52 Chapter 2 and the proportion of male participants varied from 38.7% to 87.4%. All studies used a regular RCT design, with the exception of the study of Kjeldgaard Pedersen et al. (2023) using a crossover design. See Table A.10 (Appendix) for the characteristics and findings of these studies. Twenty-one studies examined the effects of (both applied and casual) games as a distraction tool to reduce anxiety during the procedure. Nine of those studies used a virtual reality game (Chan et al., 2019, study 1 and 2; Dunn et al., 2019; Gold & Mahrer, 2018; Jivraj et al., 2020; Jung et al., 2021; Kjeldgaard Pedersen et al., 2023; Osmanlliu et al., 2021; Schlechter et al,. 2021) and ten of those studies allowed participants to select a game of their choice (Burns-Nader et al., 2017; Dwairej et al., 2020; Inan & Inal, 2019; Ko et al., 2016; Marechal et al., 2017; Pande et al., 2020; Patel et al., 2006; Sahin & Karkiner, 2022; Sakızcı Uyar et al., 2021; Stewart et al., 2019). In the study of Kumari et al. (2021), participants played a virtual reality game of their choice. Nilsson et al. (2013) also used a game as distraction, however, all participants were given the same game. In three studies, an applied game was provided prior to dental treatment or surgery and the effect on anxiety or pre-operative worries was examined (Elicherla et al., 2019; Fernandes et al., 2015; Matthyssens et al., 2020). Finally, the study of Kassam-Adams et al. (2016) examined the effects of an applied game to prevent posttraumatic stress symptoms in children following medical events. Effect sizes were calculated for the group of studies that used games as a distraction tool to reduce anxiety during the procedure. Because all games were used as a distraction tool, the distinction between applied and casual games was deemed irrelevant. For the purpose of this review, the effect of game distraction was compared to standard care. Data from 15 studies were used. For five studies, data could not be obtained (Dunn et al., 2019; Gold & Mahrer, 2018; Jivraj et al., 2020; Kjeldgaard Pedersen et al., 2023; Schlechter et al., 2021) and one study did not include a standard care comparison group (Kumari et al., 2021). The primary variable of interest for the current review was self-reported anxiety during the procedure or during mask induction/ anaesthesia. For both studies of Chan et al. (2019) and the study of Pande et al. (2020) no measurement during the procedure was available. Therefore, effect sizes were calculated on the post-test measurement. For seven studies no self-reported anxiety was available, hence (clinician) observed anxiety was taken as outcome (Burns-Nader et al., 2017; Dwairej et al., 2020; Jung et al., 2021; Patel et al., 2006; Sahin & Karkiner, 2022; Sakızcı Uyar et al., 2021; Stewart et al., 2019). Ko et al. (2016) measured participants’ heartrate as an indication of anxiety. Finally, Nilsson et al. (2013) measured distress during the procedure
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