Introduction

In the past two decades, digital technology has advanced significantly and transformed our lives (Cowie and O’Connor, 2022). It has allowed us to create, process, store, and access large amounts of data. With the help of digital technologies and the internet, we can interact on various platforms and engage in activities over long distances. There are approximately five billion internet users worldwide, with 93% using social media as of April 2022 (Bardus et al. 2022). On average, people spend 147 min daily on social media (Liu et al. 2023) and 6 h and 58 min online (Evenson et al. 2023). This highlights the need to examine the impact of the internet and social media on its users’ mental health (MH).

Undoubtedly, digital technology is becoming an integral part of our lives, and its impact reshapes society and our behavior. Similarly, we cannot run from societal transformation due to these technological changes and advancements. It is so powerful that digital technology has become an important part of many societal functions (Hodson, 2018). As a result, no one can escape from using digital technology, and its adoption is becoming obligatory without any other choice.

Technological transformation always comes with its issues and challenges. And so the use of digital technology has also given rise to many MH problems and issues (Pandya and Lodha, 2021). For example, depression, anxiety, and suicide attempts increased among teens after the availability of smartphones. Most parents, children, friends, etc., interact with their devices, not with each other, even if they are physically together (Mindrescu and Enoiu, 2022). This leads to weakened human and societal relationships along with a sense of empathy, creativity, introspection, etc. The final target will be the social bonding and fabric that holds society and communities together (Sherry, 2015). Due to these issues, many researchers have stressed minimizing the use of digital technologies (Cal, 2019). Such concerns were increased when efforts were carried out to immediately stop the speed of COVID-19, and willingly or unwillingly, every aspect of society’s business, including educational, professional, personal, cultural, etc., was shifted online (Marandi, 2023). This craving for virtual togetherness was made possible by the digital technological revolution, which developed dramatically during the epidemic under the phrase “social distancing.” Meanwhile, the adoption and acceptability of DT expanded with time (Sayibu et al. 2022). Additionally, many scientists and researchers were attracted to enhance the technology further to meet an immediate need or create the Metaverse of the future (Zhang et al. 2022). Moreover, technological giants like facebook, etc., also started to invest in the Metaverse (Chen and Zhang, 2022).

Problem statement

“The issues related to MH due to the excessive use of DT and the internet became a significant challenge in the Metaverse.” Its emergence has raised concerns regarding the possible effects of immersive digital platforms on human MH (Usmani et al. 2022). Although there is early optimism, it is necessary to look at the complex relationships connecting the Metaverse, ethical issues, healthcare availability, and its combined effect on MH (Benrimoh et al. 2022). Moreover, investigating these complex relationships is necessary for making policies, technological support systems, healthcare facilities, and service planning to increase the Metaverse’s benefits and ensure MH. This study aims to determine how the Metaverse affects MH, emphasizing the mediating roles of healthcare and ethical concerns.

The objectives of the study are:

  1. 1.

    To find out the impact of the Metaverse on MH

  2. 2.

    To find out the role of the Metaverse in creating ethical issues in healthcare

  3. 3.

    To find out the impact of the Metaverse on healthcare

Research questions

The research addresses the following questions, which provide a base for examining the complex links among the Metaverse participation, ethical issues, healthcare, and MH.

  1. 1.

    How does the Metaverse affect human MH?

  2. 2.

    How does the Metaverse affect ethical issues?

  3. 3.

    Do the ethical issues and healthcare mediate the relationship between the Metaverse and MH?

  4. 4.

    Is there any role of the Metaverse in providing access to healthcare?

Research significance

The study has many significant aspects. It highlights a new and important issue in the current digital era. Understanding the possible effects of the Metaverse on MH is essential as it grows increasingly and integrates into everyday life (Benrimoh et al. 2022). This study also highlights the potential advantages, the considerable ethical issues, and the requirements for healthcare within this setting. The study also ties technological advances and well-being together, making it further important. It attempts to offer empirical evidence regarding whether the virtual world impacts MH, clarifying whether it worsens or reduces MH problems. It provides a comprehensive view of the intricate relationships between technology, ethics, and health essential to lawmakers, healthcare providers, and technologists by examining the intermediary role of ethical concerns and healthcare. The research has implications for individuals, firms, and managers associated with Metaverse development and MH. It provides insights regarding ethical guidelines, policies, and regulations to ensure responsible development and use of Metaverse and users’ MH. Similarly, by exploring the mediating role of ethical issues and healthcare involvement, the study assists in making informed decisions, designing Metaverse technology responsibly, and supporting customized MH in the Metaverse digital world.

Hypotheses development and conceptual framework

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.

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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

Methodology

Research philosophy

The philosophical foundation of social sciences research is often based on interpretivism and positivism (Babones, 2016). A positivism paradigm is recommended whenever a study is based on prior theories in a specific context to enhance its generalizability, and the researcher believes in a pre-determined reality. On the other hand, when the researcher wants to explore a new dimension that has not been discovered and is not properly supported by a prior theory, then an interpretivism paradigm is recommended (Moon and Blackman, 2014). This study is based on previously established ideas that the researcher will test in specific contexts, so it follows the positivism paradigm. The Positivist paradigm is a scientific paradigm based on objective beliefs about social phenomena in research. The study is quantitative and was conducted with the help of a close-ended questionnaire adopted from prior studies.

Research population and sampling

The population of this study includes medical doctors and nurses in the health sector of Pakistan, China, and Saudi Arabia. There are two primary options for the researcher to adopt: probability sampling and non-probability sampling (Baker et al. 2013). When the exact number of the population is known and every individual in the population is accessible, the probability sampling technique is recommended; otherwise, it is suggested to adopt a nonprobability sampling technique (Rahi, 2017). As in this study, the researchers adopt a non-probability sampling technique. Among the several types of nonprobability sampling techniques, a purposive sampling technique was used to select useful respondents for the research. Data was gathered from the 392 respondents across the research population.

Research instrument and statistical technique

The measures used in the study were adopted from the prior validated studies to ensure reliability and validity. A five-point Likert scale was used for the measurement where 1 denotes the lowest level of agreement, and 5 denotes the highest level of agreement. The partial least square technique by the SmartPLS software was used to analyze the gathered data. The list of the scales for all constructs with their items and sources is mentioned in Table 1.

Table 1 Research instrument.
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Result and findings

Demographic profile of the respondent

Table 2 shows the demographic statistics of the respondents. The table’s first section indicates the gender-wise distribution of the respondents. This section shows that among 392 respondents, 178 are males and 214 are females. The second section shows the country of the respondents. This section indicates that 119 respondents are from China, 149 are from Pakistan, and 124 are from Saudi Arabia. The last section shows the professional level of the medical respondents. This section shows that among the 392 respondents, 223 are nurses, and 169 are medical doctors.

Table 2 Respondent demography.
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Common method bias

Common method bias is a significant problem of primary survey data research. The main reason is the response tendency, in which the respondents intentionally rate all questions equally. It can be measured through the Variance Inflation Factor (VIF). The VIF values of any model are not limited to multicollinearity diagnostics, but they also denote the common method bias (Kock, 2015). If the VIF value of any construct is equal to or less than 3.3, then the model is believed to be free from the common method bias. Table 3 shows that all the values are less than 3.3, which shows that the collected data is free from the issues of common bias.

Table 3 Variance inflation factor (VIF).
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Reliability and convergent validity

Table 4 shows the statistics of reliability, construct reliability, and the convergent validity of the scales. The measure used for the item’s reliability is outer loading values (Griffiths et al. 2022). The threshold value for the outer loading value is 0.7, but even a value of 0.6 or close to 0.6 is also acceptable if the convergent validity of the construct is established (Bagis, 2022). Table 4 shows that all the items have outer loading values greater than the threshold value, which indicates that all the items are reliable. The measure used for the construct reliability is Cronbach alpha and composite reliability. Both have a threshold value of 0.7 or greater. Table 4 shows that all the constructs have Cronbach’s alpha and composite reliability values more than the threshold value, indicating that all the study’s constructs are reliable for further analysis. The measure used for the convergent validity is the Average Variance Extracted (AVE). The threshold value for the AVE is 0.5 or greater (Melkamu Asaye et al. 2022). Table 4 shows that all the constructs have AVE values greater than the threshold value, indicating that all the constructs are convergently valid.

Table 4 Reliability and convergent validity.
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Discriminant validity

In primary data analysis, three major measures are used for discriminant validity: cross-loading, HTMT values, and Fornell Larcker criteria (Alwi et al. 2022). However, most researchers suggest HTMT values as the most suitable measure for the discriminant validity of a structural equation model. The threshold value for the HTMT values is 0.85 or less. Table 5 shows that all the constructs have HTMT values smaller than the threshold value, which indicates that all the constructs are discriminately valid.

Table 5 HTMT values.
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Structural model

Figure 2 shows the relationship among the variables.

Fig. 2
figure 2

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

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Regression analysis

Table 6 shows the regression analysis of the hypotheses. The statistics show that five of the six hypotheses are significant. The following are the details.

Table 6 Hypothesis Testing.
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H1: The results give evidence in support of H1 that there is a positive and significant relationship between the Metaverse and healthcare with a significant coefficient, a Beta value of 0.320, a T-statistic 7.277, and a p-value of 0.000. The statistics show a statistically significant relationship between the Metaverse and healthcare, showing that the Metaverse will facilitate healthcare in general.

H2: The results give evidence in support of H2 that there is a positive and significant relationship between the Metaverse and its ethical issues with a significant coefficient, a Beta value of 0.484, a T-statistic 9.60, and a p value of 0.000. The statistics show that a statistically significant relationship between the Metaverse and its ethical issues and the increase of the Metaverse adoption will lead to more ethical issues.

H3: The results give evidence in support of H3 that there is a positive and significant relationship between the ethical issues of the Metaverse and MH with a significant coefficient, a Beta value of 0.383, a T-statistic of 8.82, and a p value of 0.000. The statistics show a statistically significant relationship between the ethical issues of the Metaverse and MH, and with the increase of ethical issues, mental health problems will increase.

H4: The results do not support H4 that there is a positive and significant relationship between healthcare and MH. The statistics show a Beta value of −0.053, a T-statistic of 0.99, and a p value of 0.319 for the hypothesis.

Mediation analysis

Table 6 also shows the mediation relationship of the model. It indicates that there are two mediation relationships. These relationships show the mediation of the ethical issues between the Metaverse and MH and the healthcare mediation between the Metaverse and MH. Using a mediator variable, a mediation analysis using PLS-SEM examines the indirect effect of an independent variable on a dependent variable. Using this method, the researcher develops mediating hypotheses between independent and dependent variables. After finding the validity and reliability and other necessary tests as discussed in other sections of the study, the mediating analysis is assessed by finding the significance and interpreted accordingly. A p value, beta, and T-statistics are the common measures used in the interpretation. The P-value must be less or equal to 0.005 for a significant relationship, otherwise, there will be no relationship. The following are the details.

H5: The results show evidence in support of H5 that there is a mediating influence of ethical issues between the Metaverse and MH with a significant coefficient, a Beta value of 0.185, a T-statistic 5.61, and a p-value of 0.000. This means that the relationship between the Metaverse and MH will be mediated by the ethical issues of the Metaverse. The threshold value for the significance of a relationship based on the mediation relationship is the p-value, which must be 0.05 or less and the t-value is 1.96 or above. These values show a significant mediation between the Metaverse and MH by the ethical issues. The beta value shows the strength of the relationship and how much the Metaverse impacts mental health.

H6: The results show against evidence in support of H5 that there is no mediating influence of healthcare between the Metaverse and MH with a Beta value of −0.017, a T-statistic 0.99, and a p-value of 0.322. The threshold value for the significance of a relationship based on the mediation relationship is the p value, which must be 0.05 or less and the t-value is 1.96 or above. These values show an insignificant mediation between the Metaverse and MH by the ethical issues.

Model fitness

Once the reliability and validity of the measurement model are confirmed, the structural model fitness must be measured. For the model fitness, several measures are available in the SmartPLS, like SRMR, Chi-square, NFI, etc., but most of the researcher recommends the SRMR for the model fitness in the PLS-SEM. When applying PLS-SEM, a value less than 0.08 is generally considered a good fit (Hu and Bentler, 1998). Table 7 shows that the SRMR value is 0.06, less than the threshold value of 0.08, indicating the model’s fitness.

Table 7 Model Fitness.
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R square

Table 8 shows the value of the coefficient of the determination of the model of study, which describes the percentage of the variation in the dependent variable due to independent variables. For the primary data analysis, even an R square value equal to 0.1 or greater is considered a good coefficient of determination. Table 8 shows that MH has an R square value of 0.132, which shows that 13.2% of the variation in MH is due to the model’s independent variables.

Table 8 R Square and Q Square.
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Predictive relevance of the model

Table 8 also shows the predictive power of the model of the study. A model is considered good for predicting social sciences based on primary data if its predictive relevance value is greater than zero. Table 8 shows the MH having a predictive power of 0.058, which shows that the model has 5.8% prediction power if the same model is applied in a different context.

IPMA analysis

Table 9 shows each variable’s importance and performance for the model’s target variable. According to the statistics, ethical issues of the Metaverse have an importance value of 53.6%, the most important variable of the model for MH. At the same time, healthcare, which has a performance value of 77.8%, has the highest but least important value. Based on this model, it is recommended that ethical issues of the Metaverse must be addressed properly to improve the users’ MH.

Table 9 IPMA Matrix.
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Multigroup analysis

Table 10 shows the categorical comparison of the model based on gender and profession. Gender includes male and female, including 178 males and 214 females, while profession also includes two categories, including 169 doctors and 223 nurses. The p value of the Table 10 shows the significance of the relationships. The threshold value for this is 0.05 or less. Table 10 shows no statistically significant difference in responses between the gender (either males or females) and profession (either doctors or nurses).

Table 10 MGA Analysis.
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Discussion

The study investigates the impact of the Metaverse technology on the MH, considering the ethical issues and healthcare as mediating factors in the healthcare industry of Pakistan, China, and Saudi Arabia. The first hypothetical argument claims that the Metaverse significantly impacts healthcare. The findings of this study support this argument (β = 0.320, p < 0.05). If we look at the prior research, we also see the same pattern where the researchers have tested the same argument in a different context (Sun et al. 2022) (Bhugaonkar et al. 2022). The second hypothetical argument claims that the Metaverse in the healthcare industry will lead to different ethical issues. The results of this study also support this argument (β = 0.484, p < 0.05). If we look at the prior research, the same pattern of findings exists. Even ethics means different in different cultures. Still, it prevails as a significant cause for people to avoid healthcare facilities based on the Metaverse technology (Grote and Berens, 2020). The third hypothetical argument claims that ethical issues will lead to MH problems. The findings of this study support the argument that ethical concerns will lead to MH issues (β = 0.383, p < 0.05). According to several researchers, ethics always remains a problem in healthcare. It is not only limited to digital healthcare but also a challenge faced by the physical healthcare system (Bucci et al. 2019). The fourth hypothetical argument claims that healthcare access significantly impacts people’s MH. The findings of this study in the context of Pakistan, China, and Saudi Arabia do not support this argument (β = −0.053, p > 0.05). Still, according to many other researchers, this remains a problem for people’s MH. This may be due to culture or the acceptance of the new technology because people resist new technologies and their applications (Marx, 1998) even if the new technology is more reliable and economical (Ratten, 2020).

The study’s model proposes mediation relationships. First, with the introduction of the Metaverse in the healthcare sector, various ethical issues will arise, ultimately impacting healthcare professionals’ mental health (MH). The study’s findings also support this (β = 0.185 and a p value = 0.000). Previous research supports this hypothesis, revealing consistent findings in the empirical analyses of researchers like Dwivedi et al. (2023). Second, the study explores the idea that healthcare itself could mediate the impact of the Metaverse on people’s MH. Surprisingly, the results do not support this hypothesis (β = −0.017, a p value = 0.322). Past research, represented by studies such as Michie and West (2004), has shown mixed findings, with some aligning with our results and others presenting opposite conclusions. This is surprising and noteworthy because it goes against the consensus of the present understanding regarding how healthcare affects mental health problems in an era of modern technologies. It indicates that conventional healthcare services do not mediate the Metaverse’s impacts on mental health; rather, virtual and immersive digital experiences directly impact it. It provides new directions for future studies to explore the relationships between advance technologies, healthcare, and MH.

Whether we accept it or not, technology has intensely changed healthcare (Shrestha and Kim, 2019). Some of the contributions include introducing new medicines, new ways of treating patients, new operating instruments and theatres, lower costs, addressing the problem of distance, and so on (Matricardi et al. 2020). Fortunately, technology is also assisting in the treatment of MH problems. Its outcomes will increase further with the adoption of this new technology. Companies like “Brain lab AG, Novarad Corporation, GE Healthcare, Siemens Healthiness, Meta Platforms Inc., Nvidia, Microsoft, Roblox, Game Change, VR, AR,” etc., are continuously driving this shift for improvement (Pillai and Mathew, 2019).

A significant section of the public is unable to receive treatment for mental disorders due to financial constraints, long wait times, lack of professionals and healthcare facilities, burden on doctors, and other factors. The Metaverse could treat and minimize these concerns (Corrigan et al. 2014). Telehealth, VR, AR, MR, etc., will provide an environment that could assist MH patients. Loneliness, anxiety, depression, etc., could be lessened with the help of the Metaverse (Dwivedi et al. 2023). Specialists of various kinds could be approached remotely, and mental disorders could be treated effectively (Mohr et al. 2013). More options could be available for patients to get a doctor of their choice and avail themselves of more personalized therapy and treatment. Patients and the general public should also be monitored and directed 24/7 by digital healthcare assistants in the Metaverse (Ghazal et al. 2021). Their data and readings could be recorded through various applications and shared at the right time with their therapist, increasing the timeliness of treatment (Vismara et al. 2012). In short, the Metaverse will take mental healthcare to the next level through high-speed internet, applications, AR, VR, MR, etc. It should be welcomed by addressing ethical concerns, digital divide, interconnectivity, availability, and convergence.

Theoretical implications

The results provide credence to the framework that tested the relationships among the Metaverse, ethics, healthcare, and MH. It advances the understanding by stressing the influence of the Metaverse on moral, ethical, and healthcare concerns and their influence on MH in the virtual world.

Managerial implications

  1. 1.

    The study suggests that using the Metaverse in mental healthcare is crucial. Healthcare organizations should use the Metaverse’s technologies, such as virtual reality therapy, remote healthcare delivery, etc., for improved healthcare.

  2. 2.

    Strong ethical rules must be developed and implemented due to the Metaverse’s enormous impact on ethical concerns.

  3. 3.

    Organizations should prioritize the Metaverse’s MH support systems (peer assistance, online counseling services, and MH resources) because of the relationship between ethical concerns and MH.

Practical implication

  1. 1.

    It is necessary to educate and train the users of the Metaverse regarding its impact on MH to ensure its responsible use, awareness about risks, and support. It is important to support the promotion of digital well-being and a healthy balance between virtual and real-life activities.

  2. 2.

    Ethical concerns should be given priority during the design and development of the Metaverse by platform providers and developers. Virtual environments will become safer and more inclusive when privacy features, content control tools, and inclusive features are implemented.

  3. 3.

    Collaboration among technological professionals and healthcare practitioners is essential. To develop and incorporate virtual reality-based therapies into healthcare practices, healthcare professionals and technology experts should work together. This partnership will result in ground-breaking innovations for improving MH assistance in online settings.

Conclusion

The study investigated the complex relationship of the Metaverse, healthcare, ethical issues, and MH. The study found positive relationships between the Metaverse and healthcare, the Metaverse, and ethical issues. This highlights the importance and need for incorporating ethics into the Metaverse healthcare services. However, the assumed relationship between healthcare and MH was not supported, underlining the importance of a comprehensive approach to MH treatments beyond digital technology. As the Metaverse evolves, prioritizing ethical issues, improving healthcare provisions, and recognizing the broader landscape of MH is essential to ensure that the Metaverse can drive a positive shift while adhering to ethical principles and dealing with the diverse aspects of MH.

Future work

  1. 1.

    The Metaverse is a relatively new concept in healthcare; research is needed to explore its opportunities and threats further in the mental healthcare system.

  2. 2.

    The ethical issue may be a major concern for the Metaverse in mental healthcare, and further research is needed to explore the most important ethical factors.

  3. 3.

    Research is needed on the Metaverse regulatory framework for its better use in mental healthcare.

Limitations

  1. 1.

    The Metaverse is a relatively new concept in mental healthcare; people know little about it, which may have impacted the study.

  2. 2.

    The study stresses on ethical issues of the Metaverse, and it is necessary for future studies to explore this aspect of the Metaverse further. It is essential for researchers from different areas, policy makers and innovators to collaborate in future studies and address this limitation.

  3. 3.

    The results may differ for technologically advanced societies or from culture to culture or country to country.