1 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 avatar, 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. There 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 The list of online virtual worlds continues to grow so any attempt to provide a current list would be instantly outdated.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 virtual world is Linden Labs Second Life (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