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BOX 10-10 THE USE OF VIRTUAL WORLDS IN HEALTH PROMOTION

Authors: Joan E. Cowdery, PhD; Sun Joo (Grace) Ahn, PhD

VIRTUAL REALITY TECHNOLOGY

Virtual reality technology can refer to a variety of applications but typically consists of some type of immersive 3-D experience for the user. Virtual reality environments are created by digital devices that simulate multiple layers of sensory information so that users are to see, hear, and feel as if they are in the real world1 and give the user the perception of existing in an alternate space. Depending on the purpose of the application, these spaces can mimic the real world or be highly fantasized, as is the case in many gaming environments. Early virtual reality applications such as flight simulators have expanded into many areas of health care including surgery simulations and trainings.

While the initial application of virtual reality technology and the development of virtual worlds took place in the gaming realm, more recent applications have included social networking, education and training, and health care. One of the defining characteristics of virtual worlds is that they generate simultaneously shared spaces. 2 In addition to fostering real time social interaction, virtual worlds allow users to have a physical presence in these shared spaces. Users in virtual worlds exist and interact in these computer-simulated environments where participants create what is commonly known as an , a digitally constructed form of virtual representation that marks a user’s entity. 3

PUBLICLY AVAILABLE SPACES

Unlike previous gaming applications that required additional equipment, current virtual technologies are readily available to anyone with a computer and an internet connection.

2 are a plethora of publicly available spaces where one can interact with others for a variety of reasons for little to no cost. Many are game specific and targeted toward specific age groups for example, Virtual Worlds for Teens, (http://virtualworldsforteens.com/), Twinity

(www.twinity.com), and 3Dchat (http://www.3dchat.com). The list of online virtual worlds continues to grow so any attempt to provide a current list would be instantly outdated. One of the oldest, largest and most active is Linden Labs

(www.secondlife.com). Current estimates indicate approximately 1 million regular monthly users with 70,000 concurrent users. In Second Life, residents can shop, attend business meetings, take classes, participate in trainings, swim, ski, watch a live concert, and just about anything that one could do in real life. To learn more about Second Life and the things residents can do visit http://secondlife.com/whatis/?lang=en-US.

The geography of Second Life is organized as Islands. One of the most popular and frequently visited is Health Info Island (http://maps.secondlife.com/secondlife/Healthinfo%20Island/172/222/27 ). Created and funded by a grant from the National Library of Medicine, HealthInfo Island has grown from a resource for health information to include over a 120 support groups for patients and caregivers, as well as mental health simulations and an area for individuals with disabilities called Virtual Ability Island (http://slurl.com/secondlife/Virtual+Ability/132/165/25). An increasing number of real world health related institutions and organizations have begun to promote the use of virtual worlds and have created virtual world presences. For example, the

National Institutes of Health has suggested the use of virtual reality technology for research and education on diabetes and obesity because of the potential to engage patients in interventions that focus on healthy eating and physical activity. 4 Given that interactive technologies have been used to facilitate the delivery of health information and interaction between patients, caregivers,

3 and health professionals, the application for health behavior change interventions seems plausible.

USE OF VIRTUAL WORLD TECHNOLOGY IN PUBLIC HEALTH AND HEALTH

PROMOTION RESEARCH

Virtually Experiencing the Consequences of Negative Health Behaviors

Virtual worlds offer novel media characteristics that allow researchers and health care practitioners to implement new strategies in approaching health behavior change that may have been difficult or impossible with traditional tools and media platforms. One such characteristic is the virtual acceleration of time,5 wherein users are able to transcend temporal boundaries of the physical world by experiencing digitally depicted events of the past or future in the virtual worlds. For instance, with the help of simulated sensory information via digital devices, users may be able to virtually experience the negative future consequences of present problematic health behaviors, allowing users to construe the health risks as personally relevant6 and temporally imminent.5 The increased sense of relevance and urgency through the virtual experience encourages individuals to reduce problematic health behaviors.

The virtual acceleration of time would be particularly useful for health care issues because one of the greatest challenges of communicating health risks is the large temporal gap that exists between present health behaviors and future negative health consequences. This gap explains why individuals tend to have a more “rosy” view of distant futures;7 it may be that individuals are unaware of how imminent the health risk may be. For example, smoking a cigarette is unlikely to lead to immediate illnesses or fatality. The length of time it takes for negative health outcomes to manifest renders the causal relationship between the present cause (smoking) and future outcomes (e.g., lung cancer) abstract and difficult to grasp. Relatedly, earlier research

4 demonstrates that when health messages are able to present the risk (i.e., a negative health consequence) to be temporally proximal, they are effectively able to elicit behavioral modification.

Virtual Selves

Another novel characteristic of virtual worlds is a byproduct of the plasticity of avatar creation.

With the development of advanced digital technology, users may now easily create photorealistic avatars that share realistic physical feature similarities with the self. For example, imagine a health pamphlet that features a virtual entity that looks photo realistically like you, rather than a typical, but unfamiliar, person; you would be more likely to pay attention and feel that the message is personally relevant. 8 Moreover, once the photorealistic virtual self is created, computer software are easily able to manipulate its appearance—the virtual self may be aged to make you look like you are in your 60s, or its physique may be altered so that it looks like the virtual self has gained weight—and these virtual selves may be plugged in to create health messages that allow individuals to realize that the health risk may influence everyone, including themselves.

In one such study, the effect of virtual experiences that incorporate virtual acceleration in time and photorealistic virtual selves on health attitudes and behaviors in the physical world were explored in the context of soft drink consumption.5 In this study, different groups of participants were exposed to four experimental conditions in a 2 (medium: pamphlet only vs. pamphlet with virtual experience) x 2 (tailoring: other vs. self) between subjects design. Participants either saw only the pamphlet, which was tailored to the self or untailored, or were exposed to both the pamphlet and the virtual depiction of it. The six-page full color pamphlet provided specific information on the health risks of soft drinks, with an emphasis on weight gain and obesity. In

5 the virtual experience, participants wore a head-mounted display, a goggle that provides three- dimensional perception through stereoscopic views of the virtual world, and observed either a virtual self or an unfamiliar, generic virtual human (i.e., virtual other) (Figure 1). During the two- minute virtual experience, participants saw the virtual self or virtual other imbibe a soft drink and continue to gain weight. Two years in the physical world were depicted in two minutes in the virtual world. Self-reported soft drink consumption intentions were assessed immediately following experimental treatments and actual soft drink consumption was measured one week following experimental treatments.

(Insert figure 1 here)

Figure 1. Participants entered the virtual world and saw either a virtual self or a virtual other (left panel). As time in the virtual world progressed in an accelerated speed, the virtual human continued to drink the soft drink. In two minutes in the virtual world, two years in the physical world was depicted to have passed, with the virtual human gaining 20 pounds in weight as a result of drinking soft drinks (right panel).

Results indicated that immediately following experimental treatments, the effect of tailoring significantly affected intentions to consume soft drinks in the future. Messages, regardless of whether they were presented in a pamphlet or in virtual worlds, led to shorter perceived distance between the self and the health risk, and in turn, higher involvement. The increased involvement ultimately led to lower intentions to consume soft drinks than untailored messages. Interestingly, however, the effect of tailoring seemed to dissipate over time. One week following experimental treatments, only the effect of medium was significant. The participants that were given the pamphlet coupled with the virtual experience perceived shorter temporal distance between their present health behaviors and future health outcomes, which led to greater perceived imminence

6 of the risks related to soft drink consumption. The increased risk then resulted in significantly lower soft drink consumption than participants who only saw the pamphlet. This experiment provided strong preliminary evidence for the potential of incorporating virtual experiences as a part of multicomponent and multimedia health promotion campaigns.

In another study, Ahn and colleagues demonstrated that not all virtual representations used to promote health behaviors are required to take on human forms. 9 A virtual pet system was developed guided by the framework of social cognitive theory10, to systematically promote physical activity in children through goal setting, vicarious experiences, and positive reinforcement. A kiosk was built to present the virtual pet system, using a laptop and a flat screen television stationed on top of a rolling cart. A Microsoft Kinect for Windows device with motion-detecting capabilities was mounted on top of the television (Figure 2). In the study, children’s physical activity was measured with an activity monitor and synchronized with a unique pet so that he or she would interact with his or her personalized pet for the duration of the intervention. The integration of the activity monitor with the virtual pet system allowed children to use this system with minimal or no technical expertise; they simply had to plug in the activity monitor into the computer and the system would automatically synchronize the activity data with the child’s unique virtual pet and update the system as necessary.

(Insert Figure 2 here)

Figure 2. The virtual pet kiosk, created with consumer grade digital devices

The interaction cycle was a repetition of goal-setting, evaluation, and reinforcement processes.

Upon first engaging with the virtual pet, children were asked to personalize their pets (e.g., selecting the collar color, selecting the tag color, naming the pet, etc.). The virtual pet then asked children to establish self-set physical activity goals, which was designed to promote physical

7 activity self-efficacy by way of mastery experiences. That is, by setting and meeting goals for behavior change and recognizing one’s ability to overcome challenges along the way, individuals gain confidence in their capacity to engage in that particular behavior. 11 Similarly, the goal- setting feature in the virtual pet was designed to allow children to repeatedly engage in the experience of setting and meeting physical activity goals to promote mastery experiences.

Once the goal was set, children engaged in physical activity away from the kiosk, wearing the physical activity monitor. When children felt that they had met their physical activity goal, they returned to the kiosk and plugged in the activity monitor in the computer. The computer then automatically synchronized the unique identifier chip embedded in the activity monitor to his or her unique virtual pet and brought the pet up on the screen while also evaluating the physical activity recorded on the activity monitor. If the child was unable to meet the goal, the virtual pet verbally informed the child that he or she had failed to meet the physical activity goal and encouraged the child to go back to engaging in physical activity. If the child did meet the goal, the virtual pet invited him/her to teach it a trick using verbal and gesture commands detected by the Kinect for Windows device. For instance, the child could verbally command, “Fetch!” and see a virtual ball appear on the screen. He or she could then make a throwing motion toward the

Kinect, and the ball would fly into the virtual world, following the trajectory of the child’s physical arm. The virtual pet would then chase after the ball and bring it back. Because the underlying assumption was that the virtual pet would be engaging in physical activity in the virtual world while children stayed physically active in the physical world, the tricks began with simpler ones (e.g., sit, stay) and eventually more sophisticated ones as children met more goals and the virtual pet became more fit (e.g., fetch, moonwalk). Once the child taught his/her virtual

8 pet one trick, the pet asked him/her to set a new physical activity goal and the cycle would repeat.

This virtual pet system was compared against a computer system that offered the same goal- setting, evaluating, and reinforcing features without the virtual pet. The study took place for three full days at a local summer camp with children between the ages of 9-12. When compared with children in the control group who were given an identical computer system with the same functionalities but without the virtual dog, children who interacted with the virtual dog engaged in approximately 1.09 more hours of physical activity daily. Self-report survey data revealed that interacting with the virtual dog led children to feel confident about their abilities to set and meet physical activity goals, which in turn, heightened their beliefs that physical activity is good for them. The increase in physical activity belief ultimately led to an increase in physical activity. When virtual worlds are established using highly mobile setups as this one, they can be used in health promotion campaigns outside of the laboratory. For instance, this virtual pet system may be set up anywhere the children are, including classrooms, doctor’s offices, or health centers as a highly translatable and scalable solution for using virtual worlds in public health promotion efforts.

PROMOTING HEALTH IN A VIRTUAL WORLD

To examine the use of an online virtual world for the delivery of health communication messages designed to encourage healthy behavior change regarding physical activity and nutrition, a study was conducted entirely within the virtual world of Second Life (SL). 12

Participants included 40 undergraduate students with little to no prior experience with Second

Life. During an initial orientation session participants were assisted in creating their avatars and in learning how to navigate and communicate in world. In Second Life participants have the

9 ability to customize their avatars in many different ways including gender, physical attributes, clothing, accessories, and even whether or not to be human, animal, or an object. The majority of participants in this study chose to be represented by human looking avatars.

The study consisted of a brief intervention delivered by a trained health educator avatar in a common area of a teaching parcel. Participants were sent a link to the location and upon logging in, were instructed to travel (teleport) there. The geography of Second Life is set up as Islands divided into parcels of land. Our intervention was conducted in a common area on a teaching parcel where our university had a virtual presence. The program was designed as a traditional lecture followed by a question and answer session held in an open air amphitheater. The space included rows of bench seats facing a stage with a podium, and overhead interactive signs. The intervention consisted of approximately 15 minutes of information regarding physical activity and nutrition that included recommended guidelines and on and off campus resources. The program was developed by trained health educators and was delivered by a health education graduate student. Her avatar was intentionally designed to present a conservative, somewhat authoritarian image. Second Life allows participants to communicate in several different ways.

For this study the health educator and the participants could speak to each other using the chat feature. Interactive signs were designed so that participants could click on them to receive additional information.

Qualitative and quantitative data was collected on a multitude of variables including usability, participant satisfaction, changes in theoretical constructs of health behavior change (readiness to change, motivation, self-efficacy, intention), and the relationship between participant BMI and participant body ratings of self and avatar. Quantitative data was collected through the use of pre

10 and post-test surveys while qualitative data was collected with a series of 4 focus groups, 3 of which were held in Second Life.

Results showed that although all participants had less than 3 months experience with Second

Life, the majority thought the program was easy to use (87.5%) and would be interested in experiencing other health related programs in Second Life (82.5%). Furthermore 80% found the information useful in helping them think about changing their health behaviors while 92.5% found the information easy to understand and to be personally relevant. 12

Given that this was a brief intervention, the pre-test and post-test data collection occurred during the same session. Therefore theoretical constructs related to behavior change were assessed rather than actual behavior change outcomes. Although increases were observed in motivation, intention, and self-efficacy to make healthy behavior changes regarding physical activity and diet, only participants’ rating of self-efficacy regarding physical activity was statistically significant (p=.039). 13

One of the concerns regarding the delivery of health information in a virtual world is whether or not the information is perceived and processed as our real world selves or as our in–world avatars. In Second Life, before users customize their avatars, the default human avatars tend to be attractive and typically normal to underweight. It was therefore of interest to us to explore how the participants processed, received, and applied the health information as their real–life selves. Both survey and focus group data from this study show that by and large participants received and processed the information as their real world selves. Additionally, over 50% of the participants in our study reported that they designed their avatar to look like themselves. Only

5% stated that they sometimes appeared in SL as the opposite gender and 2.5% as an animal. 12

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Previous research has indicated SL users prefer to create avatars that represent an idealized self.

Users who create an idealized avatar tend to have a high attachment to their avatar and that people with high BMIs tend to create idealized avatars more so than other users.14 It has also been found that avatars generally resemble their owner’s body image more than their owner’s actual body and that virtual world user’s perceptions of their avatar’s body influence their perceptions of their own body. 15 In order to explore these relationships in our study, we collected data on participants’ BMI (from self-reported height and weight), ratings of self and avatar body weight, and avatar appearance and attractiveness compared to their ratings of their own real life attractiveness. Our results showed that based on BMI, 42.5% of participants were overweight or obese which was the same percentage that rated themselves as slightly or markedly overweight. In contrast, only 12.5% rated their avatars as slightly or markedly overweight. With regards to attractiveness, 40% rated their avatar appearance as more attractive than their real life appearance. 13

Overall the results of this study support the approach of using a virtual world as a feasible and potentially effective way to accomplish health promotion objectives regarding physical activity and nutrition. Participants were receptive to receiving health information in this virtual world setting and to use the internet in general to access health information. Web 2.0 technologies are continuing to provide opportunities for patients and caregivers to share information and support as well as for individuals to engage in behavior change efforts. The anonymity of Web–based interaction including Second Life, can also potentially contribute to the engagement of hard to reach populations and for addressing particularly sensitive subjects such as drug use and sexual behavior.

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DESIGNING VIRTUAL REALITY TECHNOLOGY FOR RESEARCH

Novel virtual technologies allow researchers to conduct laboratory experiments that optimize ecological validity without compromising experimental control. There are several advantages to using virtual technologies in social and behavioral science studies. First, virtual worlds allow researchers to create experimental situations with more mundane realism compared to the rigidly controlled traditional laboratory settings, potentially eliciting more genuine participant reactions to stimuli.16 For example, rather than invoking fear by asking participants to imagine developing lung cancer as a result of smoking or giving them a traditional pamphlet with details on lung cancer, virtual worlds allow participants to perceptually experience lung cancer through vivid and realistic simulations. This contributes to high external validity.

Despite this freedom to construct any environment or stimulus of the researcher’s desire, with his or her imagination being the only limit, virtual worlds still allow researchers to tightly control every element down to the millisecond and millimeter. For instance, once virtual humans are created, researchers may control and manipulate minute details.17 If researchers were to study the effect of body posture on perceptions of a speaker’s credibility, they must deal with several confounding cues, such as the speaker’s natural facial expressions, head movements, and gestures. Using virtual humans, these cues can all be removed or neutralized to allow researchers to examine the specific cue of interest “in a vacuum.” Furthermore, the exact same stimulus can be replicated and shared with other researchers almost flawlessly for countless iterations of experiments, eliminating variance that may impact outcomes.16 This contributes to high internal validity.

Thanks to the incorporation of sensitive tracking devices, researchers can go above and beyond traditional means of measure user’s naturalistic responses in virtual worlds.16,18 For instance,

13 virtual worlds may be programmed to automatically record data regarding the user’s movements, gaze, and gestures19, alleviating the subjective and often painful process of having coders review videotape and follow coding schemes. These functions also gather data almost continuously, reporting at fractions of a second that are too minute for human coders to make distinctions. The level of detail presented in the behavioral data can serve as meaningful supplements to surveys and self-report questionnaires that are open to multitude of errors and misrepresentations. These affordances make virtual worlds ideal environments to study human cognition and behavior.

STRATEGIES, CHALLENGES, AND IMPLICATIONS FOR FUTURE USE

Although virtual technologies offer a multitude of health promotion opportunities, they are not without challenges. Although widely available and accessible, these virtual worlds such as

Second life can be transient as can the resources and programs contained within them. It is therefore incumbent upon health promotion program planners to be diligent in confirming their availability before recommending to clients or program participants, and in updating materials frequently.

Future areas of research inquiry should include the examination of how people create and interact with online personas and how such interaction might translate to real world behavior change. The creation and use of avatars presents a unique dynamic for exploration regarding the receptivity to health messages. Understanding how participants process health information relevant to the needs of their real-world selves versus the perceived needs of their in-world avatars is crucial. Future research should also include the examination of how our experiences in virtual worlds change with long term participation.

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Finally, virtual systems are becoming more accessible and affordable through gaming platforms and consumer-grade devices. In the near future, it may be possible to send tailored health promotion messages directly to individuals’ homes to existing infrastructures of virtual worlds.

For instance, the Microsoft Kinect Xbox console is one of the fastest selling consumer electronics with more than 24 million units sold since its launch in late 2010.20 Sophisticated head mounted displays, similar to the ones used in the studies discussed in this chapter, are now available for a few hundred dollars and easily incorporated into everyday computing systems as a plug-and-play device. Moreover, a number of large companies, including Samsung, Facebook,

Apple, and Sony, are vying to create the most sophisticated yet affordable head mounted display for consumers, signaling a virtual revolution in the near future. Much similar to the progression of the Internet and the mobile revolutions, the virtual revolution is likely to transform traditional patterns of health communication and health promotion campaigns.

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