influence how people learn and modify their behaviors and attitudes. Users engage and observe various content and avatars while immersed in the Metaverse, influencing their MH. Similarly, TDT highlights the impact of technology on human beings and society. It implies that the Metaverse inevitably influences users’ interactions with digital environments and one another. It impacts individuals’ encounters with ethical issues and their ability to access healthcare resources in the Metaverse.

Moreover, the study considers HCI principles when navigating the Metaverse’s organization and interface, as it strongly emphasizes the importance of usability and user-centered design. Implementing HCI concepts in the Metaverse can help users access ethical norms and healthcare data. User’s friendly design of the Metaverse technology and easy access to healthcare can improve users’ engagement with healthcare facilities. Finally, DW Frameworks provides an organized approach for evaluating how digital technology impacts people’s well-being. They can be used in the Metaverse to assess how ethical concerns and healthcare procedures fit with standards for fostering mental health. These frameworks provide a window to evaluate ethical issues and healthcare facilities in enhancing users’ MH by considering elements like autonomy, relatedness, competence, and user satisfaction.

SCT focuses on the process during which people interact within the Metaverse, influencing the behaviors associated with their MH. TDT highlights the Metaverse’s inherent influence on ethics and healthcare access. HCI principles ensure that the Metaverse is designed to make it easier for users to interact with moral and medically relevant material. The DW framework evaluates how the Metaverse affects’ users’ MH. These theories collectively provide a thorough knowledge regarding the influence of the Metaverse on MH through the mediating roles of ethical concerns and healthcare, as shown in Fig. 1. The Metaverse offers a new horizon for healthcare and MH. It can provide an appealing, interesting interface for users and healthcare professionals because of its user-centric design. The metaverse will be a lively environment for experiential learning, encouraging positive behaviors, and nurturing social networks that support one another and positively impact psychological well-being. Likewise, it will advance innovation in healthcare supply, expanding connectivity, professional collaboration, and healthcare access. However, ethical considerations and healthcare mediate the relationships between the Metaverse and MH. Establishing an equilibrium between ethical use and the Metaverse is essential to minimize problems like digital addiction, data breaches, etc. Furthermore, as the Metaverse can be accessed by a wide range of demographic groups, enhancing the healthcare system’s current efficiency, healthcare also becomes an important mediator between the Metaverse and MH.

Fig. 1
figure 1

Proposed theoritical framework of investigating the mediating role of ethical issues and healthcare between the metaverse and mental health.

The study uses these theories to comprehend the relationships as given in the hypotheses.

Hypotheses

The above theoretical mechanism provides the foundation for the following hypotheses.

H1: The perceived Metaverse has a significant impact on the healthcare

H2: The perceived Metaverse has a significant impact on the ethical issues of the Metaverse

H3: Ethical issues of the Metaverse have a significant impact on the MH

H4: Healthcare has a significant impact on the MH

H5: Ethical issues of the Metaverse mediate the relationship between the Metaverse and MH

H6: Healthcare mediates the relationship between the Metaverse and MH

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