Journal of Virtual Worlds Research - Volume 2, Number 2: 3D VWs for Health & Healthcare

3D MODEL OF THE HIV VIRUS CREATED BY SL:MADCOW COSMOS (KARUNA ISLAND) - HTTP://SLURL.COM/SECONDLIFE/KARUNA/84/212/22

Volume 2, Number 2.

3D Virtual Worlds for Health and Healthcare

Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009 Editor

Jeremiah Spence

Guest Editors

Maged N. Kamel Boulos Susan Toth-Cohen Simon Bignell

Reviewers

Nabil Habib Ray B. Jones Rashid Kashani Inocencio Maramba Kathleen Swenson Miller Pamela Mitchell Carol Perryman Anne Roberts Maria Toro-Troconis Jane "Esme" Wilde

Technical Staff

Andrea Mu単oz Kelly Jensen Roque Planas Amy Reed Margaret Hill

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Journal of Virtual Worlds Research Volume 2, Number 2 August 2009 “3D Virtual Worlds for Health and Healthcare” ISSN: 1941-8477 Table of Contents • Shaping the ‘Public Sphere’ in Second Life: Architectures of the 2008 U.S. Presidential o Annabel Jane Wharton, Duke University • Development of a Virtual Reality Coping Skills Game to Prevent PostHospitalization Smoking Relapse in Tobacco-Dependent Patients o Paul Krebs, Jack Burkhalter, Shireen Lewis, Tinesha Hendrickson, Ophelia Chiu,Paul Fearn, Wendy Perchick and Jamie Ostroff, Memorial SloanKettering Cancer Center • Virtual Worlds, Collective Responses and Responsibilities in Health o Rashid M Kashani, University of Alberta, Canada o Anne Roberts, University of Plymouth, UK o Ray Jones, University of Plymouth, UK o Maged K. Boulos, University of Plymouth, UK • Does this Avatar Make Me Look Fat?: Obesity and Interviewing in Second Life o Elizabeth Dean, RTI International o Sarah Cook, RTI International o Michael Keating, RTI International o Joe Murphy, RTI International • Musings on the State of '3-D Virtual Worlds for Health and Healthcare' in 2009 o Maria Toro-Troconis, Imperial College London, UK o Maged N Kamel Boulos, University of Plymouth, UK

• The Growth and Direction of Healthcare Support Groups in Virtual Worlds o John Norris, Albany, Oregon • Towards a Virtual Doctor-Patient Relationship: Understanding virtual patients o Vanessa G. González, Macquarie University, Australia • Pitfalls in 3-D Virtual Worlds Health Project Evaluations: The Trap of Drugtrial-style Media Comparative Studies o Maged N. Kamel Boulos, University of Plymouth, UK o Inocencio Maramba, University of Plymouth, UK • Virtual Worlds in Health Care Higher Education o Constance M. Johnson, Duke University School of Nursing o Allison Vorderstrasse, Duke University School of Nursing o Ryan Shaw, Duke University School of Nursing • Development of Virtual Patient Simulations for Medical Education. o Douglas Danforth, Ohio State University o Mike Procter, Athabasca University, Canada o Robert Heller, Athabasca University, Canada o Richard Chen, Ohio State University o Mary Johnson, Florida State University • Development and Evaluation of Health and Wellness Exhibits at the Jefferson Occupational Therapy Education Center in Second Life o Susan Toth-Cohen, Thomas Jefferson University o Therese Gallagher, Thomas Jefferson University

Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Editor –in-Chief’s Corner Shaping the ‘Public Sphere’ in Second Life: Architectures of the 2008 U.S. Presidential

By Annabel Jane Wharton, Duke University

Abstract The “public sphere” – that space of the civil intellectual engagement of the population with the politics of the state – has been consistently addressed as the exclusive realm of speech, whether in oral or written form, from its origins in print culture to contemporary blogs. Though Jürgen Habermas, formulator of the classic understanding of the public sphere, acknowledged the contribution of the built environment to political interchange, the material setting of the public sphere has been largely absent in its subsequent discussions. Indeed, now that those concerned with the degeneration of public sphere have turned their attention to its survival on the web, physical space has virtually disappeared from any assessment of democracy’s vital signs. The description offered here of the figuration of the 2008 campaign venues of Second Life attempts to demonstrate the effect of architecturally articulated space, virtual as well as real, in the formation of the polity. I have argued that the architecture of the campaign venues of the recent U.S. presidential election is the necessary complement to the discourses that went on within them. Buildings, even digital ones, certainly modify the acts of those who use them. Muggings are more likely to occur in back allies than in the lobbies of five-star hotels; miracles seem to happen more often in churches than in prisons. If buildings inform behaviors, certainly they also contribute to the shape of politics.

Keywords: agency; architecture; public sphere; space; theory; immersive worlds; 2008 presidential campaign.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

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Editor –in-Chief’s Corner Shaping the ‘Public Sphere’ in Second Life: Architectures of the 2008 U.S. Presidential

By Annabel Jane Wharton, Duke University

Discursive space

A modest speculation on the agency of architecture in the virtual world is offered here.

The ‘architecture’ considered is not, obviously, physical or material construction. Less obviously, this ‘architecture’ is not merely a depicted or represented place, objective and rational. It is, rather, representational: an experienced space, a space that is subjectively and partially understood only by moving through it (Lefebvre, 1991, 38-39). These digital environments have the affects of physical structures. Like real-life structures, they both embody the culture of those who construct them and model the behaviors of those who occupy them. The election venues built by Democrats and Republicans in Second Life during the 2008 presidential campaigns in the United States provide the examples for my argument.

Second Life, which went on-line as a fully-formed virtual world in June, 2003, is the product of Linden Lab, a corporation based in San Francisco. The world it offers is large. At the time of the U.S. Presidential elections in November, 2008, 18,000 servers maintained 450 square miles of virtual land with a population of over sixteen million registered residents embodied in “uniquely named” avatars with limited citizens’ rights including ownership and movement (Linden Lab, 2008). Second Life is the best documented of those immersive environments that depend on their residents to build them (Spence, 2008). Second Life’s relatively older demographics – the average age of participants in November, 2008, was 32 – makes it an attractive arena for social and political analysis. A recent monograph published by Princeton University Press offers an anthropological assessment of the culture of Second Life – an indication of the seriousness of the digital world’s human implications (Boellstorff, 2008). The book also provides a bulky bibliography covering the history and historiography of this digital world. Most of those participating in Second Life are ‘in World’ for entertainment (e.g. live music performances, soft porn, shopping) or other forms of personal satisfaction (e.g. creating objects, practicing religion, exploring). A very few are ‘in World’ to make a real-world living (e.g. as builders, land speculators, skin-makers, police). But education and discussion groups are also prominent preoccupations of residents. Here is the locus of politics in Second Life.

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The readers of The Journal of Virtual Worlds Research may be more familiar with Second Life than with academic discussions of the ‘public sphere’. The public sphere is a discursive site in which the educated public defines, through rational-critical disquisition, communal political positions which may subsequently affect the actions of the state. This understanding of the public sphere depends on Jürgen Habermas’ powerful analysis published as Structurwandel der Öffentlicheit in 1962 and, with even greater effect, as The Structural Transformation of the Public Sphere in 1989 (Habermas, 1989). Therein, Habermas posits the public sphere as essential to the work of modern democracy. He describes the emergence of the public sphere in the eighteenth century and its disintegration in the twentieth. The media and the venues of the civic interaction of individuals have been spectacularized (Debord, 1983). Loci for the civil exchange of political ideas have become sites of profit. Newspapers have been superseded by television, coffee houses by sports arenas, and reasoned arguments by unsubstantiated opinions. (Calhoun, 1993, for a survey of criticisms of Habermas’ theories). In the twenty-first century the web has become the medium of choice for communication, eliciting a new set of investigations of the Habermasian public sphere. The potential scaffolds for deliberative democracy – as well as the obstacles to civil political dialogue – now offered by the web generally and by immersive worlds in particular, have been registered by a growing number of researchers. Representative are the works of Dahlberg, Papacharissi, Bohman, Wodak and Wright, and Barlow (Barlow, 2008; Bohman, 2004; Dahlberg, 2001; Papacharissi, 2002; Wodak & Wright, 2006). Considerable optimism has been expressed by these researchers about the formation of new critical communities by means of the internet, though they fully acknowledge the burdens placed on the realization of a new discursive realm in virtual space by bad actualworld political habits.

In his historical introduction to the public sphere, Habermas positioned the exchange of ideas within specific material conditions, referencing physical sites from the Greek oikos to the English coffee house as well as developments in technology and the economy. Subsequent discussions of the contemporary public sphere among historians, sociologists and philosophers have concentrated almost exclusively on its discursive content and technological means. The architectural and topographic settings of the public sphere have been largely ignored. By considering the architectures of political meeting places in the immersive world, this article makes a foray into the understudied material settings conducive to the serious political discourse that sustains deliberative democracy.

If Habermas’ theory provides the object – namely, the public sphere – of this paper, the works of Lefebvre, Deleuze and Guattari contribute significantly to its theoretical frame.

Lefebvre establishes space as a product of human action and an expression of the political, rather than a passive presence (Lefebvre, 1991). Importantly for the purposes of this paper, his understanding of the world’s space as a human construction has been posthumously reified in digital worlds: the space of Second Life exists only as product of Linden Lab’s programmers and Second Life’s entrepreneurially creative participants. Deleuze and Guattari, with their generative investigation of space as the matrix of power, have also greatly contributed to the definition offered here of the spatial differences between Republican and Democratic sites (Deleuze & Guattari, 1987). Indeed, the nomadic, unmapped territory of evolving opposition – identified as smooth space – and the ordered and institutional territory of established state power – termed striated space – present uncomfortably close correspondences to the virtual sites under discussion.

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Nomadic and fixed space: Democrats and Republicans in Second Life The immersive world of Second Life featured a number of political structures supporting candidates in the 2008 U. S. presidential election. Seven sites were identified through the use of Second Life’s “place” search engine with terms like “political,” “Republican,” “Democrat,” “McCain,” and “Obama.” This search engine also recorded the number of avatars visiting the sites. Locations which were exclusively commercial – such as shops selling political paraphernalia – or those sites whose functions were undisguisedly ironic, though included by the search engine, were excluded from this assessment. Some of the structures discussed in this paper continued to exist in Second Life after the conclusion of the election campaign.

Nevertheless, the past tense is used throughout this piece as a sign of the uncanny transience of the built environment in virtual space. ‘Uncanny’ usually suggests an unexpected disturbance in what should be familiar and secure (Vidler, 1992); in immersive worlds it references the odd expectation of the instability of the familiar and ephemerality of the secure.

Figure 1 Although the Democratic Party apparently had no established official headquarters in Second Life, Barack Obama was the principal subject of several simulated environments. The “Unofficial Obama Headquarters” (Silicon Island 70.182.26) was the largest of the sites devoted to the Obama campaign (Fig. 1).1 The structure was located on an island between a wind farm and research offices. The size of a supermarket, this two-storied hyper-Modernist building was all virtual steel, glass, and plastic. Emphasis was on the periphery of the interior of the structure: high-tech devices in the form wall-plaques and computer consoles frame the space. These information instruments offered direct internet access to voter registration, volunteer opportunities, and the candidate’s position papers. The cool, gray space was barely furnished.

The few aluminum benches in the building presented no attractive social alternative to studying the data provided. Indeed nothing in the venue suggests social interaction – there was no coffee bar, no over-stuffed sofas.

1

The first name in this citation and those that follow identifies the 68-square acre block (sim) occupied by the site.

The sim is the basic module of Second Life. The numbers plot the location of the site within the sim.

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Figure 2 Another Democratic site, “Obama for President – Headquarters for Victory” (Seokcheon 108.201.49), was set off a lonely highway in an unroofed stone enclosure (Fig.2). Its gray, windowless walls had as adornment only red, white, and blue-starred swags at their apex. It presented a large, open area, minimally furnished with a few leather-covered couches and lounge chairs. The enclosure walls were lined with identical box-like portals, differentiated only by their titles: “Arts,” “Civil Rights,” “Defense,” “Energy,” “Ethics,” “Urban Policy,” “Health Care,” “Women.” A click on a portal provided the visitor with a web-link to Obama’s policy comments on the indexed subject. Though the raw textures with which the Seokcheon site was defined were very different then the slick ones on Silicon Island, the spatial orders of the two sites were remarkably similar, in that they were dauntingly empty both of things and of avatars.

If the Silicon Island and Seokcheon sites were large-scale, functionalist and austere, two other Obama venues were more intimate. The “Obama/Biden Lounge and Unofficial HQ at Hope Beach” (Donggyeo, 25.101.22) offered a small, resort-like retreat on a tropical island. A space, the size and shape of a garage, presented familiar posters of Obama and free campaign paraphernalia for interested avatars. It featured a large, shaggy, black robotic dog named Hope.

Like the Silicon Island and Seokcheon structures, Donggyreo’s Obama/Biden hall was not a closed space, but an open one. The accessibility of the lounge area was complemented with two other public amenities. A small bandstand adorned with bunting was built in front of the hall.

Next to the meeting room there was, in addition, an orientalizing tent. There the visitor was invited to relax on floor-pillows under an Obama banner.

“Americans for Obama” (Ryder Jungle 137.30.24) presented another intimate setting: a simple timber and glass country retreat with a large fire place at its center and log furniture. The site, complementary to its architecture, expresses preservationist interests. Like the other Democratic sites, its walls were papered with posters. Avatars were offered free Obama teeshirts, buttons, hats and hand-held American flags. One negative poster was on display: “McCain Votes Against the Vets – CNN.” It also had a message board on which visitors could post their

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thoughts on both the site and on campaign itself. Though it was an enclosed space, avatars were teleported to the interior of the structure; doors only needed to be opened to leave the cabin.

The Donggyeo and Ryder Obama-for-President venues were both rendered somatically attractive with their saturated colors and elaborate textures. Their island and jungle locations, however, represent them as remote, exotic sites of holidays and adventures, as opposed to places of community construction. Whether designed as practical or as pleasurable, all of the Democratic campaign settings in Second Life appeared marginal and relatively isolated. They had few visitors, most of whom were self-identified as non-U.S, citizens.

In contrast to the detached character of Democratic venues, Republican sites in Second Life were fixed, ordered places. Of the three indexed Republican Party sites devoted to the McCain and Palin campaign in Second Life only one was intimate in its scale. This structure was not, however, isolated. “A Republican Place” (Oro 26.114.27) was a Tudor-style bungalow settled in the suburban grid of a Catholic neighborhood. It had yard signs outside and political posters in the living room. In the immediate neighborhood were the Catholic Now Café and Chapel and two large churches – the Cathedral Basilica of All Saints and the Shrine of the Most Sacred Heart of Jesus. In addition there was an enclosed garden with a commemoration of Roman Catholic “Glories” and a Rosary-O-Matic for avatars. A store in which various religious statues and paintings were sold and the Catholic Information Center were also located within a two block radius. Although the site was not highly populated, “A Republican Place” appeared to be very much a part of a broader, apparently stable religious community.

Figure 3 Much more monumental than ‘A Republican Place’ were the two other McCain/Palin campaign locations indexed in Second Life. The largest was the site of the “Republican Party of SL” (Keen 77, 173, 21) (Fig. 3). This monumental complex, about the size of two football fields, was too large to photograph as a whole. Images in Second Life “rezz” or resolve into sight only as an avatar approaches, and they disintegrate as the avatar retreats. Distant views of the built environment are impossible. The “Republican Party of SL” campus was organized around the Washington Monument, which occupied the center of a grand, cruciform reflecting pool. The 8

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dominant building in the complex was rendered in a style that might be called Washington-DCRevival or Wedding-Cake-Classical. It took the form of an oblong mass with a relief frieze as a cornice and arched windows draped in the Stars and Stripes, topped with a clerestory level and finally crowned with a domed belfry. The structure was introduced by a monumental staircase and porch supported by five (sic!) columns of a mock-Doric order. (No self-respecting Greek or Roman colonnaded porch would have a column frustrating the axis of its entrance.)

An avatar visiting this structure found, at ground level, a spacious, open lobby with a reception desk, a few chairs, a table offering free virtual cigars, and several Second Life political posters on the walls. The lobby was flanked by two smaller rooms – one devoted to a display of books denouncing liberal politics, including works by Ann Coulter (Godless: The Church of Liberalism), Sean Hannity (Deliver Us from Evil: Defeating Terrorism, Despotism, and Liberalism), and Jonah Goldberg (Liberal Fascism). A left click on the cover of any of the volumes linked to Amazon for the book’s acquisition. The spacious meeting room on the second floor interior was lined with traditional, faux-oil portraits of all American presidents up to George W. Bush. Portraits of Republican presidents might be identified by hovering the cursor over the image. At one end of the room there was a podium, with chairs arranged for a lecture.

Figure 4 The classicizing headquarters and the Washington Monument were apparently the only structures retained from an earlier version of the site during its recently initiated rebuilding (Hunghi, 2008). Reconstruction was on-going, which perhaps explained the setting’s lack of landscaping: bushes, flowers, gardens, and trees were almost entirely absent. Other buildings in the complex were all rendered in a non-descript Corporate Postmodern style: Dryvit-like containers with rounded corners sprayed brick-red, flesh-colored faux marble and black structural details. Dryvit is the trade name that has become a generic term for a currently popular mode of construction--basically stucco blown over Styrofoam--that has many variations. Such processes are deployed to produce not only slick works like those of the Republican Party of Second Life, but also ornamental facades with the faux-classical details popular with banks and hotels. Styrofoam is much cheaper to model into pilasters, cornices and capitals than stone.

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These faux-Dryvit buildings at Keen in Second Life included a café with an expansive You Tube screen for members of the “Republican Party of SL” only. There was also a large auditorium where streaming video presented by the “East Coast Conservative Podcast: News and comment from behind the Blue Curtain” could be viewed collectively on Sundays at 5:30. The screen was flanked to the right by a Second Life poster of the group and to the left a picture of Obama waving his hand, labeled “Sig (sic!) Heil, Hitler.” Across the campus was the “University of Conservative Studies” which was intended “To solidify and fortify young skulls formerly full of liberal mush” (Fig. 4). Although still under construction at the time of the election, there were two high-tech classrooms on the second level. Finally, between the café and the theater there was a skeet-shooting game. Only members could play; each game costs 1L$. The game is very inexpensive: the conversion rate of Linden dollars to US dollars has been relatively stable at 250L$ = $1.00. On the margins of the site there were two separate spaces – a darkly ominous, unlabelled monument and an open-air pavilion with McCain (no Palin) information, a Nobama sign, and a parked jet fighter plane.

Figure 5 Another elaborate site in Second Life devoted to the McCain/Palin campaign was “The Straight Talk Café: John McCain and Sarah Palin for America” (Sagamore 166.152.31) (Fig. 5).

The teleport station was a gazebo. The architecture surrounding the avatar’s landing point was realized in the Georgian and Beaux-Arts styles, variations of the classical. On axis were monumental buildings with colonnaded pedimented porches – the incomplete Ronald Reagan Building on one side and the Georgian town hall on the other. The inside of this last structure was as formal as its exterior, space being arranged symmetrically around a grand double stairway. All the open rooms were empty of furnishings; the walls were adorned with elaborately framed paintings of American presidents and heroic occasions in American history. Another under-construction building was sign-posted as the new Republican Hall of Fame. The Straight Talk Café itself, another Georgianesque structure, was furnished as a meeting place with a bar and comfortable couches as well as informational materials on McCain and negative posters about Obama.

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On a hill above the central quadrangle was another Washington Monument. At the base of the front side of the obelisk’s base were bronze plaques with battle scenes from wars in which the US fought, including World Wars I and II, the Korean War, the Vietnam War. Following on the right side are memorials to the Persian Gulf War and the Iraqi (sic!) War flanking a memorial plaque representing Somerset County, PA (trees), New York, NY (Twin Towers), and Washington, DC (Pentagon) with additional space in which to add further plaques to future wars.

The central square around the gazebo was formally divided into quadrants, each of which was artistically marked. The most impressive of these monuments was a great equestrian statue of Theodore Roosevelt. The second quadrant displayed a series of reliefs with portraits of the American astronauts on granite mounts framing a raised circular area with an American flag and the imprint of an astronaut boot on the surface of the moon. A model of the Wright brothers’ first plane and a plaque with their portraits occupied a third quadrant. The final quadrant was adorned with a Civil War cannon. The trees and bushes of the landscaping softened the seriousness of the architecture.

The Straight Talk Café site acts like a town square from a nostalgically remembered United States of the 1950s or from Main Street in Disney World. The Sagamore sim was by far the most popular 2008 campaign venue in Second Life. It seemed to attract as many Democrats as Republicans. Debate was lively and arguments were heated, but for the most part remarkably civil. Volunteer security avatars were always present but I never witnessed an eviction.

Architectural agency Structures in Second Life are, of course, distinct from buildings in real life. Buildings in digital environments are not restrained by weight-bearing technologies. Their roofs do not leak and their foundations do not subside. They do not decay. They can be destroyed without creating waste. Old forms may be readily exchanged for new ones. In their evanescence and insubstantiality, Second Life buildings behave more like fashionable real life clothing rather than like real life structures. Second Life buildings present no primordial presence in the landscape; they contain no nooks and crannies for the residue of memory. Indeed, the built environment of Second Life offers a rich source of criticism of phenomenological treatments of space. From Eliade and Rosen’s primordial eruptions of the Divine to Heidegger and Bachelard’s oneiric huts, phenomenological theories of space have no traction in the architectures of immersive worlds (Bachelard, 1992; Eliade, [1957] 1987; Heidegger, 1971; Rosen, 2004).

In other important ways, however, virtual structures act in ways similar to material ones.

Digital buildings, though much, much cheaper than real-life structures, do require the possession of “land” and the purchase or production of construction materials or textures. Large compounds and big buildings infer wealth in the immersive world, just as they do in the physical one.

Further, the form that a patron gives to her building is as much an expression of her interests and peculiarities as the figuration that she gives her avatar. Architectures in immersive worlds, like those in real life, reveal a great deal about their makers. They even appear to have embodied their producers’ ideological perspectives. But perhaps most fundamentally, the virtual structures of Second Life, like built ones in real life, may well act as agents in their environments. In real life, shopping malls cultivate the obsessions of consumers, casinos the compulsions of gamblers, arenas the manias of sports fanatics. Places are shaped for the same purposes in Second Life: buildings manipulate the movement of their users and condition their actions and even their thinking, often without those avatars’ conscious realization.

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The digital environments of the Republicans and Democrats in Second Life eerily resembled their political campaigns in real life. The Democrats urged change, exploiting new media as a means of conveying their message. Correspondingly the major Democratic sites in Second Life tended to be digitally articulated either as modern or as vernacular spaces without historical reference. Venues were typically open, unhierarchical, and directionless. Architecture shaped a place, but gave it no particular meaning or resonance. Technology had a dominant presence. Communication was primarily textual – political positions had to be read by the visitor, not intuited. The sites seemed to assume that their visitors were coolly rational. The mechanically accessed messages were largely positive, devoted principally to describing the presidential candidate’s positions. The buildings – both the non-descript modern spaces and the vacation sites – appeared even during the campaign period to be temporary or only temporarily political. All of the locations were didactic and programmatically a little dull. They were also all minimally inhabited. The Democratic sites in Second Life were empty, un-policed, and nondiscursive. They were temporary, abstract spaces designed for the purpose of disseminating ideas and information. The only social engagement promoted was that which might occur elsewhere – in real life political activism. By the time of the final editing of this text in June, 2009, all of the Democratic sites discussed in it had disappeared. They were nomadic spaces.

In contrast to the Democrat’s focus on change, the Republican campaign emphasized the maintenance of traditional values. The architecture of their campaign venues corporealized those values through familiar and reassuring forms. Republican complexes all were anchored in a broader community. The scale and form of buildings were given much greater emphasis. The style of choice in the two major Republican sites was Classical. Classicizing architectural forms were, from the nineteenth century through the early twentieth century, associated with the gravitas of the state and those institutions that represented the state’s political, cultural or economic authority: legislatures, courthouses, museums, banks. Classicizing principles establish an authoritative order: bilateral symmetry contributes to a clear articulation of hierarchy; reference to the Greek and Roman past lend that symmetry the weighty sanction of revered tradition (Taylor, 1974). These spatial practices were put to use in the Republican sites.

Though textual materials were certainly available at the headquarters of the Republican Party of SL and at the Straight Talk Café, communication was image-oriented. Ideas were visually conveyed by monuments and pictures: great events and great men. The sites appealed to the patriotic through reference to the illustrious national past. Attacks on the opposition were much more prominent; polemical violence was greater. Surveillance was more extensive. The Republican locations tended towards the iconic and dogmatic. The labor involved in the planning and construction of these sites was apparent. The producer’s dedication to architecture was complemented by a devotion to programming. The two major Republican sites were coded by their makers to act socially not in real life but in Second Life. In both, formal discussions and lectures were organized and advertised. In Sagamore, there were, in addition, beach parties, dances, and conversations which attracted avatars of different political persuasions. This commitment to the immediacy of avatar interaction is instantiated in the sites’ settings. They were less boring then the Democratic venues. At the time of the final editing of this article in June, 2009, Straight Talk Café and the Official Republican Headquarters of SL are still active.

The end of the campaign effected a marked reduction in creative contention. Nevertheless, those sites, as fixed spaces, still provide potential venues for discursive engagement.

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The importance of sustaining a public sphere for engaging effectively with state policies and practices is broadly acknowledged. The 2008 US presidential campaign venues in Second Life suggest how immersive worlds might contribute to the construction of that public sphere.

Immersive worlds, in their virtual place-making, present possibilities for the production of a public sphere unavailable to other web-based fora—political blogs, facebook, twitter. Immersive worlds provide architecturally articulated spaces that attract individuals and sustain their communal interaction.2 These venues, by their spatial order and programming, also affect the discourses which they accommodate. By recognizing the force of space-shaping in the production of politics we take one step towards the transparency of a democracy.

Acknowledgements

I am grateful to Professors Julian Lombardi, Mark McCahill and Victoria Szabo for introducing me to the pleasures and frustrations of immersive worlds. I also want to thank Professor Kalman Bland and Professor Jeremiah Spence for their valuable suggestions. I am also indebted to the students in my Spatial Practices seminar, particularly Lauren Burack, Kency Corneyo, Aurelia D’Antonio, Jill Hicks, Kevin Kornegay, Camila Maroja, Caroline Schermer and Charles Sparkman, who helped me find instructive uses for Second Life.

2

More recently I was the only U.S. Citizen in a group of Egyptians, Turks, Saudis, and Palestinians who met to discuss President Obama’s speech in Cairo. The discourse was powerful and enlightening.

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Vidler, A. (1992). The Architectural Uncanny: Essays in the Modern Unhomely. Cambridge, MA: MIT Press.

Wodak, R., & Wright, S. (2006). The European Union in Cyberspace: Multilingual Democratic Participation in a Virtual Public Sphere? Journal of Language and Politics, 5(2), 251-275.

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Development of a Virtual Reality Coping Skills Game to Prevent Post-Hospitalization Smoking Relapse in Tobacco-Dependent Patients

By Paul Krebs, Jack Burkhalter, Shireen Lewis, Tinesha Hendrickson, Ophelia Chiu,Paul Fearn, Wendy Perchick and Jamie Ostroff, Memorial Sloan-Kettering Cancer Center

Abstract Many hospitalized smokers return to smoking after hospital discharge even though continued smoking can compromise treatment effectiveness, reduce survival, increase risk of disease recurrence, and impair quality of life. After leaving a smoke-free hospital, patients encounter smoking cues at home, such as family members who smoke or emotional triggers such as stress, which can elicit powerful urges to smoke and lead to smoking relapse. Enabling smokers to experience such urges in a controlled setting while providing the ability to practice coping skills may be a useful strategy for building quitting self-efficacy. We are developing a virtual reality coping skills (VRCS) game to help hospitalized smokers practice coping strategies to manage these triggers in preparation for returning home after hospitalization. Our multidisciplinary team developed a prototype VRCS game using Second Life, a platform that allowed rapid construction of a virtual reality environment. The prototype contains virtual home spaces (e.g., living room, kitchen) populated with common triggers to smoke and a “toolkit� with scripted actions that enable the avatar to rehearse various coping strategies. Since eliciting and managing urges to smoke is essential to the game’s utility as an intervention, we assessed the ability of the prototype virtual environment to engage former smokers in these scenarios. We recruited eight former smokers with a recent history of hospitalization and guided each through a VRCS scenario during which we asked the patient to evaluate the strength of smoking urges and usefulness of coping strategies. Initial data indicate that patients report high urges to smoke (mean = 8.8 on a 10 point scale) when their avatar confronted virtual triggers such as drinking coffee.

Patients rated virtual practice of coping strategies, such as drinking water or watching TV, as very helpful (mean = 8.4 on a 10 point scale) in reducing these urges. With further development, this VRCS game may have potential to provide low-cost, effective behavioral rehearsal to prevent relapse to smoking in hospitalized patients.

Keywords: smoking cessation; health behavior; virtual reality.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

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Development of a Virtual Reality Coping Skills Game to Prevent Post-Hospitalization Smoking Relapse in Tobacco-Dependent Patients

By Paul Krebs, Jack Burkhalter, Shireen Lewis, Tinesha Hendrickson, Ophelia Chiu,Paul Fearn, Wendy Perchick and Jamie Ostroff, Memorial Sloan-Kettering Cancer Center Of the 39 million Americans hospitalized in 2005, 8 million are estimated to have been smokers, using a smoking prevalence of 20.9% (Centers for Disease Control, 2007). While most smokers are able to abstain from smoking during inpatient stays within the smoke-free hospital environment, resumption of smoking following hospital discharge from the smoke-free hospital is common (Emmons & Goldstein, 1992; France, Glasgow, & Marcus, 2001; MacKenzie, Pereira, & Mehler, 2004; Wolfenden, 2003). Typical triggers for smoking relapses are distress (both psychological and physical), other household smokers, and environmental smoking cues.

Higher self-efficacy (confidence) for managing smoking urges is a consistent predictor of quitting success (Ockene, et al., 2000), while low self-efficacy for coping with smoking urges can leave a smoker particularly vulnerable to these triggers.

High rates of return to smoking have stimulated extensive research effort and theory development directed toward relapse prevention (Marlatt & Gordon, 1985; USDHHS, 2008), but outcomes for relapse prevention interventions have been mixed. A recent systematic review of smoking relapse prevention studies found no benefit from trials typically using low-intensity interventions, such as brief face-to-face encounters, written materials, mailings, and telephone contact (Lancaster, Hajek, Stead, West, & Jarvis, 2006). More intensive interventions involving hospital-based and post-discharge counseling, however, do show promise (Rigotti, Munafo, & Stead, 2008). Given the high relapse rates and the health risks of continued smoking, novel approaches to relapse prevention are needed.

The standard behavioral treatment for smoking urges has been behavioral rehearsal, which entails the identification, modeling, and role-playing of diverse cognitive and behavioral coping strategies. This treatment promotes skill acquisition and mastery, bolsters confidence in coping with smoking cues, and reduces relapse to smoking (Irvin, Bowers, Dunn, & Wang, 1999). By enabling patients to interact with realistic environments, virtual reality environments are uniquely suited to engaging recent ex-smokers in skill-building activities for managing urges to smoke.

Through exposure to conditioned cues to smoke, (e.g., socializing with friends who smoke), smokers may be able to virtually practice coping skills and build crucial self-efficacy skills for resisting smoking urges. In initial trials, virtually-presented cues have been shown to elicit more cravings than static photographs presented during traditional therapies (Baumann & Sayette, 2006; Bordnick, et al., 2004; Carter, Bordnick, Traylor, Day, & Paris, 2008; Kuntze, et al., 2001; Lee, et al., 2003). In contrast to “laboratory”-focused virtual craving studies, our project has focused on direct clinical application using a virtual-reality-based intervention to help smokers prevent relapse to tobacco use. Only one study (Nemire, 1999) has attempted a virtual reality intervention related to smoking, creating a virtual park where “avatars” (computergenerated people) offered cigarettes to adolescents. Participants could interact with the avatars and rehearse strategies for refusing cigarettes. Those using the virtual game acquired superior refusal skills compared to those receiving traditional life skills training. Despite the promise such interventions hold, no study has yet examined the efficacy of using a virtual reality intervention to promote smoking cessation and prevent smoking relapse among adult smokers.

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The overall aim of our current project is to develop a prototype virtual reality coping skills (VRCS) simulation game to help hospitalized smokers increase their skill and confidence in managing post-hospital discharge smoking cues. We chose to focus on the development of a Virtual Reality Coping Skills (VRCS) because a VRCS game: a) can be individualized to address a patient’s specific smoking triggers; b) can create realistic simulations that provide behavioral rehearsal opportunities that are either not possible or unethical in real-world treatment settings; c) can be readily disseminated to a broad audience of hospitalized smokers with minimal resource burden; and d) may be cost-effective as the initial outlay of costs for an effective game can be recouped with wide access and efficiency through reduced therapist/cessation counselor time.

Prior to creating an intervention game, however, we wanted to gather preliminary “proofof-concept” and usability data to inform eventual intervention development. We hypothesize that a virtual reality game used by hospitalized smokers can simulate high risk triggers for smoking relapse and help smokers master effective coping strategies to manage these triggers in preparation for discharge to home environments saturated with smoking cues. This preliminary stage is vital to ensuring a final product that will have the most utility in achieving our goal of moving the proposed project into the next phase of research in which we will examine the utility of the VRCS with actual inpatients at risk for smoking relapse after hospital discharge.

Method Virtual World Development A multidisciplinary team of investigators from the Behavioral Sciences Service (Krebs, Burkhalter, Ostroff) and the Strategic Planning and Innovation Department (Perchick, Fearn, Lewis, Chiu, Hendrickson) met over a 6-month period to plan a VRCS game using recommended game development methods (deFreitas, 2006; Garris, Ahlers, & Driskell, 2002).

The process of creating virtual elements has been a collaborative process that relies on instructional content input from behavioral scientists, input from technology and gaming experts, and feedback from former smokers representing end users.

To begin development of the VRCS game, the MSKCC Strategic Planning and Innovation team leased a private “sim” in Linden Lab’s Second Life (SL) (Linden Lab, 2009), which is a real-time virtual environment where users have the ability to create customized “avatar” characters to represent themselves. In SL these avatars have the ability to explore virtual islands, or “sims,” ranging from recreational places to islands with educational purpose. Several organizations have begun to use SL as a venue for support groups, social networking, and to provide didactic education.

While we ultimately envision our smoking cessation program to operate more like a selfcontained “game” with program-generated prompts and feedback, we employed SL (which is not a game but a virtual “world”) (New Media Consortium and the Educase Learning Initiative, 2007) because it is an ideal platform for rapidly creating virtual environments. Our aim at this developmental phase was to create a realistic environment to test the feasibility and acceptability of presenting smoking cues and coping strategies to hospitalized smokers in a virtual world.

With content consultation from behavioral scientists knowledgeable in tobacco cessation 5

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treatment, the Innovation team worked with a programmer to build the virtual spaces, create custom avatars and props, and develop scripts for particular movements and interactions.

Consistent with cognitive-behavioral counseling techniques used in smoking cessation treatment, we created a virtual environment with the following features: • • • •

Virtual spaces (living room, kitchen, office, and sidewalk in front of office building) populated with challenges for a patient trying to resist smoking urges, such as sitting at a computer or watching television.

Illness-specific contexts, such as experiencing distress or pain (via a scripted action in which the avatar engages in anxious behavior such as holding a hand to the forehead).

“Guest avatars” that smoke and elicit social smoking cues for the patient to manage.

A “coping toolbox” that when touched presents techniques the patient can use to cope with urges to smoke (e.g., exercising on treadmill, having a drink of water or a snack, engaging in deep breathing).

Figure 1. Female avatar in virtual dining and living room area created for the project

Prototype Testing Sample.

We recruited participants via telephone using the patient database of an urban hospitalbased smoking cessation clinic in the northeastern United States. Participants had recently quit smoking, had been hospitalized within the past year for a cancer-related illness, and had adequate visual-manual dexterity to participate. Our institutional review board classified this developmental work as quality improvement and therefore did not require approval as human subjects research.

Testing protocol.

Since the virtual environment’s ability to elicit urges to smoke and to allow patients to practice coping strategies is essential to the intervention’s central premise, each patient was guided through two VRCS scenarios populated with common environmental smoking triggers and cues (such as drinking coffee). Patients could also create their own tempting situations and coping strategies using elements present in the environment and SL interface (such as taking a 6

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walk outside). As our primary interest was eliciting and managing temptations during this evaluation phase, a project staff member (Krebs, Lewis) operated the user interface to control for patient familiarity with the operation of SL. For each scenario we asked participants how tempted they felt to smoke using a scale of 1-10, with 10 designated as the greatest possible temptation. After each tempting scenario we directed each participant to the coping toolbox where he/she selected a coping strategy, observed their avatar use the strategy, and then rated its ability in helping them cope with the urge to smoke using a 1-10 scale, with 10 representing the most helpful in reducing the urge. After two guided iterations of temptation and coping strategy scenarios, we allowed patients a few minutes to explore the environment using the computer on their own. We then asked a series of overall evaluative questions encompassing domains of realism and usability. Testing was conducted at the hospital’s Smoking Cessation Clinic and each session was video-taped, viewed, and coded by both the lead author and SL. Results Participants Eight participants (7 female) completed an evaluation of the VRSC game. Their mean age was 48 (range 28 to 73). Seven identified as White and one as Black. The average length of program evaluation session was 40 minutes.

Temptations Participants chose the following scenarios to elicit temptation to smoke: typing at a computer (2), sorting papers at a desk (1), drinking coffee (5), watching TV (3), sitting with a smoker (3), taking dog for a walk (1), and cooking (1). The average temptation score for these situations was 8.8 (range = 5 to 10). Suggestions for additional tempting situations were: having an alcoholic drink (5), talking on the phone (3), socializing with others (4), sitting in a car (1), lying in bed (1), and finishing a meal (1).

Coping Strategies Strategies that participants chose to cope with urges to smoke were: looking out the window (1), watching TV (1), using nicotine inhaler (1), leaving the situation (1), exercising (2), “asking” a smoker to not smoke around them (1), washing dishes (1), thinking about effects of smoking on others (1), and having a glass of water (1). Participants’ average rating score for the helpfulness of situations in reducing their urge to smoke was 8.4 (range = 5 to 10). Additional coping strategies participants suggested adding were: getting rid of ashtrays (2), practicing cognitive techniques such as thought-stopping or thinking of cons of smoking (3), cooking (1), listening to music (1), taking a nap (1), eating a snack (3), getting a pet (1), being able to ask the smoking avatar to put out the cigarette (3), using nicotine replacement (1), chewing gum (1), reading (2), shopping (1), and completing a puzzle (1).

Design and Usability Upon completion of the scenarios, we asked a series of questions to evaluate the design and usability of the game. Response categories, mean ratings, and selected comments are shown in Table 1.

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Table 1. Response categories, mean ratings, and selected comments Outcome Stimulating

Mean (SD) (1-10 scale) 5.6 (2.2)

Representative comments

Easy to Use

5.4 (1.6)

“I didn’t navigate too well, but with a little practice it wasn’t too difficult” “Would be easier if you could just drag her [avatar] along” “Frustrating because navigating her [avatar] around is difficult” “Really good program but frustrating to manipulate”

Helpful

6.5 (2.2)

“Not sure if it would help me unless it did something like a game, like ability to earn points” “The more interactive it is the more helpful it would be”

Ability to engage as character

4.4 (3.1)

“I could certainly be her” “I didn’t engage as the character at all. I don’t have gray hair” “Probably if you could change the clothes” “The character doesn’t look like me—that’s a big part of it” “Need to give more layout options for the house” “Not enough activities to do”

Clarity of labels

8.2 (1.5)

“Not confusing at all” “Need to be bigger”

“People would be more interested if they had options to touch things” “I like games more quick-moving” “Even though there’s not enough activities going on, the architecture of it is pretty good” “For me it was fun and interesting but I don’t relate to it because this is a big fancy house and I live in a studio apartment”

Most (n = 6) participants noted that they would prefer to move the avatar using the mouse, which was not possible in the prototype given that the interface was governed by Second Life. Additional suggestions were that we arrange the furniture to make the room easier to walk though and add more contrast between colors. One patient noted that the unrealistic eating and drinking movements made it difficult for her to engage as the character. To make the game more interesting, a few patients suggested greater interactivity such as allowing patients to load the tool box with their own coping strategies, earning points and rewards, having more options to interact with objects (open drawers, pick up books), and the ability to add sounds such as telephones ringing or the sound of typing.

In terms of its current status and potential to help patients prepare to quit smoking, participants noted, for example “I think it would help people because when they get home they forget about challenges, like seeing the bed or somebody on the couch as automatic cues;” “If the computer interacted it would be fairly helpful;” and “I like the idea of having another modality to rehearse, practice, and prepare.”

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Discussion The qualitative and quantitative feedback that we gathered from former smokers indicated three primary conclusions regarding the potential for a virtual reality smoking cessation intervention. First, virtually presented smoking cues can elicit moderate to high levels of temptation to smoke. Second, virtually presented coping strategies can reduce temptation to smoke, and third having an engaging design and high usability are essential for creating a program that smokers would find beneficial.

The finding that virtual cues elicit temptation to smoke is consistent with the limited number of other studies showing that nicotine craving can be elicited in virtual environments (Bordnick, et al., 2004; Carter, et al., 2008; Lee, et al., 2003). These studies, however, employed head-mounted displays which are costly and not feasible for most treatment environments or for home use. Most similar to our study was one conducted by Baumann & Sayette (2006) that used a standard computer monitor and found that a free exploration of an outdoor environment containing smoking cues elicited stronger urges to smoke than exploration of an environment without such cues.

While research has largely established the ability of virtual cues to generate nicotine craving, our pilot project is the only study we know of that assessed real-time reactions to virtual coping scenarios. For instance, the virtual reality program Nemire (1999) created was directed at nonsmokers, allowing them to practice only refusal strategies. Our preliminary finding that enactment of coping skills in the virtual environment may alleviate urges to smoke provides initial “proof of concept” support for the development of the proposed virtual reality-based cessation intervention.

The qualitative data, in particular, provided useful direction for creating a virtual-reality intervention that patients would use. There was a clear consensus that patients would prefer a program that operated more like an interactive computer game with prompts, feedback, ability levels, and a reward/point system. Our trial relied on the therapist to guide participants to cues and strategies, and patients noted that exploring a virtual world without prompts or interaction from the computer would not be helpful. Environments such as one created by Baumann & Sayette (2006), which simply enable participants to walk through situations containing cues, do not necessarily produce opportunities to practice coping strategies. Participants also emphasized the importance of the ability to personalize their avatars, as most noted they did not identify with the “neutral” avatar we created. They also stated that they would not engage in a program that proved frustrating to use. Therefore labels and text need to be clear and large, avatars should be intuitively movable via a mouse, and the program should start with a brief training module.

There were no apparent age differences in usability, diminishing our initial concerns regarding the acceptability of this program for hospitalized smokers, many of whom are older adults.

The feedback we gathered largely supported the importance of “situated learning” (Brown, Collins, & Duguid, 1989), such that problem solving is best carried out in conjunction with the environment and that concepts are best learned in realistic situations. While traditional smoking cessation interventions often provide smokers with a list of “coping strategies,” such as distraction and stimulus avoidance, these directives are abstract and not as readily acquired outside a specific environmental learning context. The importance of situated learning is supported by a number of comments we received such as, “Instead of talking about what you 9

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would do, now you can actually go and do it” and “You remember things as you are doing them [so it could] definitely help you plan for cues.” Our trials also highlighted a point made by Schneider (1996) that virtual environments must be adaptable and should contain objects that can be manipulated in a natural manner. Indeed, while we prepared the environment with common smoking triggers and strategies, participants instead used the environment in unexpected ways, such as having their avatar stand at the sink as if washing dishes or walking outside to cope with smoking cues. Participants also noted, for example, that they would be more engaged if they could touch and move objects such as opening drawers, throwing away ashtrays, preparing food, etc.

Limitations Our data was limited due to the nature of the volunteer, convenience sample. Our sample was primarily (7/8) female, white (7/8), and composed of those who quit smoking within the past year. It should also be noted that while much of the literature regarding virtual reality interventions focuses on Web 2.0 social-networking capabilities, our prototype does not make use of this capability. The goal of this intervention is to develop tobacco cessation skills rather than to provide nonspecific social support, although this latter element could be incorporated in future intervention development phases.

Conclusions While a Virtual-Reality Coping-Skills game may not be suitable for every hospitalized smoker, its development holds promise as an additional treatment modality. Tobacco cessation is characterized by chronic relapse, necessitating engaging methods to tailor treatment to a person’s unique triggers and situation. As noted in the Horizon Report and elsewhere (Gorini, Gaggioli, Vigna, & Riva, 2008; New Media Consortium and the Educase Learning Initiative, 2007), integration of real-time data capture devices, such as phones, with the virtual environment offers the possibility of increasing the immersive nature and feedback quality of virtual interventions.

With further development as an interactive game, the virtual environment we have created has the potential to provide low-cost, effective behavioral rehearsal to prevent relapse to smoking in hospitalized patients. The process we undertook of collaborative, systematic development and end-use feedback has enabled our team to confidently pursue creation of a virtual-reality coping skills game and to implement a research trial that would test its efficacy in reducing relapse to smoking.

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Baumann, S. B., & Sayette, M. A. (2006). Smoking Cues in a Virtual World Provoke Craving in Cigarette Smokers. Psychology of Addictive Behaviors, 20(4), 484-489.

Bordnick, P. S., Graap, K. M., Copp, H., Brooks, J., Ferrer, M., & Logue, B. (2004). Utilizing Virtual Reality to Standardize Nicotine Craving Research: A Pilot Study. Addictive Behaviors, 29(9), 1889-1894.

Brown, J. S., Collins, A., & Duguid, P. (1989). Situated Cognition and the Culture of Learning.

Educational Researcher, 18(1).

Carter, B. L., Bordnick, P., Traylor, A., Day, S. X., & Paris, M. (2008). Location and Longing: The Nicotine Craving Experience in Virtual Reality. Drug and Alcohol Dependence, 95(12), 73-80.

Centers for Disease Control (2007). Cigarette Smoking Among Adults - United States, 2006.

MMWR, 56(44), 1157-1161.

De Freitas, S. (2006). Learning in Immersive Worlds: A Review of Game-Based Learning.

London: Joint Information Systems Committee.

Emmons, K. M., & Goldstein, M. G. (1992). Smokers Who Are Hospitalized: A Window of Opportunity for Cessation Interventions. Preventive Medicine, 21(2), 262-269.

France, E. K., Glasgow, R. E., & Marcus, A. C. (2001). Smoking Cessation Interventions among Hospitalized Patients: What Have We Learned? Preventive Medicine, 32(4), 376-388.

Garris, R., Ahlers, R., & Driskell, J. E. (2002). Games, Motivation, and Learning: A Research and Practice Model. Simulation & Gaming, 33(4), 441-467.

Gorini, A., Gaggioli, A., Vigna, C., & Riva, G. (2008). A Second Life for eHealth: Prospects for the Use of 3-D Virtual Worlds in Clinical Psychology. Journal of Medical Internet Research, 10(3).

Irvin, J. E., Bowers, C. A., Dunn, M. E., & Wang, M. C. (1999). Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology, 67(4), 563-570.

Kuntze, M. M. F., Stoermer, R. R., Mager, R. R., Roessler, A. A., Mueller-Spahn, F. F., & Bullinger, A. A. H. (2001). Immersive Virtual Environments in Cue Exposure.

Cyberpsychology & Behavior, 4(4), 497-501.

Lancaster, T., Hajek, P., Stead, L. F., West, R., & Jarvis, M. J. (2006). Prevention of Relapse after Quitting Smoking: A Systematic Review of Trials. Archives of Internal Medicine, 166(8), 828-835.

Lee, J. H., Ku, J., Kim, K., Kim, B., Kim, I. Y., Yang, B. H., et al. (2003). Experimental Application of Virtual Reality for Nicotine Craving through Cue Exposure.

Cyberpsychology and Behavior, 6(3), 275-280.

Linden Lab (2009). Second Life. Retrieved Nov 11, 2008, from www.secondlife.com MacKenzie, T. D., Pereira, R. I., & Mehler, P. S. (2004). Smoking Abstinence after Hospitalization: Predictors of Success. Preventive Medicine, 39(6), 1087-1092.

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Marlatt, G. A., & Gordon, J. R. (1985). Relaspe Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press.

Nemire, K. K. (1999). Preventing Teen Smoking with Virtual Reality. Cyberpsychology & Behavior, 2(1), 35-47.

New Media Consortium and the Educase Learning Initiative (2007). The Horizon Report. Austin, TX. Ockene, J. K., Emmons, K. M., Mermelstein, R. J., Perkins, K. A., Bonollo, D. S., Voorhees, C. C., et al. (2000). Relapse and maintenance issues for smoking cessation. Health Psychology, 19(1 Suppl), 17-31.

Rigotti, N. A., Munafo, M. R., & Stead, L. F. (2008). Smoking Cessation Interventions for Hospitalized Smokers: A Systematic Review. Archives of Internal Medicine, 168(18), 19501960.

Schneider, D. K. (1996). Virtual Environments for Education, Research and Life Retrieved Feb 28, 2009, from http://tecfa.unige.ch/moo/paris96/papers/daniel.html#BROWN89 USDHHS (2008). Treating tobacco use and dependence: Clinical practice guideline 2008 update. (May ed.). Bethesda, MD: US Department of Health and Human Services.

Wolfenden, L. (2003). Smoking Cessation Interventions for In-patients: A Selective Review with Recommendations for Hospital-based Health Professionals. Drug and Alcohol Review, 22(4), 437-452.

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Virtual Worlds, Collective Responses and Responsibilities in Health

By Rashid M Kashani, University of Alberta, Canada Anne Roberts, Ray Jones and Maged K. Boulos, University of Plymouth, UK

Abstract Virtual worlds are an exciting area offering opportunities in clinical teaching and interventions. Clinicians and academics alike may approach these emerging opportunities with enthusiasm or scepticism. Attitudes towards applying virtual worlds in clinical practice may arise from a number of sources, facilitating a more or less positive view towards this media. Virtual worlds have the potential to provide a considerable amount of control to end users’ (in this case, the client’s) hands. The argument put forth is that we should collectively acknowledge changes in information technology and the power that this gives the health care user, but we also have a collective responsibility to ensure virtual worlds are adapted, tested, and studied with sufficient rigour to benefit health care consumers and population needs.

Occupational therapists specifically may be in a unique position to adopt the use of virtual worlds in clinical practice.

Keywords: virtual worlds; health; occupational therapy; client; clinician.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

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Virtual Worlds, Collective Responses and Responsibilities in Health

By Rashid M Kashani, University of Alberta, Canada Anne Roberts, Ray Jones and Maged K. Boulos, University of Plymouth,UK

Following a recent demonstration of virtual worlds using Second Life (SL) to a visiting academic and a handful of observers, one student occupational therapist (OT) created an avatar on SL the same day. Later that evening, I received an instant message on my Blackberry for Professor Boa, my SL avatar. “Hi, this is Anna [her avatar name]. There are weird people bothering me. How do I get out of here?”

While lending some immediate support and answering another question from her the next day, I reflected on how her experiences were not unlike others first venturing into this medium.

My student continued to use SL despite her initially unpleasant experiences. For others though, such experiences may result in abandoning virtual worlds out of frustration. The new user experience, which is often characterized by a combination of learning the social norms and technical aspects of interacting with a virtual community, may be a sufficient barrier preventing clinicians from seeing the potential value of using virtual worlds in education, research, and interventions. In fact, several factors require acknowledgment before clinicians widely adopt virtual worlds in practice. The aim of this paper is to stimulate discussion around potential barriers to adopting virtual world applications for use in health care, and ways to eliminate or reduce barriers.

Fear of the Unknown Immersing oneself into a completely new and different environment can feel threatening.

One is learning to navigate and interact in a novel, immersive, and sometimes misunderstood medium. Some media coverage has included a decidedly biased slant and lack of understanding of the purpose of virtual worlds, referring to them repeatedly as games (Garntner, 2009). There have been documented issues with virtual crimes too (Holyoke, 2007). Some SL avatars wait at orientation areas for new arrivals, such as the “weird people” mentioned by my student, and embarrass them with their lack of familiarity with virtual worlds. Such experiences may be enough to make some health professionals reluctant to adopt this media.

Clinician Barriers While most health professionals are required by their regulatory body to maintain a portfolio of clinical competencies, many formal continuing competence opportunities offered to clinicians, such as to OTs, may be focused on the maintenance of existing skill sets, or restricted to an approved course list (American Occupational Therapy Association, 2008). Depending on the specific profession and legislated continuing competency program, learning to use a virtual world may not count towards a clinician’s continuing competency hours.

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An additional obstacle to adopting the use of virtual worlds in clinical practice may be a perception that one must be fluent in computer programming and graphics applications to interact within a virtual world. As a result of these perceptions, clinicians may not see virtual worlds as a priority for practice development, state that they do not have time to explore them, and derive most of their information on virtual worlds from the popular press, as there are few research papers to date on clinical applications in virtual worlds. For example, occupational therapy literature has very few studies dedicated to virtual technologies. At the time of writing, an OTDBASE search reveals fewer than twenty studies using virtual reality, and none specific to virtual worlds.

Paternalism The transfer of more control, not less, into a client’s hands is a goal towards which many health professions, particularly OTs, strive. SL, however, has been characterized as potentially addictive (Cremorne, 2007) or having deleterious side-effects (Gorini, Gaggioli, Vigna and Riva, 2008), even by supporters of this media (although without providing empirical data). Clinicians may be inclined to protect those deemed at risk for manipulation in a virtual world, or even to discourage clients from using them, especially since the popular press has skewed public perception of them as potentially causing harm.

Responsibility of virtual world designers and administrators If virtual worlds are to be used widely in health application, there needs to be more than just acknowledgement that there are real technical issues in using them. Developers need to address issues pertaining not only to bandwidth, but also acknowledge cognitive and physical skills required to access present forms of virtual worlds. Other responsibilities are the assurance of safety and inclusivity beyond the basic terms of service. Depending on the user population and demographics, some may still find the user interface of virtual worlds, such as SL, too physically or cognitively taxing for meaningful interactions. What must also be acknowledged by virtual world administrators is that those who elect to discount the issues of the new user experience, or provide a decidedly skewed view in the media, do virtual worlds a disservice as a legitimate tool of clinical practice.

Virtual world designers and administrators need to respond to the technical issues, but also have to become adept at addressing public opinion, possibly both through position statements and through collaborating on research. Without addressing the issues of public opinion, inclusivity, and protection of what may perceived as the more vulnerable users, adoption may be slowed by these barriers. Virtual world designers and administrators need to consider purposively recruiting health professionals and health consumers as a means to collaboratively construct virtual worlds free of these barriers.

Including clinicians who are early adopters of virtual worlds in the planning and implementation of orientations, development of more inclusive user interfaces and a concerted effort to support widespread research might ameliorate some of the direct challenges previously outlined. There needs to be a specific action plan by developers to demonstrate increasing ease of use, a reduction in technological barriers, and development of partnerships between developers and the clinical community. Approaching disciplines that incorporate the influence of cultural, social and physical environments, such as occupational therapy, would be prudent.

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What then, might be the clinician responsibility?

Virtual worlds offer a level of three dimensional interactivity and flexibility not available in other forms of online interaction. Clinicians, researchers, and educators need to be introduced to both the potential beneficence as well as adverse effects of virtual worlds to health and well being. Given the available literature in some disciplines, many areas remain unstudied.

Therefore, rigorous studies are needed to focus on specific populations to determine if this is an effective intervention. While this may sound like a new, daunting practice challenge, it behoves clinicians to realize that this sound scientific reasoning is missing from many clinical practices, not just in the area of virtual worlds (Booth, n.d.).

Perhaps what are needed in addition to the tailoring of specialized programs are more indepth orientations and more formal mentor support in using virtual worlds with specific populations. The development of this support may ameliorate some of the new user issues of the present day, and our own concerns of exposing those we consider at risk to this media.

Academics may try to introduce this as both a tool and a meaningful occupation of future clients.

Clinicians and researchers could be encouraged to develop programs and orientations specific to individualized client populations.

Geographic areas in some virtual worlds do focus on inclusion of those with varying cognitive and physical ability. SL has an area dedicated to this concept of inclusion, an area called Virtual Ability. Though an orientation area, such as Virtual Ability, for people with varying abilities is a valuable resource, perhaps what are needed are customized orientations for specific population needs. Further exploration is also required to see if these are effective in meeting client needs. While several different disciplines are capable of researching and using this media in teaching and clinical use, OTs have specialized activity analysis skills, and are in a unique position to develop programs addressing specific diagnostic population needs within an immersive virtual world environment. Virtual worlds offer medical information, and much more, in terms of socialization, creativity, occupation, and even spirituality.

How we best determine tailoring and testing of individualized programs and engaging input into their development and testing remain significant questions. Input from expert clinicians and consumers of health services may serve as a partnership in the development of the next-generation social web and may be a natural progression from the collaborative nature of many social web developments in wide use presently.

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Journal of Virtual Worlds Research- Virtual Worlds, Collective Responses and Responsibilities in Health 7

Bibliography American Occupational Therapy Association (2008). Continuing Education WebFind: American Occupational Therapy Association’s Searchable Database of Approved CE Providers.

Retrieved February 12, 2009 from http://www.aota.org/News/Announcements/CEWebFind.aspx Booth, A. (n.d.). What Proportion of Health Care Is Evidence Based? Resource Guide.

Retrieved January 19, 2009 from http://www.shef.ac.uk/scharr/ir/percent.html Cremorne, L. (2007). Addiction – SL as the Double-Edged Sword. The Metaverse Journal.

Retrieved January 22, 2009 from http://www.metaversejournal.com/2007/01/10/addictionsl-as-the-double-edged-sword/ Gartner, H. (2009). Strangers in Paradise. The Fifth Estate, CBC News. Retrieved January 30, 2009 from http://www.cbc.ca/fifth/2008-2009/strangers_in_paradise/ Gorini, A., Gaggioli, A., Vigna, C. and Riva, G. (2008). A Second Life for eHealth: Prospects for the Use of 3-D Virtual Worlds in Clinical Psychology. Journal of Medical Internet Research, 10(3):e21. Retrieved January 30, 2009 from http://www.jmir.org/2008/3/e21/ Holyoke J. (2007). SL Crime Wave!-L$3 Million Bank Heist!!!: Were Weekend Griefing Attacks a Cover for Bank Jobs? The Alphaville Herald. Retrieved January 29, 2009 from http://www.secondlifeherald.com/slh/2007/11/was-the-griefin.html OTDBASE (2008). Retrieved February 20, 2009 from http://www.otdbase.org/search/index.jsp Virtual Ability (n.d.). Virtual Ability Inc. http://slurl.com/secondlife/Virtual%20Ability/71/124/26 and http://virtualability.org/

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Does this Avatar Make Me Look Fat?: Obesity and Interviewing in Second Life

By Elizabeth Dean, Sarah Cook, Michael Keating and Joe Murphy, RTI International

Abstract The Centers for Disease Control and Prevention (CDC) has observed consistently increasing obesity trends over the past 25 years. Recent research suggests that avatar behavior and appearance may result in positive changes to real life individual behavior. Specifically, users may adjust their identity to match that of their avatars.

Preliminary results of survey interviews in Second Life support our hypotheses that individuals whose avatars engaged in healthy behaviors were more likely to engage in physical activities in the real world than individuals with less physically active avatars. Furthermore, thinner-looking avatars were associated with lower BMI in real life.

One unique feature of interviewing with avatars in Second Life is that researchers have the ability to manipulate environmental factors and interviewer characteristics with a consistency that is absent in the real world. In our preliminary results, respondents were more likely to report higher BMI or weight to a heavier-looking avatar than to a thinner-looking avatar.

Keywords : avatars; survey methodology; Second Life; obesity.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- Does this Avatar Make Me Look Fat? 4

Does this Avatar Make Me Look Fat?: Obesity and Interviewing in Second Life

By Elizabeth Dean, Sarah Cook, Michael Keating and Joe Murphy, RTI International

A Potential Relationship Between Obesity Research and Virtual Worlds The Centers for Disease Control and Prevention (CDC) has observed a consistent rise in obesity trends over the past 25 years (Behavioral Risk Factor Surveillance System, 2009). At first glance, increased use of the Internet, virtual worlds, and online gaming are likely to have a negative impact on the obesity epidemic because users are seated and sedentary in real life while they interact virtually. Furthermore, in a virtual world environment such as Second Life (SL) where users can customize their digital self-representations, or avatars, to be as thin and fit as they want to be, there may be less motivation for the users to be fit or lose weight in real life.

However, it is possible that self-representation by a fit, healthy avatar can have a positive impact on real life health behaviors. Yee and Bailenson (2007) use deindividualization and selfperception theory to suggest that virtual reality users may adjust their identity to match that of their avatars. They suggest that “users in online environments may conform to the expectations and stereotypes of the identity of their avatars. Or more precisely, in line with self-perception theory, they conform to the behavior that they believe others would expect them to have” (p. 274). This is called the Proteus Effect.

Through two different experiments, Yee and Bailenson (2007) found evidence to support the Proteus Effect. In one experiment, 32 students were assigned virtual avatars and were told to interact with a partner. Students who had more attractive looking avatars (as rated by a different group of students in a previous session) moved them closer to the partner and revealed more information than those students who were assigned unattractive avatars. In the second experiment, in a money-splitting game, the researchers manipulated avatar appearance using height. Two avatars had to agree upon a way to split a sum of money. If they agreed, they received the money, but if they disagreed, neither of them received anything. Though no significant differences were found in the first round of the game, taller avatars were more likely to suggest a split in their favor in the second round of the game. Also, shorter avatars were more likely to accept an unfair split than the taller or normal-sized avatars were. Yee and Bailenson (2007) propose that in the first study avatar attractiveness impacted the level of intimacy people were willing to reach with strangers, and in the second study, avatar height affected people’s confidence.

In Proteus Effect research, avatars’ interactions with other avatars are influenced by their own and other avatars’ physical characteristics. In further research, Fox and Bailenson (in press, 2009) found that humans’ real world behavior is influenced by their own self-representing avatars’ behavior. Their experiment was an application of social cognitive theory, which states that humans can learn behaviors from observing others. They found that people who watched self-representing avatars (i.e., designed to replicate their own physical characteristics) running on a treadmill were more likely to engage in voluntary exercise within the subsequent 24 hours than those who watched either another person’s avatar using a treadmill or an avatar doing nothing.

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Health professionals are starting to use virtual worlds to conduct research and even treatment based on the idea that people will emulate or be influenced by their avatars. For example, the University of Houston's Texas Obesity Research Center (TORC) has begun an online program in SL— the largest online virtual world not specifically oriented toward gaming—for the purpose of fighting obesity. It is no secret in SL that many residents prefer their avatars to be thin. The Alphaville Herald writer, Alessandra Narayan (2009), wrote an article exploring the reasons for the lack of curves on most female avatars in SL. At the TORC facility, SL avatars exercise and eat healthy foods in order to be rewarded with Linden dollars (the SL currency). The researchers hope that this program will result in participants losing weight in real life (Colliver, 2008).

In order to better understand the connection between SL and real life obesity, health attitudes and behaviors, we conducted a survey of SL residents. In this article, we discuss our hypotheses, methods, and preliminary results and conclude with thoughts on the future application of surveys in SL and issues to be explored.

Conducting Virtual Interviews about Fitness in Second Life To examine the relationships between Second Life and real life health behaviors, appearance, and perceptions, we conducted survey interviews of SL residents (see Appendix 1). For years, survey researchers have been faced with a dilemma regarding survey administration modes. Though interviewers are useful in administering questionnaires, respondents are less comfortable responding to sensitive questions and tend to provide less honest answers when another person is present in the interview situation (Tourangeau and Smith, 1996; Turner, Forsyth, O’Reilly, Cooley, Smith, Rogers, and Miller, 1998). Self-administered modes, such as Web surveys or mailed paper-and-pencil surveys, give respondents more privacy, but the absence of an interviewer requires greater reliance on the respondent’s ability to navigate the survey correctly and to stay interested and motivated enough to complete the survey. With the advancement of new virtual world technologies, survey researchers are beginning to explore the realm of virtual interviewing and the use of avatars as interviewers.

Researchers call this type of survey mode “In-Avatar Interviewing.”

In-Avatar Interviewing Because they so closely mimic real world social surroundings, virtual worlds easily lend themselves to a virtual interviewing environment. An avatar, guided by a researcher at a computer, can conduct interviews with other avatars just as a real life interviewer would do face-to-face. The main differences are that the interaction takes place in a virtual room instead of a real room, and the interviewer and respondent are represented by avatars. Their avatars are speaking or typing to each other using chat software to talk to each other instead of the individuals speaking “in the flesh.” Inavatar interviewing may provide the benefits of an interviewer (e.g., motivating survey completion, probing unclear answers, clarifying question meaning) without the disadvantages of negative interviewer effects (e.g., dishonest or reduced reporting of sensitive behaviors, lack of privacy, unintended effects of interviewer characteristics or behaviors).

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To an extent, some people treat avatars as social entities (Nass, Moon, and Green, 1997; Krysan and Couper 2003). One of our research questions in this study explored to what extent avatar respondents react to differences in avatar interviewer characteristics. Previous studies have experimented with real world interviewer effects related to race and gender and have found that these types of characteristics affect responses to questions about race and gender beliefs and attitudes (Anderson, Silver, and Abramson, 1988; Davis and Silver, 2003; Finkel, Guterbock, and Borg, 1991; Hatchet and Schuman, 1976; Kane and Macaulay, 1993; Summers and Hammonds, 1966; Tourangeau, Couper, and Steiger, 2003). Real world research has shown that manipulating even a seemingly insignificant variable can have a measurable impact on survey responses. In a study of Nicaraguan political preferences researchers used the same interviewers and same questionnaires to ask party affiliation questions, but they used different color pens on different days (Bischoping and Schuman, 1992). When interviewers used a red pen (i.e., the color associated with the country’s major political party), affiliations leaned toward that party. When interviewers used a blue pen (i.e., the color of a group of opposing parties), the affiliations were reversed. Considering the visual context in which avatars are used, it is not surprising that avatars’ physical traits, like human physical traits, may play a role in avatar-to-avatar interactions. Therefore, avatars’ physical traits may have unintended effects on survey responses.

In-avatar interviewing offers survey researchers a new level of experimentation that has never before been possible. Avatars allow researchers to have complete control over the appearance, words, actions, and inactions of the interviewer. Not only can a few clicks of a mouse produce a dramatically different interviewer appearance, but researchers can also control the reactions the interviewer has to the respondents’ answers. It is as if the interviewer is given a mask, and the respondent sees and hears only what the interviewer wants the respondent to see and hear.

Though previous studies have shown that there is an effect of interviewer attributes on responses, in order to manipulate interviewer traits in real life interview settings, multiple interviewers are needed. This increases costs and logistical complexity. Researching in-avatar allows one interviewer to appear with any combination of physical characteristics imaginable. The researcher also has the ability to manipulate just one attribute, if desired. For example, the exact same avatar can appear white in one interview and black in the next, but with the same clothes, face, and body both times. The only difference between the two interviewers would literally be the color of the avatar’s skin. Any type of single variation can be tested this way when in-avatar interviewing. Controlling environmental and social variables in order to manipulate a single element in real world interviewing situations is a constant challenge to social research, but in virtual worlds, these environmental and social factors are under the designer’s control.

Hypotheses In our current study, we tested hypotheses about the relationship between SL behaviors and real life behaviors related to physical health and activity. We also examined the relationship between selfreported SL body shape and size and real life body mass index (BMI). Finally, we assessed the impact of avatar-interviewer characteristics on the report of real life characteristics by manipulating the appearance of the avatar-interviewer. We tested three hypotheses:

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1. Individuals with avatars who engage in physical activities in SL are more likely to engage in physical activities in real life.

2. Individuals with thinner avatars are more likely to be thinner in real life.

3. Avatar-respondents are more likely to report a heavier SL body size and higher real life BMI to a heavy avatar than to a thin avatar, since a heavy avatar conveys that a higher BMI is more socially acceptable.

Methods

For this study, we conducted interviews of SL residents in our facility in SL. Avatar respondents were recruited through a notification sent to all members of the facility’s Survey Group in SL. The facility’s Survey Group is free for any avatar to join by signing up at a kiosk in the facility in SL; by joining, residents expressed interest in learning about participating in the facility’s surveys.

Interested participants were asked to notify one of our staff avatars via Instant Message (IM) to schedule an appointment.

Once contact was made via IM, our staff avatar screened the respondent for eligibility. In this study, our only eligibility requirement was that the respondent live in the United States in real life, so we asked respondents, “Do you currently live in the United States?” This requirement was stipulated for future comparisons of these data with those from nationally representative surveys. If the respondent indicated that he/she lives in the United States, then an appointment was made for the avatar to come to the facility for an interview. Respondents were assigned to one of two groups: interview by heavy avatar and interview by thin avatar. Each interview took about 10 minutes.

Respondents were paid 500 Linden dollars (the equivalent of approximately $2) for their time. All interviewing was done using the private text chat feature in SL that allows for privacy, as well as easy transcribing. Voice chat was not used.

Preliminary Results As of March 1, 2009, we conducted 29 interviews in SL. Of these, a random 15 were with the heavy interviewer, and 14 were with the thin interviewer. Preliminary results related to our hypotheses follow and appear in Table 1 at the end of this section.

Hypothesis 1: Individuals with avatars who engage in physical activities in SL are more likely to engage in physical activities in real life.

About half (15) of the respondents reported that their avatars in SL participated in vigorous or moderate physical or leisure activities (e.g., running, playing a sport, dancing) at least once a week.

The remaining 14 (48.3%) reported their avatars participated in such activity occasionally or not at all.

Most respondents (69.0%) reported that in real life, they participated in vigorous physical activities at least once a week. Of those who reported high levels of physical activity for their SL avatars, 80.0% also reported participating in high physical activity in real life. This compares to only 57.1% of those who do not participate in physical activity weekly or more often in SL. These results suggest preliminary support for Hypothesis 1.

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Hypotheses 2: Individuals with thinner avatars are more likely to be thinner in real life.

All respondents described their avatar’s body shape as either thin (14) or about average (15).

Among those who described their avatar as thin, average real life BMI was 24.7. This compares to a slightly higher average BMI of 27.4 for those describing their avatar as about average. For reference, a BMI of 18.5 – 24.9 is considered normal weight and 25.0 – 29.9 is considered overweight. While there are insufficient cases to draw statistical conclusions at this point, Hypothesis 2 is supported in the preliminary results.

Hypothesis 3: Avatar-respondents are more likely to report a heavier SL body size and higher real life BMI to a heavy avatar than to a thin avatar, since a heavy avatar conveys that a higher BMI is more socially acceptable.

Respondents interviewed by the thin avatar were more likely than those interviewed by the heavy avatar to describe their own avatar shape as thin (64.3% vs. 33.3%).

When asked whether respondents considered themselves in real life to be obese, overweight, underweight, or about right, only 10.3% reported considering themselves obese, 24.1% as overweight, 6.9% as underweight, and 58.6% as about right. By interviewer type, only 33.3% with a heavy interviewer considered their own real life status to be about right, and 64.7% with a thin interviewer considered their own real life status to be about right.

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Table 1. SL Survey Preliminary Results N

%

Respondent described own avatar as thin Did not describe own avatar as thin

14 9 5

64.3 35.7

Considered real life weight/size "about right" Did not consider real life weight/size "about right"

9 5

64.3 35.7

Respondent described own avatar as thin Did not describe own avatar as thin

15 5 10

33.3 66.7

Considered real life weight/size "about right" Did not consider real life weight/size "about right"

5 10

33.3 66.7

Once a week or more Real life vigorous activities once or more a week Real life vigorous activities less than once a week

15 12 3

80.0 20.0

Less than once a week Real life vigorous activities once or more a week Real life vigorous activities less than once a week

14 8 6

57.1 42.9

Interviewer Type Thin

Heavy

Avatar Participates in Vigorous Activities

Average BMI

BMI Describe own avatar as thin Describes own avatar as about average

14 15

24.7 27.4

Thin interviewer Heavy interviewer

14 15

24.8 27.6

Concerning respondents’ BMI, we saw a slight difference between those with a thin vs. heavy interviewer. The average BMI for respondents reporting to the thin interviewer was 24.8, and the average BMI for those reporting to the heavy interviewer was 27.6. These preliminary results support Hypothesis 3.

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Discussion

This research study is ongoing, and the above results represent only preliminary findings.

However, preliminary results without significance testing suggest that our hypotheses are supported.

People who are physically active in SL are also physically active in real life, and people with thinner avatars have lower real life BMIs. Our preliminary research implies no causality in either direction, just an association. Therefore, physically fit people could choose to have thinner and more active avatars because that’s how they exist in real life. Yet, the consistency suggests a pattern that invites further investigation into causal relationships.

With regard to the effects of the avatar-interviewer, manipulating interviewer size had an impact on results. Respondents interviewed by the thin avatar were much more likely to say their own avatar shape was thin. Most respondents reported that their real life weight was about right, but these numbers decreased with the presence of the heavy interviewer and increased with the thin interviewer.

Average BMI was slightly higher for the respondents interviewed by the heavy avatar-interviewer.

The avatar may have served as a reference point for what is thin and what is heavy, or perhaps the avatar conveyed what was socially more desirable.

There are two distinctly different reasons these findings are important. First, the growth of virtual worlds for social engagement requires the consideration of virtual reality as the next survey interviewing mode. An examination of the role of avatar-interviewer and the relationship between interviewer and respondent is necessary to compare virtual survey interviewing to other modes.

Second, the public health urgency surrounding the issue of obesity means that any intervention that might possibly affect real life health should be considered. Moreover, the ease of manipulating single factors, such as avatar size and shape, in the virtual social environment, gives researchers the opportunity to understand social factors in complex and increasingly value-laden (hence sensitive) issues, such as obesity, body image, and physical fitness.

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Bibliography Anderson, B., Silver, B., & Abramson, P. (1988). The effects of the race of the interviewer on race-related attitudes to black respondents in SRC/CPS national election surveys. Public Opinion Quarterly, 52, p.

289–324.

Bischoping, K. and Schuman, H. (1992). Pens and polls in Nicaragua: An analysis of the 1990 pre-election surveys. American Journal of Political Science, 36(2), p. 331–350.

Colliver, V. (August 8, 2008). Fat people get online chance to lose weight. San Francisco Chronicle, C-1.

Davis, D. and Silver, B. (2003). Stereotype threat and race of interviewer effects in a survey on political knowledge. American Journal of Political Science, 47, p. 33–45.

Finkel, S., Guterbock, T., & Borg, M. (1991). Race of interviewer effects in a pre-election poll: Virginia 1989. Public Opinion Quarterly, 55, p. 313–330.

Fox, J. and Bailenson, J. N. (in press). Virtual self-modeling: The effects of vicarious reinforcement and identification on exercise behaviors. Media Psychology.

Hatchett, S. and Schuman, H. (1976). White respondents and race-of-interviewer effects. Public Opinion Quarterly, 39, p. 523–528.

Kane, E. W. and Macaulay, L. J. (1993). Interviewer gender and gender attitudes. Public Opinion Quarterly, 57, p. 1–28.

Krysan, M. and Couper, M. P. (2003). Race in the live and the virtual interview: Racial deference, social desirability, and activation effect in attitude surveys. Social Psychology Quarterly, 66, p. 364–383.

Linden Lab (2008). Linden Lab builds bridge between Second Life and real world with new voice-driven instant messaging client. Retrieved March 2, 2009 from http://lindenlab.com/pressroom/releases/09_03_08.

Narayan, A. (February 25, 2009). Stop being so damn skinny – Real life is enough! The Alphaville Herald.

Retrieved March 4, 2009 from http://foo.secondlifeherald.com/slh/2009/02/-stop-being-so-damnskinny-real-life-is-enough-.html#more.

Nass, C., Moon, Y., & Green, N. (1997). Are computers gender-neutral? Gender stereotypic responses to computers. Journal of Applied Social Psychology, 27, p. 864–876.

Summers, G. F. and Hammonds, A. D. (1966). Effect of racial characteristics of investigator on selfenumerated responses to a Negro prejudice scale. Social Forces, 44, p. 515–518.

Tourangeau, R., Couper, M. P., & Steiger, D. M. (2003). Humanizing self-administered surveys: Experiments on social presence in Web and IVR surveys. Computers in Human Behavior, 19, p. 1– 24.

Tourangeau, R., & Smith, T. W. (1996). Asking sensitive questions: The impact of data collection mode, question format and question context. Public Opinion Quarterly, 60, p. 275–304.

Turner, C. F., Forsyth, B. H., O’Reilly, J. M., Cooley, P. C., Smith, T. K., Rogers, S. M., & Miller, H. G. (1998). Automated self-interviewing and the survey measurement of sensitive behaviors. In M. P. Couper, R. P. Baker, J. Bethlehem, C. Z. F. Clark, J. Martin, W. L. Nichols II, and J. M. O’Reilly (Eds.), Computer Assisted Survey Information collection. New York: Wiley and Sons, p. 455-474.

Yee, N. and Bailenson, J. (2007). The Proteus Effect: The effect of transformed self-representation on behavior. Human Communication Research, 33, p. 271–290.

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Editors’ Corner Musings on the State of '3-D Virtual Worlds for Health and Healthcare' in 2009

by Maria Toro-Troconis, Imperial College London, UK and Maged N Kamel Boulos, University of Plymouth, UK

Keywords: future Internet; standards; frameworks; game-based learning; OpenSim; Second Life ÂŽ; health and medicine; virtual patients.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- Editor’s Corner – M. T.Troconis & K. Boulos 4

Editors’ Corner Musings on the State of '3-D Virtual Worlds for Health and Healthcare' in 2009

by Maria Toro-Troconis, Imperial College London, UK and Maged N Kamel Boulos, University of Plymouth, UK

“Much like the (original) Internet, virtual worlds will allow us to do “older” things more effectively, and do other things anew” -- Yesha Sivan

A ubiquitous, immersive and engaging online platform for future generations Despite their current “teething” problems, which are in many ways similar to the problems that faced the World Wide Web during its early days (Kamel Boulos et al., 2008), 3-D virtual worlds are poised to become a major online communication, learning, business and entertainment platform for our future generations. Today’s kids are being taught school lessons in 3-D virtual worlds (http://news.bbc.co.uk/newsbeat/hi/technology/newsid_7869000/7869303.stm) and are increasingly becoming used to the 3-D medium. A recent article in the British magazine Computer Shopper (http://www.computershopper.co.uk/columns/243207/raves-virtual-real-ale-it.html) discussed how today’s children are very heavily involved in virtual worlds, perhaps much more than youths and older adults, which gives some clue about where the (3-D) Internet is heading when these kids grow up: “We’ve already seen the birth of the first generation of children who will always inhabit virtual worlds and pre-packaged experiences. In fact, the highest growth area in virtual worlds is those aimed at children between the ages of five and eight. Have you ever heard of Wales? Of course you have. It has a population of just over three million souls. Have you ever heard of Neopets? No? It’s a bit bigger than Wales. In fact, it’s a virtual world with a population of 45 million registered users, and all of them are children. How about Habbo Hotel? One hundred million children regularly inhabit this artificial existence. As for the likes of Cyworld in South Korea and Hipihi in China, there are probably more citizens of these virtual worlds than were living on the entire planet when The Machine Stops (written by EM Forster and published in 1909) was originally written.”

While some of the above mentioned virtual worlds are 2.5-D (e.g., Habbo Hotel) and much more basic and less immersive compared to Second Life®, Hipihi (China http://www.hipihi.com/index_en.html) is a direct match to Second Life®. It seems the virtual worlds “empire” is now moving to Asia, with offerings from Hipihi, Nurien (South Korea http://www.nurien.com/ —Nurien is far more superior than Second Life® in terms of graphics and immersiveness), Cyworld Mini Life (South Korea - http://us.cyworld.com/), and others from this part of the world.

We have also begun to see 3-D virtual worlds that offer a 3-D mirror world experience like Near London from Near Global (http://www.nearglobal.com/About.aspx) and GeoSim Cities (http://www.geosim.co.il/). This is a very welcome trend that will definitely continue and contribute to shaping the ultimate 3-D Internet over the second decade of the twenty-first century.

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Journal of Virtual Worlds Research- Editor’s Corner – M. T.Troconis & K. Boulos 5

Also, and in a way similar to the early Web and how its interface was gradually integrated into mainstream desktop computing (like Microsoft Windows Desktop, starting in Windows 9x and Internet Explorer 4), 3-D virtual worlds might one day shape the graphical user interfaces of mainstream operating systems and even of cloud computing on small Internet devices. Apple is already exploring 3-D desktop and application interfaces (see patent application at: http://appft1.uspto.gov/netacgi/nphParser?Sect1=PTO2&Sect2=HITOFF&p=1&u=%2Fnetahtml%2FPTO%2Fsearchbool.html&r=1&f=G&l=50&co1=AND&d=PG01&s1=20080307360&OS=20080307360&RS=20080307 360 and figures at: http://www.macrumors.com/2008/12/11/apple-exploring-3d-desktop-and-applicationinterfaces/), while AMD and others are developing systems to compute a game’s (or 3-D virtual world’s) graphics, compress them, and send them out over the Internet, so that online users can run the results on platforms, such as cellphones, that are too computationally underpowered to render the graphics on their own (Ross, 2009; see also OnLive’s cloud gaming service: http://www.spectrum.ieee.org/apr09/8548).

Multi-touch user interfaces, augmented reality and other technologies already available today will also contribute to realising the future 3-D Internet of ubiquitous real-virtual worlds, where the boundaries will increasingly get fuzzier between ‘real’ and ‘virtual’ and between ‘humans’ and ‘user interfaces’. A recent video-montage by Microsoft illustrates the company’s vision for 2019, where one can see examples of the above boundaries getting blurred (see: http://www.istartedsomething.com/20090228/microsoft-office-labs-vision-2019-video/ or on YouTube at: http://www.youtube.com/watch?v=RvtxupQmRSA&feature=PlayList&p=DC88D59DC711D462&index =0&playnext=1), while General Electric has an inspiring mini-example of augmented reality that anyone can try online (see: http://www.youtube.com/watch?v=00FGtH5nkxM and http://ge.ecomagination.com/smartgrid/#/augmented_reality). SixthSense, developed at Massachusetts Institute of Technology’s Media Lab, is a wearable, gesture-driven computing platform that can continually augment the physical world with digital interactive information (http://news.bbc.co.uk/1/hi/technology/7997961.stm).

New forms of human—3-D virtual space interaction are also being developed that could, in the next few years, transform the way we use and inhabit 3-D virtual worlds. For example, Microsoft is currently working on a fully hands-free control system that will use face and voice recognition, as well as motion sensors to allow users to customise their avatars and interact in 3-D virtual spaces (see: http://www.neowin.net/news/gamers/09/06/01/microsoft-introduces-controller-free-gaming-projectnatal).

Towards an integrative vision of a novel 3-D virtual worlds platform —moving beyond today’s Second Life®

As the main component of the next-generation 3-D Internet, and much like the flat (2-D) Web, 3D virtual worlds are, and need to be, generic (i.e., application-neutral) by design for maximum flexibility.

Then purpose-built applications can be developed on top of this generic foundation to serve specific purposes (cf. Moodle (http://moodle.org/), the well-known Web-based Virtual Learning Environment, which runs as a specialised application or platform over the generic flat Web, and SLoodle (http://www.sloodle.org/), Moodle’s Second Life® extension).

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Journal of Virtual Worlds Research- Musings on the State of 3-D Virtual Worlds 6

Figure 1. An integrative vision of a novel 3-D virtual worlds platform. Content development and storage (content syntax and storage location) should ideally be separate from, and independent of, the presentation platform, allowing presentation to take place in different 3-D virtual worlds, on the flat Web, on mobile phones, etc., following the spirit of, and building on, the new Open Source PIVOTE toolkit (http://code.google.com/p/pivote/) that adopts this approach.

Figure 1 illustrates an integrative vision of a novel 3-D virtual worlds platform that seamlessly weaves into, and harnesses, existing and emerging Social Web services and data sources, and also

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gracefully adapts to different Internet devices that have different input and output affordances, to provide the ultimate ‘immersive visual collaboration and communication hub’ for our different daily (online) activities and interests.

Metaplace (shown in Figure 1 – http://www.metaplace.com/) is a successful example of an emerging 3-D virtual world platform that, albeit not very immersive as Second Life®, manages to integrate very well with existing flat Web content and even runs in standard Web browsers (with the Adobe Flash Player plugin) without the need for a special software client viewer, all while being extremely easy to learn and develop presences in (see comments about Metaplace at https://www.jiscmail.ac.uk/cgibin/webadmin?A2=VIRTUALWORLDS;QyPIQA;20090322220248%2B0000).

The quest for 3-D Internet standards Standards will play a key role in realising the integrative vision shown in Figure 1 and to ensure smooth interoperability among various 3-D virtual worlds and between those worlds and other online services and data sources.

Today (in March 2009), the Open Source OpenSim platform (http://opensimulator.org/) and the largely proprietary/closed-source Second Life® are sporting some very welcome inter-compatibility between them. For example, the same software client (Second Life® viewer or Hippo viewer http://mjm-labs.com/viewer/) can be used to visit both OpenSim-based and Second Life® grids. Second Inventory (http://www.secondinventory.com/) allows most (full-permission) objects to be ported (with any associated textures and internal scripts) from Second Life® to any OpenSim grid.

Figure 2. The University of Plymouth Sexual Health SIM on the OpenSim-based New World Grid. Most of the interactive objects that appear in this snapshot were successfully ported unmodified from our primary presence in Second Life® and are fully functional under OpenSim, thanks to the Second Inventory application (http://www.secondinventory.com/files/products.php).

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Kamel Boulos, with help from the administrators of the French OpenSim-based New World Grid (http://www.newworldgrid.com/), have successfully ported many of the interactive objects at the University of Plymouth Sexual Health SIM in Second Life® (see: Kamel Boulos and Toth-Cohen, 2009) to a new, mirror presence on the New World Grid (http://osurl.org/grid.newworldgrid.com:8002/Eleniel/58/45/33 and Figure 2).

Using the same Second Inventory software, we have also ported the free Open Source PIVOTE scripted objects (part of the PREVIEW Immersive Virtual Training Environment—see http://www.pivote.info/) from Second Life® (where they can be collected at: http://slurl.com/secondlife/St%20Georges%20University/123/16/21) to our place on the New World Grid.

OSurls (OpenSim URLs - http://osurl.org/, similar to Second Life® SLurls) have made access to OpenSim presences very user-friendly, while recent developments like OpenSim Made Easy (http://lab.newworldgrid.com/index.php/OpenSim_Made_Easy) are opening 3-D virtual world region hosting to the masses and significantly reducing its costs. Viewers like RealXtend (http://www.maxping.org/technology/viewers/intergrid-teleportation-with-rex.aspx) and the Hypergrid concept of OpenSim (http://opensimulator.org/wiki/Hypergrid) are promising to make intergrid teleportation as simple as clicking a link to move to another site on today’s flat Web. However, OpenSim, much like Second Life®, is still a “closed” platform in some ways. Yesha Sivan beautifully expresses the current situation in a recent online post at http://www.dryesha.com/: “Currently the virtual worlds industry operates more like the Computer Gaming Industry than like the Internet industry. Each developer, be it private (e.g., Linden, Forterra) or an Open Source (e.g., Sun Darkstar, OpenSim) is developing its own server, client, and rules of engagement. The inherent rationale of these efforts is a combination of “we know best” and “we will conquer the world.” While this may be the case (see Microsoft Windows, Apple iPod, or Google search), the common public good calls for a connected system like the internet, where different forces can innovate in particular spots of the value chain.”

Linden Lab (the creator of Second Life®) and IBM are currently mulling together their new ‘MMOXi standards’ via the official IETF (Internet Engineering Task Force) channels. The proposed MMOX standards and Open Grid Protocol suite will offer an application-layer wire protocol for virtual worlds to enable inter-application interoperability; provide for access and exchange with other systems on the Internet such as Web services, e-mail and other information storage systems; and allow network layers to recognize virtual worlds traffic and make routing decisions based on its characteristics (see: http://trac.tools.ietf.org/bof/trac/wiki/MmoxCharter).

On the other hand, the Metaverse1 EU Project Consortium led by Philips Research in the Netherlands is working on a new International Organization for Standardization (ISO) MPEG-V standard to be ready by October 2010 to fill in a similar standards gap (see: http://www.chiariglione.org/mpeg/working_documents/mpeg-v/mpeg-v_Reqs.zip).

The two standards sets are not necessarily mutually exclusive or competing with one another at this early stage (despite the clear overlap in their objectives). As MMOX and MPEG-V both evolve over the next few years, we will see which one of them will ultimately win the support of the industry or dominate the virtual worlds scene, or perhaps there will be some “merger” of the two sets at some point or a failure of one of them to deliver or even some new standards sets and players joining in. In fact, Mozilla, the developer of the Firefox Web browser (http://www.mozilla.com/firefox/), has just announced (as this article was being finalised) that it has joined forces with the graphics consortium Khronos (http://www.khronos.org/), who manage COLLADA (the COLLAborative Design Activity for establishing an interchange file format for interactive 3D applications - http://www.khronos.org/collada/),

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in setting up a working group to create a standard for what they call ‘accelerated 3D graphics on the Web’, the first version of which is expected in 2010 (see: http://news.bbc.co.uk/1/hi/technology/7963302.stm). It remains to be seen how this Mozilla-Khronos development will affect (or become affected by) the recently launched 3Di OpenViewer for OpenSim, an in-Web-browser 3D virtual world viewer (see: http://www.youtube.com/watch?v=4otd5c1U0iY and http://3di-opensim.com/en/).

Years ago, SGML (Standard Generalized Markup Language, an ISO-ratified standard) lost the Web “battle” to XML (eXtensible Markup Language, a W3C specification). SGML, while powerful and comprehensive, is very complicated, and the industry eventually dropped it in favour of XML, a much simpler language that still offers most of the power of SGML but without its complexity. We might witness the same in 3-D virtual worlds over the coming years, with the simpler and agile specifications gradually gaining wide acceptance and any emerging cumbersome “dinosaur-like” standards rapidly disappearing.

Moving on from these application-neutral reflections on emerging and future developments in 3D virtual worlds, the remaining part of this article will explore in some detail one current real-world application example of these new media, focusing on how 3-D virtual worlds can support game-based learning and presenting a case study of the Respiratory Ward, a ‘virtual patients’ game-based learning module in Second Life® developed at the Faculty of Medicine at Imperial College London.

Are Multi-User Virtual Environments (MUVEs) ready to support game-based learning?

Multi-User Virtual Environments (MUVEs) such as Second Life®, OpenSim and Active Worlds (http://www.activeworlds.com/) offer new collaboration and immersed teaching and learning opportunities. A large number of educational institutions are already exploring ways of making use of these new virtual environments. According to the Eduserv Spring 2009 Snapshot of Virtual World use in UK Higher and Further Education, many universities in the UK are studying the use of virtual worlds – mainly Second Life®- in education. A range of different uses of virtual worlds in UK higher and further education were identified with learning and teaching activities predominating, as well as simulations, the visualisation of complex structures and safety role-play.

According to Livingston et al. (2008) very few MUVEs have been designed specially to support educational objectives. MUVEs generally are not purposely built to effectively support educational activities. In order to take advantage of the potential of MUVEs and to produce effective immersive and engaging learning environments, a large number of developers and designers are required.

Games provide a meaningful and relevant context in which learning activities can be delivered.

Good games have clear goals and “explicit information both on-demand and just in time when the learner needs it” (Gee, 2003). The term game-based learning has emerged as a generic name for the use of games for learning or educational purposes. It has also been termed ‘serious games’, and includes fully immersive environments (or ‘metaverses’), in which learners can take on virtual presence in virtual worlds (Joint Information Systems Committee 2007).

Game-based learning implementations in MUVEs may provide the means to deliver guided and engaging teaching and learning experiences more suited to the ‘digital natives’ generation. It could be said that some MUVEs already provide ready-made games engines and some authors recognise Second Life® as a game-based application providing a space in which games can be created, allowing highly structured linear experiences as well as more open-ended ones. However, some do not classify it as a game, because of its lack of predefined goals (Livingstone 2007). MUVEs lack of effective built-in

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authoring tools which may guide educators and learning technologists in the design of effective gamebased learning implementations.

Designing game-based learning activities in MUVEs The Faculty of Medicine at Imperial College London has developed a Respiratory Ward in Second Life® with a series of virtual patients activities following a game-based learning model (Figure 3). The game-based learning activities aim to drive experiential, diagnostic and role-play learning activities within the 3-D world, aiming to support patients’ diagnoses, investigations and treatment. The Respiratory Ward was developed with five virtual patients covering (medical history, differential diagnosis, investigations, working diagnosis and management plan). Different narratives and modes of representation were developed within the areas described above (introductions, scaffolding information, diagnostic capabilities, assessment and triggers) (Toro-Troconis et al, 2008b).

Figure 3. Virtual Patient at the Respiratory Ward – Imperial College London region in Second Life® (http://slurl.com/secondlife/Imperial%20College%20London/150/86/27/).

The game-based learning process covers a wide range of activities and phases which should be followed in order to ensure a pedagogically sound game-based learning implementation. The following phases where followed for the design of game-based learning for virtual patients in Second Life®. It is worth highlighting these phases may apply to the development of game-based learning activities in any other MUVE and any other health or healthcare area.

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Concept Development Phase This phase started when the idea of game-based learning for virtual patients was conceived. The main learning outcomes of the activities were determined. The framework for evaluating games and simulation-based education developed by De Freitas and Martin (2006) were also adapted for this research (Toro-Troconis et al, 2008b).

Draft paper prototypes were created and a Concept Document was produced covering the following: • High Concept. This looks at what makes the game-based learning experience different from other similar activities.

• Player Motivation. This section identifies the key motivational factors across the target population.

• Game Play. This looks at what the learner will do while playing the game.

• Story. The story identifies the main events, characters and setting in which the learning experience takes place.

• Target Audience.

• Game Genre.

• Target Platform and hardware requirements.

• Competitive analysis.

• Game Goals.

Another document produced at this stage is referred as ‘Pitch Document’. The pitch document discussed the same topics highlighted in the Concept Document but in an abbreviated form. Learning technologists, instructional designers, educators and technical developers play a key role in formulating ideas and preparing concise and persuasive concept and pitch documents. The role of a game designer or learning technologist with a strong background in instructional design is crucial at this stage. They all have to work together to come out with a clear idea about: a) learning outcomes, b) learner characteristics, c) important contextual factors, and d) a desired instructional approach which will guide the nature of interactions to be designed to facilitate game-based learning (Hirumi and Stapleton, 2008).

The game should be identified within a specific instructional strategy or theory addressing the right instructional design model to be applied. For example, Case-Based Reasoning (Aamodt and Plaza, 1994), Learning by Doing (Schank, Berman & Macpherson, 1999) or Problem-Based Learning (Barrows, 1985). The selection and application of an instructional design principle will determine the nature of the learning environment guiding the sequencing of critical learning interactions and game activity which will influence the way learners achieve the game learning outcomes.

The instructional strategy selected for the design of game-based learning activities for the delivery of virtual patients was a constructivist approach. In this case the “story” presents the learners with a virtual patient scenario and the “game play” requires the learners to interact with different tools and dialogue messages to access content information and construct their own knowledge on how to work their way through the virtual patient cases.

Pre-Production Phase Once the game concept has been produced after completion of the concept design phase, the development team starts planning the pre-production phase. This phase aims to identify the following:

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• Story (nature of characters, activities and events the learners will interact with when playing the game-based learning activity).

• Game play (rules, tools and goals).

• User controls.

• User interface.

• Game levels.

• Media assets (audio, video, art design and technical issues).

• Production details.

During the pre-production phase for the Respiratory Ward the main activity of the virtual patient characters were identified as well as the levels of interaction within the environment. It was decided to keep the game-based learning experience to a single-player, although multiple players can communicate in a Problem-Based Learning approach when accessing the virtual patients. The rules were established and the virtual patient components implemented following the MedBiquitous Virtual Patients Model (http://groups.medbiq.org/medbiq/display/VPWG/MedBiquitous+Virtual+Patient+Architecture - also used in the above mentioned PIVOTE project) helped to establish the different rules, media assets and tools required at each stage (Toro-Troconis et al., 2008a).

Figure 4. Virtual patient user controls and interface.

User controls and interfaces were designed to accommodate to the Second Life® capabilities. The use of notecards and on-screen text messages were used as the main user communication interface (Figure

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4). The design of a Heads-up display (HUD) was originally planned to keep the learner informed of his/her performance. HUD elements indicate player/learner status showing which direction the player/learner is going or where the player/learner ranks in the game.

Production Phase The production phase began once the prototype was approved. The production phase was broken down into Alpha and Beta versions and the final “Gold” version was delivered once the Alpha and Beta versions were fully tested. Each section of the game-based learning activity was tested and any bugs were documented in a testing document. Production of the Beta version concentrates in fixing all the bugs and incorporating all the code, art work, audio, user-interface, navigation and media assets required. Once the game-based learning activity passed satisfactorily Beta testing, the final Gold version was delivered.

The HUD is a very good method for conveying information to the player/learner during the game.

However, it was decided not to design a HUD at this stage in order to keep the development simpler and more economical. This will be re-assessed for the next development phase.

Final notes The game-based learning design and development process described above shows the need of a large team and key team members to ensure an effective implementation of game-based learning activities. It is believed that the process of designing and authoring game-based learning activities not only in Second Life® but in any other MUVE may be made more accessible if design guidelines and built-in game authoring tools were available.

It is very unlikely e-learning teams in further and higher education institutions will have learning technologists with expertise in game design, which makes the process of designing game-based learning activities in MUVEs more challenging and expensive. Game designers may be brought into the team from external providers. However, this may increase development costs as well as making the development process longer until the game designers become acquainted with the culture of the educational institution and the learning outcomes of the game-based learning activity to be produced.

At the same time, the development of generic game authoring environments across MUVEs may lead into interoperable game-based learning activities, which means that one game-based learning activity authored in one MUVE, such as Second Life®, could be exported and re-used in another MUVE, such as Active Worlds. The IMSii Learning Design specification is worth looking at in this respect. The implementation of the IMS Learning design specification allows different game implementations authored in different game engines to be played in different IMS conformant game engines (Moreno-Ger et al., 2007).

A successful story not focused on game-based learning but in the educational context is the aforementioned Sloodle project, which aims to bring flexible support for teaching and learning to 3-D virtual worlds via integration with a VLEiii – specifically Second Life® and the open-source Moodle VLE (Livingstone et al., 2008).

The Implementation of game-based learning within MUVEs is potentially very interesting and very challenging for formal educational settings. The development of game-based learning guidelines and easy to use authoring environments may result in a greater proportion of game-based learning being developed and delivered via MUVEs, which are based on higher order principles of education and learning.

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Bibliography Aamodt, A. & Plaza, E. (1994) “Case-Based Reasoning: Foundational Issues, Methodological Variations and Systems Approaches. Artificial Intelligence Communications, 7(1), 39-59.

Barrows, H. S. (1985). How to Design a Problem-Based Curriculum for the Preclinical Years. New York: Springer Publishing Co. BECTA (2001).Computer Games in Education Project: Report. Retrieved February 14, 2009 from http://partners.becta.org.uk/index.php?section=rh&rid=13595 De Freitas, S. & Martin, O. (2006) “How can exploratory learning with games and simulations within the curriculum be most effectively evaluated?”, Computers and Education, Vol. 46, No. 3, pp 249–264.

Eduserv (2009). Snapshot of Virtual World use in UK Higher and Further Education: Report. Retrieved February 27, 2009 from http://virtualworldwatch.net/snapshots/virtual-world-use-in-hefe-jan-09/ Gee, J. P. (2003). What video games have to teach us about learning and literacy. New York: Palgrave/ St. Martin’s.

Hirumi, A. & Stapleton, C. (2008). Games: Purpose and Potential in Education. KY, USA: Springer Publishing Co. 127-162.

Joint Information Systems Committee. (2007). Game-based learning. E-learning innovation programme.

Briefing papers. Retrieved March 24, 2009 from http://www.jisc.ac.uk/publications/publications/pub_gamebasedlearningBP.aspx Kamel Boulos, M.N., Ramloll, R., Jones, R., Toth-Cohen, S. (2008). Web 3D for Public, Environmental and Occupational Health: Early Examples from Second Life®. International Journal of Environmental Research and Public Health, 5(4), 290-317; DOI: 10.3390/ijerph5040290 http://www.mdpi.com/1660-4601/5/4/290/pdf Kamel Boulos, M.N., Toth-Cohen, S. (2009). The University of Plymouth Sexual Health SIM experience in Second Life®: evaluation and reflections after one year. Health Information and Libraries Journal, 26(x), in press.

Livingstone, D. Kemp, J. Edgar, E. (2008) “From Multi-User Virtual environment to 3D Virtual Learning environment”, ALT-J, 16:3, 139 -150.

Livingstone, D. (2007) “Learning support in multi-user virtual environments”, In Proceedings of the European Conference on Game-Based Learning, University of Paisley, Scotland, 25–26 October.

Moreno-Ger, P., Burgos, D., Sierra, J.L. & Fernandez-Manjon, B. (2007) “A game-based adaptive unit of learning with IMS Learning Design <e-Adventure>” International Journal of Learning Technology, 3(3): 252-268 Ross, P.E. (2009). Cloud Computing’s Killer App: Gaming. IEEE Spectrum, 46(3), 12 (INT). Retrieved March 24, 2009 from http://www.spectrum.ieee.org/mar09/7892 Schank, R. C.,Berman, T. R., & Bransford, T. R., & Macpherson, K. A. (1999). Learning by doing. In C. M. Reigeluth (Ed). Instructional Design Theories and Models: A New Paradigm of Instructional Theory (pp. 161-179). Hillsdale, N. J.: Lawrence Erlbaum Associates.

Toro-Troconis, M., Mellström, U., Partridge, M. and Barrett, M. (2008a) "An architectural model for the design of game-based learning activities for virtual patients in Second Life®", In Proceedings of the European Conference on Game-Based Learning, The Universitat Oberta de Catalunya (UOC),

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Barcelona, 16–17 October. Retrieved February 27, 2009, from http://www.elearningimperial.com/SL/Barcelona_Toro_V06.pdf Toro-Troconis, M., Mellström, U., Partridge, M., Meeran, K. Barrett, M., Higham, J. (2008b) “Designing game-based learning activities for virtual patients in Second Life®”. Journal of Cyber Therapy and Rehabilitation, 1(3):225–238 . Retrieved February 27, 2009 from http://www.elearningimperial.com/SL/J-CyberTherapy-Rehab_Toro-Troconis_V04.pdf

i

NE: MMOX – concept related to Massive Multiplayer Online.

ii NE: IMS – Internet protocol Multimedia Subsystem. iii

NE: VLE – Virtual Learning Environment.

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

The Growth and Direction of Healthcare Support Groups in Virtual Worlds

By John Norris, Albany, Oregon

Abstract

What is the growth and direction of healthcare support groups grow in virtual worlds? Data was collected on over 300 groups from virtual worlds, including Second Life速, IMVU, There, and Kaneva. Similar categories of groups were found to be generally popular across worlds. The percentage of groups in categories of healthcare issues was also generally analogous between worlds. The long tail effect was shown- only a few groups had high populations. Group creation rate displayed generally similar growth between worlds. The worlds' demographics and features were suggested to account for differences. Limited data availability and vague definitions of groups and categories hampered analysis.

Keywords: Second Life;IMVU; There; Kaneva; Support Groups; Healthcare.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 4

The Growth and Direction of Healthcare Support Groups in Virtual Worlds

By John Norris, Albany, Oregon

This article reports a study that explored the growth and direction of healthcare support groups in virtual worlds. The article begins with a brief definition of healthcare support groups in virtual worlds, and then focuses on four virtual worlds: Linden Lab's Second Life®® (secondlife.com), IMVU (www.imvu.com), There (www.there.com), and Kaneva (www.kaneva.com). Each virtual world is discussed in terms of its general characteristics and themes, and analysis includes possible reasons for the direction of growth in each world's healthcare support groups.

A support group is "a group of people with common experiences and concerns who provide emotional and moral support for one another"(Merriam-Webster, 2009.) Note that this does not require that didactic or expository information will also be exchanged regarding their mutual concern. A simple chat type group may offer support. By healthcare it is meant, "the prevention and treatment of illness or injury, esp. on a comprehensive, ongoing basis"(Webster's, 2009 ). Note that this does not require a licensed professional. Non-professionals and peers may also provide healthcare. "Virtual worlds" may be defined as including three characteristics: (1) they are a common areas that people can network into and share; (2) they exist whether people are logged in or not; and (3) people are represented by avatars- allowing them to interact with the environment of the virtual world and each other (Koster, R. (2007.) Thus, a healthcare support group in a virtual world consists of a number of individuals that communicate healthrelated supportive messages using the various features of their networked, persistent space through the use of their avatars.

There are a wide variety of virtual worlds. For this study, worlds that are not new were selected, as they offer richer historical data. They are also oriented towards young and older adults that from this author’s perspective are more likely to discuss matters of healthcare (K Zero, 2009) Second Life® Background Second Life®, by Linden Lab, began in June of 2003. Its theme is "a world of exploration, socializing, creativity, self-expression, and fun unlike any other"(Your Second Life®, 2009). Second Life® includes free membership.

Those who use the adult Second Life® grid need to be 18 years and older. As of the 4th quarter of 2008, there were 15 million users of second life (K Zero Universe, 2009.) The largest group of users are from the U.S. but amount to just 39% of the total. The average age of users is around 40 and almost 60% of the users are male ("Second Life® Virtual World Expands", 2008.

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Method of Data Collection The study looked only at those groups in Linden Lab's Second Life速 adult grid. To identify healthcare support groups in Second Life速, its in-world search feature was used. A list of possible groups was obtained from the website SLHealthy and these words were used to perform a search. An additional search with the keyword "support" was performed via Linden Lab's Second Life速 inworld seach feature, using the "groups" tab. A total of 152 groups were identified. Data was collected about them from their inworld group information search page.

However, when doing the "support" search, Second Life速 did not allow the viewing of more than 100 pages of results. Of the approximately 2000 returned items from that keyword search, only the first 1000 were viewable. Because the healthcare support groups accounted for 15% of the first 1000 groups, if there are more results, the number of unaccounted for support groups may be significant. The 152 groups that were identified may not be a complete list.

The 152 groups were organized into categories of healthcare issues based on the taxonomy of the American Self-Help Group Clearinghouse.(E White, Madara 2002). This enabled a broad overview of trends within worlds as well as a more general cross comparison between worlds.

Results and Discussions Total Membership The groups collected had a total of about 10,000 members. However, since each avatar can join up to 25 groups and a person can have multiple avatars it is difficult to identify how many individuals may be participating.

Membership per Group The following graph shows the group membership of all 152 groups. Only some of the group names are shown.

Group Members

Second Life Group Membership 1000 800 600 400 200 0 Asperger Support for Healing

SL Foundation for Diabetic Children All About Cancer Friends of Lois W Cancer Support Netw ork Obsessive Ambulatory Disorder

Groups

Of the 152 groups only 25 of them have one hundred members or more, and there are over 50 groups with less than a dozen members. Chris Anderson dubbed this the "long tail effect" (Anderson, 2004) because the Internet allows people to publish things cheaply. Thus

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niches that only appeal to a few people and would never be able to make it in old, expensive media, flourish on-line.

For a healthcare support group, this is a boon, in that it allows those with rare diseases to interact with each other. However, in a larger sense, it also allows people with unique approaches to their issues to interact with each other. Thus, there are 19 groups concerning cancer and 17 groups for autism/spectrum disorder. This suggests that people are making or finding groups that they feel comfortable in.

Groups with the most membership: It is instructive to look at the top five groups with the most members. I will include a brief description for some: (1) Support for Healing 899 members (Mental health and other issues) (2) Transgender Resource Center 845 members (Gender identity issues.)

(3) Positive Mental Health 763 members (4) Wheelies 565 members. (Disabilities themed nightclub.)

(5) Depression Support Group 427 members issues.

Other groups with significant memberships include: (6) Dream Travelers 258 members (Stroke and Autismt Spectrum Disorder issues.).

(7) Breast Cancer Awareness 224 members (8) SL's Cancer Survivors 210 members.

(9) Autistic Liberation Front 207 members.

(10) SL Deaf Underground 162 members.

(11) Aspies for Freedom 147 members (Aspergers Syndrome).

(12) Asperger Awareness 131 members.

Categories of Groups: All 152 groups were placed into healthcare issue categories and their percentages of the whole noted.

Abuse: > 1% Addictions 5% Bereavement 4% Disabilities 20% Family 0 Health 49% Mental Health 15% Miscellaneous 5% The "Health" category includes almost half the groups, but this is not too surprising given how general of a category it is. Not only does the Health category have many of the groups, it also includes many groups that are concerned with a particular issue or diagnosis. The issues 6

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 7

with the most groups are Cancer (19 groups), Autism/Spectrum Disorder (17 groups), Addiction and â&#x20AC;&#x153;Mobilityâ&#x20AC;? (7 groups each), HIV (6 groups), and Bereavement (5 groups). This shows diversity around at least these issues. It may show that individuals are involved with groups that resonate within their unique selves.

Membership in Group Categories Membership in each category of group as a percentage of total membership, shows a different breakdown: Abuse: > 1% Addictions 2% Bereavement 1% Disabilities 25% Family 0 Health 40% Mental Health 32% Miscellaneous 2% While Bereavement counted for 4% or the groups, it only has 1% of the total members.

Perhaps this shows that such an issue brings out more varieties of approaches. Mental Health counted for 15% of the groups but 31% of the total members. This would seem to indicate the opposite of Bereavement. Perhaps when dealing with the subject of mental health more people feel comfortable in fewer groups, and so unique approaches are not brought out. However, the group with the most members, Support for Healing, has several sub-groups within it, that use different approaches, but whose membership is counted in total. Further, some Mental Health groups may need a critical mass in order to be available at all hours to help respond to their member's immediate needs.

IMVU Background IMVU began in 2004 ("About," IMVU). Its theme is an Instant Messaging Service (Terdiman, 2004) with a heavy graphical user interface. It is a 2.5d type space which is room based; one does not really walk around much. Indeed, the focus on developing IMVU has been on avatars and not on land (Caoili, 2008). It includes free membership. IMVU also offers an online web based forum along with its in-world offering.

Those who use IMVU need to be at least 13 years or older. They had 22 million users as of the end of 2008. Forty percent of their users are from the US. The 'core' users are 18 to 24 years old ("Frequently Asked Questions," IMVU).

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Method of Data Collection In IMVU groups are listed in categories. Data was collected on November 23rd and 24th from the “Real Life/Health” list of groups from IMVU.com. Of the 331 groups IMVU listed in that Health subcategory, the study identifies 142 as being about healthcare. Some of the group’s details suggested that at one time, in-world payment was given to people if they started a group.

This would skew some of the data.

The study found a large number of seemingly simple ‘chat’ type groups within this health category. Many had no firm theme and only a modest amount of members. It is difficult to be sure what sort of health issues these should be understood to be dealing with. The study identifies that for 142 health groups, 13 (or roughly 10%) are chat groups. The study places them into categories, including Miscellaneous.

Results and Discussions Total Membership For all health groups identified, including those that seemed to be simple chat groups, there are 3270 members. Because 'chat' type groups account for over 1000 members, these groups were included in the analysis. Because individuals can be members of multiple groups and have more than one avatar, it is difficult to know how many people are actually involved.

Membership per Group The following graph shows the membership level of all 142 groups. Some of the group names are shown.

IMVU

Group Members

700 600 500 400 300 200 100 0

breast cancer research Psychology Clinic Life on the BorderLine Reality Life Suicide, Depression, and Relationships Bipolar Support Group Crohn's Disease Docs Free Counseling Support Group

Groups

The graph displays the long tail effect. Of the 142 groups only 5 had over 100 members.

86 groups had 10 members or less.

Groups with the most membership Here are the top 10 groups with the most membership. Brief details for some are included.

8

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 9

(1) Suicide, Depression, and Relationships 639 Members (2) <Be Yourself!> 254 Members (An example of a simple chat group. A place to talk about general issues, or just chat.)

(3) Suicide Awareness 217 Members (4) Fibromyalgia 152 Members (5) Soul ~ Heart ~ Mind ~ Body & Holistic Health 111 Members ("Ancient" ways towards wellness.)

(6) Tickle me Pink 91 Members (Cancer issues) (7) Pregnant Teens 83 members.

(8) Straight Edge 83 members (Part chat, part healthy lifestyle.)

(9) Mental Health Survivors 76 members.

(10) *Helping and Sharing Medical Advises 74 Members.

One group, the Suicide, Depression, and Relationships group, has far more members than the next. While it is categorized as a Mental Health group, the inclusion of relationships may allow them to pull people interested in the more general type chat groups. General type chat groups are quite popular in IMVU. Several of those general chat groups are in the top 10 groups.

Types of Groups Abuse 2% Addiction 3% Bereavement 0 Disability 11% Family < 1% Health 31% Mental Health 19% Miscellaneous 37% General chat groups were place in Miscellaneous and that category accounts for most of the groups.

Members in Group Types Abuse 3% Addiction 1% Bereavement 0 Disability 5% Family 3% Health 24% Mental Health 38% Miscellaneous 27% However, the mental health type groups have more members. This is mainly due to one group - Suicide, Depression, and Relationships - being included in Mental Health and perhaps giving a false impression.

9

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 10

While groups concerned with disability account for 11% of all groups, their memberships are only 5%. This would mean that unlike other group types, Disabilities has many more groups with fewer members. Perhaps for IMVU, the unique nature of individual disabilities make for a wider variety of groups.

Group Growth IMVU group information includes their beginning date. This makes it possible to graph the growth of the number of groups in each type over time. Note this graph only shows groups created in each category not weather the groups are still active.

IMVU 60

Number of Groups

50 Abuse Addiction

40

Bereav ement Disability Family

30

Health Mental Health Miscellaneous

20

10

0 04/28/07

08/06/07

11/14/07

02/22/08

06/01/08

09/09/08

12/18/08

Creation Date

The graph shows the rapid increase in most group categories in late 2007. After a month or so, there was a lessening of most category growth rates. Perhaps this rapid increase was from the pent up demand prior to the ability to create groups,. The quick accumulation of groups may have also been due people caught up in the general excitement of group creation. Perhaps some people were inspired to create groups whom normally would not, or others created more than one.

For the categories Miscellaneous and Mental Health there is a bit of a secondary increase in early to mid-2008. This may be due to policy changes at IMVU that rewarded people who created groups. From the data collected it was not clear precisely when that might have occurred, but by late 2008 it was no longer IMVU policy. This secondary increase may also have occurred during a rapid influx into IMVU in general; however, that data was not collected.

To a lesser extent the Health category also experienced a secondary increase, but at an earlier time. Perhaps there are other factors also at work. Perhaps these are people who had joined a group, but then decided later to create their own.

10

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 11

The Disability category saw a similar quick rise, but then almost nothing after that.

Disability had a lot of groups, but with fewer members. Perhaps there were not enough members to sustain such groups.

THERE Background The virtual world There went off beta in 2003. Its theme is more of " a ‘hang-out’ social destination than a creative platform, although content creation and in-world currency (therebucks) are both available (Mitham, 2007). It includes free membership. The world of There also offers an online web-based forum along with its inworld offering.

Those who use There need to be over 13 years of age (Mitham, 2007). They have 2 million registered accounts as of the 4th quarter 2008(K Zero Universe, 2009). The average age tends towards the early 20's (K Zero Universe, 2009), but 32% are between 13 and 17 (Mitham, 2007). Finally, 46% of the members are female.(Mitham, 2007) Method of Data Collection In the world of There they also list their groups in sections. On Janurary 10, 2009 the There Forum’s Health and Wellness section lists 235 groups. Despite being within the category, many groups did not describe themselves as being about healthcare. For example, there is a group called "People who like cake", and another called "People who can't stop singing the "NumaNuma" song". The study identified 48 groups that seemed to be about healthcare including some simpler chat type groups. The more general chat groups were included in Miscellaneous.

Results and Discussions Total Membership The 48 groups had a total of 443 members. Note that individuals can join multiple groups and can have more than one avatar, making it difficult to discern how many people are involved.

Membership per Group The following graph shows the membership level of all 48 groups. Some of the group names are shown.

11

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 12

Group Members

There Group Membership 80 60 40 20 0 MDTA Group

Dieters_Ring Gastric_Bypass

AA_Club

professional_friend Wounded_Healers_Support_Group

Groups

The first 3 groups each have over 50 members. The last 28 groups have less than 5. This graph shows the long tail is also in effect in the world of There.

Groups with the most membership What follows is the top ten groups in There. Shown are the membership totals, plus a few details to help understand the nature of some groups.

(1) Disability_in_There 70 members (2) Deaf_People_R_Not_Ignorant 54 members (3) Find_a_Cure 51 members (Cancer issues) (4) Anxious Avatar 38 members (Panic, Anxiety, and other disorders.)

(5) Occas_Gym 22 members (Weight loss and muscle gain.)

(6) Seizure_Disorder_Support_Group 22 members (7) Chronic_Pain_FMS_CFS_etc_Support 15 members (8) MDTA 11 members (Muscular Dystrophy Association) (9) Victims_of_Stalkers 11 members (10) Ask Mily..... 10 members (Advice) As shown above, the top ten groups in There, for the most part, address a variety of fairly specific issues. No one issue seems to dominate this world.

Types of Groups Abuse 2% Addiction 2% Bereavement 0 Disability 19% Family 2% Health 49% Mental Health 13% Miscellaneous 17% The general Health category identifies almost one-half of the groups, with the rest below 20%. This is similar to the top ten groups list above.

12

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 13

Members in Group Types Abuse <1% Addiction 2% Bereavement 0 Disability 29% Family 0 Health 42% Mental Health 15% Miscellaneous 8% We see in There that the Disability category has numerous groups but significantly fewer membership share. The Miscellaneous category also has fewer members. The reasons may be similar to the ones discussed for IMVU. Group Growth The world of There has information about each group's their beginning date. The following graph shows the growth of the number of groups in each category over time.

There 30

Number of Groups

25 Abuse Addiction

20

Bereav ement Disability Family

15

Health Mental Health Miscellaneous

10

5

0 09/01/02

01/14/04

05/28/05

10/10/06

02/22/08

07/06/09

Creation Date

In the There world, the Health category rather quickly outpaces the other areas. This shows that this world has, from its inception, favored these types of issues. Further, as Health becomes more popular, it comes to the attention of more people, who then may start their own groups. This may be why we see secondary and tertiary increases around 2007 and later 2008.

Mental Health and Miscellaneous also have a secondary increase around 2007, so there may be other factors in play (or simply not enough data to warrant analysis). Another possibility is that there was an over-all increase in the population of There. However, this may have not been the case because Disability and Addiction did not also increase at the same time.

13

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 14

Except for those groups in the Health category, few other groups were created after 2007.

The world of There may be suitable for those in the Health category, but perhaps not for others.

It is also possible that the other categories have enough groups to address the needs of new individuals. However, the Miscellaneous, Mental Health, and Addiction groups did not have many new members in late 2008 and early 2009. Perhaps people who would normally join such groups are going elsewhere.

KANEVA Background Kaneva began in 2007 ("Kaneva Virtual Entertainment",Kaneva). It provides "flexibility to easily move back and forth from the 2D web to the 3D Virtual World of Kaneva” ("Kaneva Virtual Entertainment",Kaneva). It is "built for the masses"("Kaneva Virtual Entertainment", Kaneva) and is meant to be easier to use than Second Life® (Hopkins, 2007).

Kaneva's membership in 2007 was 800,000 (Schifrin, 2007). I was not able to find more current data. This is a year earlier than the other world's memberships the study cites. Their average age of members is in the early 20's (K Zero Universe, 2009). Members need to be 14 years or older (“Kaneva Privacy Policy”, Kaneva).

Method of Data Collection Kaneva has an in-world search feature that was used to look for healthcare support groups. Keywords were based on those used in the data collection for Second Life®. Using this method, very few groups were found. Further groups were identified using the keywords from the index of the book "The Self-Help Group Sourcebook"(White B. J., Madara E., 2002). There were some chat-type groups that included in Miscellaneous. A total of 27 healthcare support groups were identified on Janurary 10, 2009.

Results and Discussions Total Membership The 27 groups had a total of 313 members. That is with the understanding that people can join multiple groups and have more than one avatar.

Membership per Group The following graph shows the membership level of all 25 groups. Some of the group names are shown.

14

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 15

Group Population

Kaneva Group Membership

100 80 60 40 20 0 Diabetes Group

Missing Pieces Alternatively You Dissociation Total LGBT United Live With It Eating Disordered Inc Gay Youth Project

Groups

The top 2 groups each had over 40 members. The remaining groups had 21 or less members, with more than half of the 25 total groups having less than 5 members. This reflects the long tail effect.

Groups with the most membership Find below the top ten groups with the most membership, including the total number of members, and a brief explanation for some.

(1) GBLT- Social and Support Center for Adults 89 members (2) Kaneva Mafia Cancer 70 members (3) Diabetes 21 members (4) Autism Awareness Open Community 20 members (5) I am Not OK 19 members (FMS (Fibromyalgia), CFSID (Chronic Fatigue and Immune Dysfunction Syndrome ) and similar diseases.)

(6) LGBT United 18 members (7) Starryangelmom Autism Awareness Chatroom 16 members (8) Deaf Peace 7 members (9) Missing Pieces 6 members (Autism) (10) Being a Teen 5 members In the world of Kaneva, the top groups predominantly deal with GBLT or autism issues.

The study is cautious to draw any firm analysis because of the small data set, but there is something in the Kaneva community that has allowed these issues to come to the fore. It may be the personality of a few major players, more than the features of the world itself.

Types of Groups Abuse 0% Addiction 0% Bereavement 7% Disability 26% Family 4% Health 22% Mental Health 7% Miscellaneous 33% 15

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 16

Members in Group Types Abuse 0% Addiction 0% Bereavement 1% Disability 19% Family <1% Health 39% Mental Health 1% Miscellaneous 41% The amount of members in each group's type is similar to the quantity of groups for that type. Thus, the more popular category of group has more members. One category of group does not seem to be more diverse than another.

Group Growth Kaneva's group information includes their beginning date. The graph shows the growth of the number of groups in each type over time.

Kaneva 10 9

Number of Groups

8 Abuse

7

Addiction Bereav ement

6

Disability

5

Family Health

4

Mental Health Miscellaneous

3 2 1 0 03/24/06

10/10/06

04/28/07

11/14/07

06/01/08

12/18/08

07/06/09

Creation Date

There is an immediate rise in the general Health category, but it is later overtaken by both Mental Health and Disability. Perhaps the early adopters were less oriented towards specific issues, reflecting a general population. However, once Kaneva became better known, those with specific issues decided to call it their home. However, later in time many of the group categories did not have new groups. Only the Miscellaneous groups continued adding groups. Upon checking the Disability and Health groups there seemed to be only a modest amount of new members in 2008. The graph also shows secondary increases in growth rates similar to the other worlds.

16

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 17

Discussion Prior to a more general discussion, the following is a simple representation of some of the studies findings:

There are many people involved in healthcare support groups in each of the virtual worlds studied. This, in itself, does not speak to the efficacy of such groups. While it is beyond the scope of this paper to make any determination as to the benefit members may derive from the group, a brief look at some studies in this area is helpful.

Past research had lead to the conclusion that the efficacy of online support groups and communities had not been established. Although anecdotal evidence seemed to show that online support groups were helpful, their value was unclear (Eysenbach 2003).

More recent studies show that online healthcare support groups may be effective. One study involving an online cancer support group found that depression, growth, and psychological well being improved over a six month period (Lieberman 2005). A professionally managed online support group concerning diabetes found 74% of the respondents reported that their ability to cope was helped (Zrebiec 2005). Preliminary data suggest that an online support group for women in rural locations with chronic illness helps these women adapt to their condition(s) (Weinert 2005). Sixty percent of the participants in an online dentistry anxiety support group felt their anxiety was lessened (Coulson 2007). Further studies, especially those for groups taking place in virtual worlds are necessary to properly address the efficacy question.

Some work has been done on the specific characteristics of a group that allow an individual to benefit from a group, which helps explain several aspects of what is seen in virtual 17

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 18

worlds. One of the traits identified in real life groups was that members who shared similar norms as their leaders benefited from the group (Lieberman 2004). Another observation from real life support groups is that the norms of the group need to be different from those of the larger society in order to effect change on their members (Lieberman 2004). Further, approaches for some members may not be appropriate for others. One example is a bereavement support that is age and gender specific (Gary 2000). Since the content of real life and online support groups are very similar (Golant 2006), we should not be surprised to see differentiation of groups in virtual worlds.

This helps explain the long tail effect, as people find the groups that best fit them, whose group/leader norms are compatible with their own, and which offer the boundaries from society that help them change. Online support groups allow one to search through or lurk to find the one that best fits with them and matches their needs (Golant 2006). One can more easily find the group that suits them and not join ones that are â&#x20AC;&#x153;good enoughâ&#x20AC;?. This point also addresses how different virtual worlds - with their own norms inherent in the platform - can be a positive force for further group differentiation.

Just what those norms are and how they contribute to what type of groups are created needs to be further explored. If more virtual worlds become popular and are populated with healthcare support groups, it may be possible to more formally identify what features encourage or prevent certain types of groups from forming.

A study such as this, identifying specific features across a wide range of virtual worlds, and their corresponding healthcare support groups, may allow one to tailor virtual worlds to successfully address particular healthcare issues. With a better understanding one would also be able to include in-world help for those types of healthcare support groups that one would be expected to be popular.

A subject that was not addressed in this study, but would be an important extension, is the levels of activity for the groups. How often do members meet? How much is information exchanged in a given time period? Which groups no longer function, but are merely listed inworld? Another component to this is how people are distributed across groups. Are there only a few people in many groups or are the groups populated with a variety of individuals?

The present study was hampered to a degree by lack of access to data. Some group data is simply not available without special access. However, using available access, the study provides a preliminary look at a fascinating and important area of virtual worlds.

In each of the worlds studied, people created areas to discuss health. It seems that when communication is available, healthcare is a topic that quickly emerges. The growth charts demonstrate how such groups spring up almost immediately. Even Google's ill-fated Lively had 19 healthcare areas in November 20, 2008, 4 months after it opened and 2 months before it was scheduled to close.

Thus, it is hoped that the present study will provide an introduction toward better understanding healthcare support groups in virtual worlds, in order to create better worlds, support, and tools required for this obvious need.

18

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 19

Bibliography IMVU. About IMVU. (n.d.) Retrieved December 2, 2008 from http://www.imvu.com/about/index.php Anderson, C. (2004). The long tail. Wired, 2, 10. Retrieved February 20, 2009 from http://www.wired.com/wired/archive/12.10/tail.html Boyd, D. M. (2008) Taken out of context: American teen sociality in networked publics.

University of California at Berkeley. Retrieved February 25, 2009 from http://www.zephoria.org/thoughts/archives/2009/01/18/taken_out_of_co.html Caoili, E. (2008, June 26). Q&A: IMVU’s Cary Rosenzweig on “building from the avatar up”.

Worlds in Motion. Retrieved December 2, 2008 from http://www.worldsinmotion.biz/2008/06/qa_imvus_cary_rosenzweig_on_bu.php Coulson, N. (2007). Self-reported efficacy of an online dental anxiety support group: a pilot study. Community Dentistry and Oral Epidemiology. Abstract only. Retrieved May 2, 2009 from http://www3.interscience.wiley.com/journal/119402067/abstract Eysenbach, G. (2003). The impact of the internet on cancer outcomes. A Cancer Journal for Clinicians. Retrieved May 2, 2009 from http://caonline.amcancersoc.org/cgi/content/full/53/6/356 IMVU. Frequently Asked Questions. (n.d.). IMVU. Retrieved December 2, 2008 from http://www.imvu.com/about/faq.php Gary, J. & Remolino, L. (2000). Coping with loss and grief through on-line support groups.

ERIC Clearinghouse on Counseling and Student Services. Retrieved April 2, 2009 from http://www.mental-health-matters.com/index.php?view=article&catid=175%3Agrief-andloss&id=932%3Acoping-with-loss-and-grief-through-online-supportgroups&format=pdf&option=com_content&Itemid=1906 Golant, M. (2006). Effectiveness of internet vs. face to face support groups. The Wellness Community-National. Retrieved April 2, 2009 from http://www.cbcrp.org/research/PageGrant.asp?grant_id=2110 healthcare. (2009). In Webster's New World College Dictionary Retrieved February 18th, 2009, from www.yourdictionary.com/healthcare Hopkins, R. H. (2007). Disrupt-o-meter Second Life® vs. Kaneva. Strategy & Innovation.

Retrieved from Kaneva January 19, 2008 from http://streaming.kaneva.com/media/news/SI_Sept-Oct_2007.pdf K Zero Universe chart. (Q1 2009) KZERO Retrieved Jan 19, 2009 from http://www.kzero.co.uk/blog/?page_id=2537 Kaneva Privacy Policy. (2008). Kaneva. Retrieved May 2, 2009 from http://www.kaneva.com/overview/privacy.aspx Kaneva Virtual Entertainment World Enters Into Open Beta Press Release. (2007, March 21).

Kaneva. Retrieved Janurary 19, 2009 from http://www.kaneva.com/channel/channelPage.aspx?communityId=551591&pageId=884841 19

Journal of Virtual Worlds Research- The Growth and Direction of Healthcare Support Groups in V Ws 20

Kizelshteyn, M. (2008, December 2). Statistics for Second Life® support groups. Message posted to http://john-norris.net/2008/10/19/statistics-for-second-life-support-groups/ Koster, R. (2007). What is a virtual world? Retrieved September 8, 2007, from http://www.raphkoster.com/2007/06/15/whatis-a- virtual-world/ Lieberman, M. (2004). Therapeutic norms and patient benefit: Cancer patients in professionally directed support groups. Group dynamics: theory, research, and practice. Retrieved May 2, 2009, from http://www.thewellnesscommunity.org/pdfs/grpdynamicsnorms.pdf Madara, E. (2008, December 14). Statistics for Second Life® support groups. Message posted to http://john-norris.net/2008/10/19/statistics-for-second-life-supportgroups

Mitham, N.(2007, July 23). There.com vs Second Life®: demographics. KZERO. Retrieved January 19, 2009 from http://www.kzero.co.uk/blog/?p=961 Otaared, V. (2008, October 20). Statistics for Second Life® support groups. Message posted to http://john-norris.net/2008/10/19/statistics-for-second-life-support-groups/ Schifrin M. (2007, December 24). Rocking the virtual world. Forbes.com. Retrievd Januray 19, 2009 from http://www.forbes.com/leadership/forbes/2007/1224/103.html Second Life® Blog. (2008). Second Life® virtual world expands 44% in Q2. Retrieved September 9, 2008 from https://blogs.secondlife.com/community/features/blog/2008/07/08/ SL Healthy File Cabinet.(n.d.) SLHealthy. Retrieved September 2008 from http://slhealthy.wetpaint.com/page/SL+Healthy+File+Cabinet support group. (2009). In Merriam-Webster Online Dictionary. Retrieved February 18, 2009, from http://www.merriam-webster.com/dictionary/support group Terdiman, D. (2004, September 16). Instant messaging goes graphical. Wired. Retrieved December 2, 2008, from http://www.wired.com/science/discoveries/news/2004/09/64969 Weinert, C. (2005). Social support in cyberspace: The next generation. Computers, Informatics, Nursing. Retrieved May 2, 2009 from http://www.cinjournal.com/pt/re/cin/abstract.00024665-20050100000004.htm;jsessionid=Jc2F9tdpBd2rNT1X2JQWwjCm94hJQ3G82chMkq04h6KP0bdyNK ch!-1429555639!181195629!8091!-1# White B. J., Madara E. (2002). The self-help group sourcebook (7th ed). Denville, NJ: Saint Clares Health Services.

Linden Lab. (n.d.). Your Second Life® begins today. Retrieved January 16, 2009 from http://lindenlab.com/pressroom/releases/03_06_23 Zrebiec J.F. (2005). Internet communities: do they improve coping with diabetes? Diabetes Education. Retrieved May 2, 2009 from http://tde.sagepub.com/cgi/content/abstract/31/6/825

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Towards a Virtual Doctor-Patient Relationship: Understanding virtual patients

By Vanessa G. Gonzรกlez, Macquarie University, Australia

Abstract The use of online virtual communities to deliver health information has grown with the creation of 3D online virtual worlds such as Second Life. The existence of virtual spaces offers the opportunity to use new media and spaces of social interaction, participation and collaboration to deliver realistic and vivid health experiences. While the potential seems great, in practice, there are significant limitations in using virtual online communities to deliver health information. First, for many residents, these virtual worlds are fantasy spaces where they can escape the limitations of their bodies to engage in social interactions. Second, virtual worlds lack the cues that usually signal medical authority, making virtual residents skeptical about health information and advice obtained in Second Life. This article explores key issues surrounding the health practitioner-patient relationship in virtual worlds.

Keywords: Virtual worlds; health; doctor-patient relationship.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- Towards a Virtual Doctor-Patient Relationship 4

Towards a Virtual Doctor-Patient Relationship: Understanding virtual patients

By Vanessa G. González, Macquarie University, Australia

“I suppose health education could work but not sure how else SL [Second Life] could have health benefits. Once you have a diagnosis there is a fabulous medium on the Internet and resources in the surgery/hospital. I wouldn’t feel the need to go on SL for that if I had a serious diagnosis I may use SL as my escapism. SL isn’t good for your RL [Real Life] health.”

SL Resident, [November, 2008] According to Bar-Lev (2008, p.519), individuals competently manipulate new technologies as they negotiate, redefine, and reinvent existing cultural codes to make sense of their illness experience. Technologies like virtual worlds offer newer possibilities for people and health practitioners to renegotiate relationships around health issues (Huang, Boulos & Dellavalle, 2008): “I believe that the explosive trend [toward increased use of the Internet for answering health questions] shown by Pew reflects individuals' distrust and lack of information - so that they search for information as self-defence, and as a way to exert some control over relationships where the power imbalance has always been enormous. Hundreds and thousands of 'us' showing up at the doctor's offices with our printouts is like a decentralized army - demanding that the interactions be two way dialogs. At Second Life, they can be. I feel like we're building the future.”

Health Practitioner (quoted in Bell, 2008, pp.11-12) The use of new technologies for health purposes is founded upon positivist attitudes about science (Sinha, 2000). Newer technology is inherently better than old, according to this paradigm, and the potential for market expansion is unlimited (Sinha, 2000, p.297). Yet, despite many predictions that virtual worlds would become a new frontier in health information and delivery, this expectation has not been realized. As Lori Bell found in her study of a Second Life (SL) project called “Health Info Island,” “targeted [health] marketing to the general population in this virtual environment continues to be an ongoing challenge” (2008, p.41). What are the constraints on using virtual worlds to deliver health information?

In this brief think-piece, I will explore issues in the patient-doctor relationship using preliminary findings from my ethnographic research on the social aspects of health in virtual environments as a springboard for discussion. The participant observation conducted in this research suggests that two primary concerns shape patients’ views about the use of virtual worlds for real life health purposes.

The first concerns patients’ reluctance to cross borders between their real and virtual lives. For some of its inhabitants, SL is about play, fun, and escapism from real life, as the following quote from a SL resident shows:

4

Journal of Virtual Worlds Research- Towards a Virtual Doctor-Patient Relationship 5

“Here you are Superman, you can fly! A paraplegic can walk here! This is a good refuge to escape from RL. If you’re not going well in your RL, in SL you get disconnected from it. People lose their sense of danger here and abandon themselves more. SL might be functional in cases of depression. But I personally see SL as a place to enjoy. ” SL resident, [October, 2008] A second concern surrounds the authenticity and reliability of the people who deliver health care and information. As the passage below illustrates, residents find it difficult to trust other people in SL:

“Even if I knew the doctor in SL personally, I wouldn’t trust them to be able to diagnose through SL so trust is in two parts: 1/ trust in who they are/how qualified they are 2/ trust in their ability to remotely diagnose via SL. I would prefer a top level domain be set up for medical websites. Sorry never going to happen for me.”

SL resident, [November, 2008]

Using a virtual environment for real life health purposes necessarily entails a deconstruction of body boundaries (Sharp, 2000). Body boundaries are transgressed when medical professionals attempt to use virtual environments to reach real people. This deconstruction of boundaries that operates in virtual environments obliges us to look at different ways of engaging with people and how their uses of these technologies can help us to achieve a real connection between professionals and patients. In these scenarios the traditional doctorpatient roles have the potential to operate in a different way. However, the ways in which these relationships could be renegotiated still remain unclear.

A substantial body of literature has documented the extent to which people are using the Internet to enquire about their real life health (Madden & Fox, 2006), and so I expected to see a similar interest in personal health in Second Life when I first started my research there in September 2008. Yet while I visited numerous medical sites and clinics in SL, I found them all empty. Universities, clinics and other health organizations had gone to considerable effort to set up elaborate architectural structures with placards and displays of health information, but not a single avatar was in sight. I wandered these empty structures, looking for health-seeking behavior in SL, but in vain. The only clinic where I found avatars was a setting for sexual role play in which people enacted sexual fantasies between doctors and patients.

5

Journal of Virtual Worlds Research- Towards a Virtual Doctor-Patient Relationship 6

Figure 1 The author touring health spaces in SL: Health Info Island.

Figure 2 The author touring health spaces in SL: Hottie Hospital.

Ambiguous uses of the same technology, with people crossing the borders of the Internet to improve their understanding about their bodily health issues and at the same time using it as an alternative to play and escape from the limitations of their real body, highlights an important obstacle for the usefulness of SL as a place to make sense about our health.

6

Journal of Virtual Worlds Research- Towards a Virtual Doctor-Patient Relationship 7

Sexuality is a clear example of the ambiguous uses of this technology. SL is a highly sexualized place. One can buy genitals and programs that enable virtual sex. Indeed, businesses related to sexuality are very prominent in SL (Hemp, 2006). In addition, sex is a core concern in health-related Internet searches, especially among young people (Kanuga & Rosenfeld, 2004, Wynn, Foster & Trusell, 2009), who value the anonymity afforded by the Internet when seeking information about sexual and reproductive health.

“Hmm, a little strange perhaps, going to a doctor in SL seems a little weird. It would be like: hi doctor, I'm not really a cat in real life… and I have sex problems, it would be too comical. But then you pointed out that people like the anonymity and sure for people who can't cope with that... but then I think an anonymous phone call would be better.”

SL Resident [October, 2008] The quote above clearly points to these fuzzy boundaries. Why do some people in SL think it is “weird” to express their real sexual problems in SL and decline talking about these real-life concerns with others? Perhaps replication of real life cultural patterns in virtual environments (Boellstorff, 2008) is an answer to that question. Perhaps the same cultural codes that make it difficult to talk about sexual problems with others in real life is mirrored in SL. Alternately, some persons may find that the anonymity of virtual worlds may actually enable them to share more about themselves than are accustomed to doing not in real life (Stein, 2007).

People’s values about which uses of technology are good or not good for their health are at stake here, and diverse cultural codes and values are operating in debates over whether SL can serve as a medium for transmitting health information. Health professionals and clinicians should be careful about assuming that avatars share their positivist enthusiasm for advancing and building the future of our science through a medium that for many, fundamentally symbolises escape from a mundane, physical reality. To create a real “virtual” connection with patients in SL, health professionals must be creative and self critical about our practices and be cautious to not replicate the same discourses that generate power imbalances between practitioners and patients, as we run the risk of being ignored.

Further research enquiry towards building virtual doctor-patient relationships could examine what cues might signal medical authority in virtual online scenarios to improve trust between doctors and patients, or how to effectively take advantage of the highly sexualised context of SL in order to provide effective sexual health advice. In order to succeed with further inquiries we also need to step out of our scientific discourse and further explore the values, attitudes, behaviours and cultural patterns that play a major role in health related activities in virtual worlds.

Acknowledgements I wish to thank Dr. L.L. Wynn for her guidance, support and encouragement on this work. Also thanks to Samina and Stephanie for their editing.

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Bibliography

Bar-Lev ,S. (2008). We Are Here to Give You Emotional Support: Performing Emotions in an Online HIV/AIDS Support Group. Qual. Health Res.18(4), p. 509-521.

Bell, L. (2008). HealthInfo Island Final Report. Alliance Library System. East Peoria Illinois.

Boellstorff, T. (2008). Coming of Age in Second Life: An anthropologist explores the virtually human. Princeton University Press.

Hemp, P. (2006). Avatar-Based Marketing. Harvard Business Review. p. 48-57.

Huang, S., Kamel, B.M.N. & Dellavalle, R. (2008). Scientific Discourse 2.0 Will your next poster will be in Second Life. EMBO reports 9(6), p.496-499.

Kanuga, M. & Rosenfeld, W. (2004). Adolescent Sexuality and the Internet: The Good, the Bad, and the URL. J Pediatr Adolesc Gynecol 17, p. 117-124.

Madden, M. & Fox, S. (2006). Finding Answers Online in Sickness and in Health. Pew Internet & American Life Project Report. Retrieved 25 November, 2008, http://www.pewinternet.org/PPF/r/183/report_display.asp Sharp, L. (2000). The commodification of the body and its parts. Annu. Rev. Anthropol. 29. p.287-328.

Sinha, A. (2000). An overview of Telemedicine: The Virtual Gaze of Health Care in the Next Century. Medical Anthropology Quarterly 14(3), p.291-309.

Stein, R. Real Hope in a Virtual World. The Washington Post 2007, October 6, A01 (http://www.washingtonpost.com/wpdyn/content/article/2007/10/05/AR2007100502391.html).

Wynn, L.L., Foster, A. & Trussell, J. (2009). Can I get pregnant from oral sex? Sexual health misconceptions in e-mails to a reproductive health website. Contraception 79, p. 91-97.

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Pitfalls in 3-D Virtual Worlds Health Project Evaluations: The Trap of Drug-trial-style Media Comparative Studies

By Maged N. Kamel Boulos and Inocencio Maramba, University of Plymouth

Abstract This 'think-piece' proposes to avoid evaluation trials comparing 3-D virtual worlds and the flat Web, and to instead investigate and evaluate the two modalities as different but complementary and synergistic media rather than as competing media trying to replace one another.

Keywords: evaluation studies; health; healthcare; media comparative studies.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- Pitfalls in 3-D Virtual Worlds Health Project Evaluations 4

Pitfalls in 3-D Virtual Worlds Health Project Evaluations: The Trap of Drug-trial-style Media Comparative Studies

By Maged N Kamel Boulos and Inocencio Maramba, University of Plymouth

Comparing the World Wide Web (also known as 2-D, two-dimensional Web or flat Web) to three-dimensional (3-D) multi-user, immersive virtual worlds can be tricky, and some might consider it similar to comparing apples with oranges or comparing the experience of reading an online health information leaflet to that of having a face-to-face meeting with a clinician. The affordances of both media are different; they are also not mutually exclusive nor a substitute for one another. Rather, they are very complementary and synergistic in many ways.

We need to identify and focus/capitalise on what 3-D virtual worlds are best at--those (useful) things and scenarios that can only be effectively carried out in virtual worlds and not via any other 'e' medium (at least, not as effectively), and also to determine the optimal formulae for blended approaches that combine 2-D and 3-D media.

Online leaflets and static information materials have no social component--even those materials offering single-user interactivity or asynchronous, multi-user (predominantly textual) interactivity remain seriously lacking in this respect. Second Life®, on the other hand, is about 3-D social networking par excellence; it has this unique 'human touch' and is instantaneous, something not found (at least not in a similar way) in 2-D social networking sites like MySpace and Facebook nor in instant messaging/voice chatting services like Paltalk and Skype. Second Life® is closer in many respects to face-to-face social encounters, but also adds to them many exciting new dimensions, fantasy, and virtually endless possibilities. And let us not forget that Second Life® is a collaborative 3-D "wiki" and an immersive audio-visual spatial experience that users can edit and experiment with - and then see the changes in real time!

People also have different tastes/preferences and currently the audiences of the 2-D Web and the 3-D Web/Second Life® are overlapping but still different. Furthermore (and in support of the above mentioned potential complementarity and synergy between both media), we are starting to see the 2-D and 3-D Webs gradually converge and merge to produce many new and novel applications.

Our main "concern", as with all such comparative evaluation studies, is about the 'generalizability' of the results. It is relatively easy to compare specific instances or productions of a number of modalities (2-D and 3-D)— instances that reflect the way we have produced or used those modalities and their production quality—and match to our specific audience (e.g., specific software packages used, ad hoc configurations and customisations, and custom content selection, blending and presentation approaches, etc.). However, it is much more difficult to boldly say "Modality X (in general, as a 'bucket category') is better or worse than Modality Y, or worse than Modalities X and Y combined"—even when we try to tie those statements to some 'best practice' conditions drawn from our own specific experience. The 'generalization' difficulty and limitations of such conclusions also remain when combining results from different studies (conducted by different groups, who have used their own different instances of those modalities) and doing a meta-analysis and pooling of those results (Cook, 2009).

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We are not saying not do a comparative study; we are just reflecting on why people should be doing one (see our comparison with drug trials below). The results of such studies can of course be very informative and useful for improving the evaluated instances or productions, and very illuminating in deciding which of those modality instances should be dropped (to save resources and money), added or improved in a future iteration of the evaluated course or situation, assuming that our student characteristics/audience profile will remain stable.

This is unlike in drug comparison trials, where unique drug entities in unique physical dispensing forms that have specific baseline pharmacokinetic and pharmacodynamic attributes need to be, and are being, compared (the purpose in these trials is not to generalise). The variations are essentially in the study subjects and their environment(s), and of course in how 'subject plus environment' interact with the evaluated drug entities (intra- and inter-subject variability). Applying the same evaluation model to the comparison of e-learning delivery modalities would be like trying to say "if a specific Antidepressant X is found to be better than Placebo, then all Antidepressants (past, present and future) are, or can be said to be, better than Placebo", which is obviously very flawed reasoning. Drugs (in the above context) are fixed; subjects and environment of course vary. On the other hand, e-learning modalities, generic or tailored, are very variable, and students and their environment also do vary. In a parallel example, one cannot judge the quality or utility (or superiority/inferiority, if comparing with other modalities) of, say, the whole motion picture industry and contributions based on a single film production (good or bad) or a limited group/selection of such productions (the 'generalisation' issue).

This is similar to the problems involved in comparing computer-based learning and noncomputer instruction, which, as stated by Friedman (1994), is logically impossible because there are no true comparison groups (see also Cook, 2009). Even comparison of different modes of computer-based learning methods is subject to a large variance within and among interventions using different media. According to Cook (2005), when comparing a discussion board to a Webpage-based tutorial, it may prove challenging to account for all the differences in instructional methods and presentation. Such differences will also be present when comparing 3-D Virtual Worlds with the 2-D Web. It has also been noted by Norman (2003) that the blind application of experimental and clinical trial methods can lead to small, non-replicable and non-interpretable results ("we cannot simply administer 20 mg of e-learning" or be certain about " how much of the 'therapy' was actually received by the student").

What kind of research should be done then? As we stated previously, research would be better focused on finding out in which situations these various modalities excel at delivering content and fostering useful interaction and communication. Also, the relationship between individual learning styles and the mode of e-learning has received relatively little attention. It may be more useful to conduct research within levels of instructional design and not across them (Cook, 2005).

So 3-D virtual worlds are here to stay and eventually become tightly and seamlessly integrated with the 2-D Web over the coming months and years, rather than replace the 2-D Web. It would be more useful to investigate the two modalities (3-D and 2-D) in this context, as different but complementary and synergistic media rather than as competing media trying to replace one another (Cook, 2009).

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Journal of Virtual Worlds Research- Pitfalls in 3-D Virtual Worlds Health Project Evaluations: 6

Bibliography Cook, D. (2005). The research we still are not doing: An agenda for the study of computer-based learning. Academic Medicine, 80, 541–548.

Cook, D.A. (2009). The failure of e-learning research to inform educational practice, and what we can do about it. Medical Teacher, 31(2), 158—162.

Friedman, C. (1994). The research we should be doing, Academic Medicine, 69, 455–457.

Norman, G. (2003). RCT = results confounded and trivial: The perils of grand educational experiments. Medical Education, 37, 582–584.

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Virtual Worlds in Health Care Higher Education

By Constance M. Johnson, Allison Vorderstrasse and Ryan Shaw, Duke University School of Nursing

Abstract Advances in information technology bring progress in distance education.

Online education programs are pervasive, however, only recently has the Web 2.0 brought about interactive, dynamic distance based health care education in virtual worlds (VWs). VWs allow for real time representations of environments, manipulable objects and interactions between avatars or bots, creating a sense of realism and presence that is absent in traditional, flat online education. Presence has been linked to knowledge transfer and better learning. Second Life速, currently the largest virtual world, has been used in higher education, including health care education at the Duke University School of Nursing. Students have indicated higher levels of satisfaction with the learning environment and quality of instruction in this VW compared to other online learning systems. There is a need for further research in online education in VWs, and room for growth in applications of VWs in education.

Keywords: Virtual Worlds; education nursing graduate; nursing informatics; Internet; cooperative behavior.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- Virtual Worlds in Health Care Higher Education 4

Virtual Worlds in Health Care Higher Education

By Constance M. Johnson, Allison Vorderstrasse and Ryan Shaw, Duke University School of Nursing

Distance education enabled learning has existed for nearly three centuries (Hesser, Hogan, & Mizell, 1992). In 1728 Caleb Phillips advertised a short hand correspondence in the Boston Gazette (Battenberg, 1971). Such courses were typical until the mid-twentieth century when radio and television emerged as popular communication mediums (Sherry, 1996). With the advent of the Internet and remarkable advances in information technology, distance education has entered a “boom” era (Albright, 1996). There are thousands of distance education programs available online from many different institutions (Bates, 2009). As the world continues to transition from the era of Web 1.0 to Web 2.0, higher education is shifting as well, moving from flat, web-based education and interfaces, to interactive and dynamic ones. With this shift, distance based health care higher education enters the era of 3-D virtual worlds (VWs).

Virtual worlds Although commercially developed VWs have been in existence since the early 1990’s, the diffusion of high-band width on the Internet and more realistic graphics have brought forth the availability for networking in these environments (Questi, 2008; Schroeder, 1996, 2002).

VWs are real time computer-generated 3D representations of a contrived or natural environment running over the Internet. Through digital technology, elements such as topography and gravity, and spaces such as buildings are created that may contain objects, e.g. tables and chairs (Guadagno, Blascovich, Bailenson, & McCall, 2007), and avatars (digital representations of humans) or bots (Bailenson, Swinth, & Hoyt, 2005). The realism of these simulated environments is perceived through sensory information giving users the perception that they are really experiencing the environment or “being there”, known as presence (Blascovich et al., 2002).

Presence Presence is defined as the subjects feeling of being in a particular place even though the user is situated in another environment. In relation to VWs, the user feels as though they are really present in the VW or have the feeling of “being there” (Blascovich et al., 2002; Witmer & Singer, 1998), even though they may be physically at home at their desks. Two different psychological states are required to experience presence; involvement which is focused attention; and immersion or feeling “enveloped by” the environment through a continuous stream of experience and stimuli (Witmer & Singer, 1998). Presence is also a function of agency or copresence (whether people see other avatars as representations of real people) and behavioral realism (the degree to which all objects including avatars and bots mimic real world objects) (Blascovich et al., 2002). According to Blascovich’s Threshold Model of Social Influence, when agency and/or realism increase, social presence should increase (Blascovich et al., 2002).

Presence has been linked to (1) knowledge transfer (transferring knowledge gained in a virtual world to the real world) (Slater, Linakis, Usoh, & Kooper, 1996); (2) potential for better learning and performance (Witmer & Singer, 1998); and (3) behavior consistent with that of the real world (Slater, Usoh, & Chrysanthou, 1995).

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Presence is a cornerstone of success in distance based higher education health care for students. At the Duke University School of Nursing (DUSON), students are immersed in the Second Life® virtual world by attending lectures in a building similar in appearance to the real world counterpart found on the Duke University campus in Durham, NC. The building has a classroom for lectures and an atrium where students can socialize and access to resources for landmarks, tutorials, and avatar clothes, skins, and shapes (http://nursing.duke.edu/modules/son_about/index.php?id=90). The classroom consists of chairs for students to sit in, a podium for the instructor to lecture, a computer to manage PowerPoint slides, a whiteboard for PowerPoint presentations, and a blackboard. The blackboard serves two purposes. First, it allows students to text questions to the professor which appear on the blackboard, thus the professor can incorporate the answers directly into the lecture without stopping the lecture. Second, it stops the students from texting each other in class using local chat, since all text appears on the Blackboard.

Figure 1. Real world DUSON and Second Life® DUSON

Second Life® is the largest 3-D virtual world, with over 15 million users (Linden Labs, 2009). Launched by Linden Labs in 1993, it is an entirely user-created environment with active educational, business and government associated communities (Linden Labs, 2009). Second Life® is being actively used for teaching and learning, social networking, focus groups, data visualization and modeling, immersive displays, research and training and simulation (Linden Labs, 2009). In particular, it is being used by numerous university faculty and institutions to provide learning experiences and conduct online classes (Kemp & Livingstone, 2006). Virtual campuses and classroom settings that mimic their real world counterparts have been created, providing a semi-realistic university atmosphere for students.

In 2008, we queried the nursing informatics students at Duke University regarding their overall assessment of the learning environment, their perceptions of learning, and their self-rated gains in content within three different environments; a learning management system, webinars and VWs. The results showed that Second Life® was significantly higher than that of a learning management system for overall assessment of the learning environment and perceived quality of instruction. Students reported that having class in Second Life helped to clarify class content and found the class discussions more spontaneous. Likewise, consist with the self-verification theory that people seek to preserve a consistent self-concept (Messinger et al., 2008; Swann, Pelham, & Krull, 1989), many of the students’ and instructors’ avatars are similar to their own likenesses, 5

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enhancing the realism of the experience and presence. The avatars that the students use to interact with the instructor and fellow classmates help to create a sense of social presence and increase the sense of community, not only visually, but within a social context (Fabri, Moore, & Hobbs, 1999; Gorini, Gaggioli, Vigna, & Riva, 2008). Students show preference for synchronous web-based learning (Murray, Belgrave, & Robison, 2006). Social presence in online learning has been positively related to student satisfaction and perceptions of learning (Richardson & Swan, 2003).

Figure 2. Professor Constance Johnson, PhD, RN lecturing to students in Second Life速

These immersive environments offer a new type of paradigm: instead of being passive observers of images on the computer, users are active participants in computer-generated 3D worlds. In these computer generated virtual worlds, avatars can interact with other avatars or bots as they would in the real world through voice or text chat via a headset with a microphone, and navigate by walking, running, swimming, flying, or teleporting from one location to another.

Avatars can stand up or sit down in various poses, move their mouths, blink, and make humanlike gestures. These online immersive environments allow users to learn, socialize and behave in ways that closely resemble how they behave in the real world. Through the combination of creating a virtual world that in many ways mimics that of the real world and allowing students the ability to customize their avatar to their liking, students are able to feel a real sense of presence and authenticity in world that is virtual.

Social Learning One of the most profound aspects of using virtual worlds in education is that they are able to support and expand on social learning. Social learning is based on the premise that our understanding of content is socially constructed through conversations and interactions we have with others (Brown & Adler, 2008). Through interaction with social networks and the ability to manipulate virtual objects, students have an added layer of social learning to enhance their

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education. Additionally, they allow health care students the opportunity to practice new behaviors in real-life scenarios without the disadvantages of making mistakes in real life.

The structure and nature of VWs support social interaction and social learning by using a collaborative manipulation metaphor (Hutchins, 1989; Stanney, Chen, Wedell, & Breaux, 2003).

Collaborative manipulation metaphors are ideal metaphors since they permit manipulation of virtual objects that mimic real world objects, yet also provide a conversational intermediary, to a scripted bot or embodied agent such as an avatar, increasing the sense of realism. Social interaction has long been used in making human interaction possible from remote geographic locations, considering the continuum beginning with the act of letter writing to present day emails, instant messaging, web cams and VWs. With the advent of VWs, the sense of connectedness is presented through the concepts of presence, agency, and behavioral realism.

Connected-ness impacts social influence, which is purported to be affected by a number of factors including behavioral realism and agency (Hoyt, Blascovich, & Swinth, 2003). Social processes that occur in real life also occur in VWs (Hoyt et al., 2003).

At DUSON, social learning is enhanced by students being able to interact and discuss topics with their peers, instructors, and others in the Second Life® metaverse. Students have the opportunity to not only communicate and travel within the virtual islands of Duke University, but travel to other second life islands such as the one created by the centers for disease control (CDC) (Cassanova, 2006). It is areas such as these where students are able to interact and communicate with other health care professionals, students and consumers’ avatars and manipulate interactive objects about health care topics. It is through these opportunities that social learning is enhanced by being only a “teleport” away.

Usability of the Environment Although social influence should affect perceived usefulness, students’ perception of the usefulness of these environments may additionally be related to the usability of the environment.

There are three important issues in the design of usable web applications. The first challenge is to determine the characteristics of the intended users of the system, including age, education, skill level, disabilities, cultural background, goals, computer literacy level, and familiarity with the domain (Shneiderman, 1998). The second is to identify system functions that have to be performed, the required input and output formats, system constraints, information categories and flow, and the communication needs of the users (Hackos & Redish, 1998; Kirwan & Ainsworth, 1993; Nielsen, 1993; Vicente, 1999). Third, environmental analysis is used to specify the conditions in which the site is used. Privacy of information is important, but social and cultural issues are also a consideration in the environment. The social environment of users can affect the success of a website. Social issues that need to be addressed are: 1) Will users share information?; and 2) are resources readily available to assist users? (Hackos & Redish, 1998).

Cultural issues are significant to consider and not only relate to ethnicity but also to socioeconomic status, professional status, and regional differences (Hackos & Redish, 1998).

In 3-D environments a few more factors need to be considered for usability and usefulness: way finding, defined as understanding one’s location or orientation when moving about the virtual space; navigation, which is moving to perform required tasks; object selection and manipulation, which is selecting objects and moving or querying for some purpose; good visual and auditory inputs and outputs that are seamlessly integrated into the activities of users; and engagement, which includes presence, immersion and the ability to socially interact with others (Hix & Gabbard, 2002; Poupyrev, 2000; Shilling & Shinn-Cunningham, 2002; Stanney, Mollaghasemi, Reeves, Breaux, & Graeber, 2003; Witmer & Singer, 1998).

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The basic objective of VWs is to provide user-centered multimodal interactions, which afford perceptual illusions that support human information processing and interactive social networking, while minimizing cognitive obstacles such as way finding, navigational, auditory, or visual difficulties. Usability is crucial in ensuring user satisfaction and acceptance, decreasing errors, and increasing use of the environment, allowing users to focus on integrating the knowledge gained from the use of these environments rather than the mechanics of these systems.

Online virtual learning is not without its challenges. As with many technologies, there is always the possibility of technical problems. This is especially true for online virtual worlds.

However, there are ways in which to help reduce technical and frivolous problems. We found that providing a proper orientation to the virtual world and allowing students time to familiarize themselves with the user-interface and underpinnings are important. Students needs to be able to learn how to customize their avatar, navigate the virtual world, interact and communicate (Calongne, 2008). This is not intuitive for many users. Though basic, it is crucial to add these elements into any curriculum involving a virtual world.

In creating optimal online education in online virtual worlds, a combination of approaches and modalities is warranted. Using additional web-based collaboration ware (i.e. wikis, blogs and podcasts) synergistically provides a coherent wholesome learning experience (Boulos, Maramba, & Wheeler, 2006).

In order to create a richer online learning experience for students, it is also important that they know their peers and instructors not only online, but in regular face-to-face meetings (Nichani, 2000). This strengthens the foundations of context and social interactions (Feenberg, 1989) and reinforces the online social relationship students have with their peers and instructors (Nichani, 2000).

Conclusion Initial studies suggest that virtual worlds, which promote social and educational interaction via repetition, practice, feedback, and application, lead to superior learning (Okita, Bailenson, & Schwartz, 2008). However, as a virtual learning environment, 3-D virtual worlds, and in particular Second Life®, have not been fully explored. There is potential for the creation and growth of innovative educational experiences as Second Life® and other 3-D virtual learning environments are investigated and incorporated into curriculum (Boulos & Wheelert, 2007).

The transition from Education 1.0, traditional classroom settings, to Education 2.0, online and blended courses, which utilize information technology, is causing a shift in pedagogy.

Education is moving from an instructor-centered pedagogy to a constructivist and student oriented pedagogy (Hiltz & Turoff, 2005) of increased participation (Robbins-Bell, 2008). As online education becomes increasingly prevalent in higher education, faculty are required to examine existing assumptions of teaching, learning and methods of content delivery. It is vital that educators identify and utilize the educational strengths of virtual worlds, as well as explore combining these environments with other applications such as learning management systems (Boulos & Wheelert, 2007).

Research is needed to understand the “beat practices” of using 3-D virtual worlds not only in higher education, but in health care higher education in particular. Research on hot to develop optimal 3-D online virtual worlds that mimic the real world through patient simulations, along side classrooms, and peer to peer social interactions is the next step. VWs such as Second 8

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Life速 are the frontiers of this new era of health care higher education. Utilizing these mediums allows for a way to train much needed health care professionals by decreasing costs of education and increasing the access of high quality education to those in remote locations. In combating a national nursing shortage (Rosseter, 2009) and a shortage of primary care physicians (Steinbrook, 2009), utilizing VWs is an opportune way to increase the number of much needed health care professionals.

Acknowledgements This work was funded in part by Duke University Center for Instructional Technology, Durham, NC.

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Murray, T. L., Belgrave, L., & Robison, V. I. (2006). Nursing faculty memebrs competence of web-based course development systems directly influences students' satisfaction.

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Development of Virtual Patient Simulations for Medical Education.

By Douglas Danforth, Ohio State University Mike Procter and Robert Heller, Athabasca University, Canada Richard Chen, Ohio State University Mary Johnson, Florida State University

Abstract Virtual Worlds such as Second Life provide unique opportunities to simulate real life scenarios and immerse the user in an environment that can be tailored to meet specific educational requirements. In these Immersive Learning Environments, students and faculty can interact from anywhere in the real world. From a general education perspective, they allow for virtual classrooms, virtual libraries, interactive role-playing, remote seminars, etc. From a medical education and science perspective, Immersive Learning Environments such as Second Life can be used to model doctor-patient interaction, clinical diagnosis skills, and three dimensional objects ranging from individual molecules and cells to whole organ systems, both healthy and diseased.

The principal goal of our project is the development of virtual patient simulations for medical education. In order to simulate real patients with greatest fidelity, the virtual patients are controlled by artificial intelligence. This allows students to engage in a natural language conversation with the patient to obtain relevant patient history, symptoms, etc, and then to develop relevant differential diagnoses and treatments appropriate for the simulated condition of the patients. Virtual world medical simulations enable students to rehearse professional behaviors in a risk-free environment, providing opportunities for skills practice prior to real-world patient encounters.

Keywords: Second Life; virtual patients; immersive learning environment; medical education.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- Development of Virtual Patient Simulations for Medical Education 4

Development of Virtual Patient Simulations for Medical Education.

By Douglas Danforth, Ohio State University Mike Procter and Robert Heller, Athabasca University, Canada Richard Chen, Ohio State University Mary Johnson, Florida State University Traditional medical education curricula often utilize simulated or “Standardized” patients as tools to help students develop skills in clinical reasoning, physical examinations, history-taking, patient diagnosis and generalized doctor-patient relationship (Brender 2005). Standardized patients are usually members of the local community, trained to enact a particular illness or condition. Whereas standardized patients are an important adjunct to medical education, development and maintenance of a quality standardized patient program can be costly and time consuming. In addition, students often have to work in fairly large groups and often only have brief interactions due to the limited numbers of standardized patients available. As such we have been exploring the possibility of using virtual standardized patients as an important additional opportunity for students to develop their physician-patient relationship skills. In order for virtual standardized patients to be effective, they must be able to interact using natural language conversation of the type patterned after traditional patient doctor interactions.

In addition to their conversational abilities, virtual standardized patients must be appropriately contextualized such that the immersive aspects of the interaction are maximized thus facilitating skill acquisition and student learning. In this regard, immersive learning environments such as Second Life provide unique opportunities to simulate real life physician-patient scenarios and immerse the user in an environment that can be tailored to meet specific educational needs. Second Life is being used for a wide variety of educational activities at the high school, college, and post graduate level (http://secondlifegrid.net/slfe/education-use-virtual-world), and more than 150 universities in the United States and around the world have a presence in Second Life (Foster 2008).

The use of Second Life for medical and healthcare education has been previously documented (Beard, 2009; Kamel Boulos 2007, Kamel Boulos 2008, Gorini 2008; Hansen 2008). Second Life has been used for disaster simulation (Kamel Boulos 2008), nursing training (Skiba 2009), nutrition education (Vital Lab 2009), etc., much of which is referenced by one of the primary in-world sources of healthcare information – HealthInfo Island (Perryman 2009) funded by the National Library of Medicine. Beard (2009) found 5 distinct health related activities in a survey of 68 health related sites in second life that were categorized into Education/Awareness, Support, Marketing/Promotion, Research, & Training.

The value of simulations in medical training is well known (Lok, 2006, Stevens et al., 2007) and virtual worlds, like Second Life, can greatly expand accessibility as well as create opportunities for real time collaborations. There are a number of SL medical simulations with actor agents behaving as

patients (see Imperial College London, http://www.elearningimperial.com, and University of Aukland, http://slenz.wordpress.com/2008/10/26/the-slenz-update-no-19-october-26-2008/) Interestingly, Payr (2003) made this suggestion over 5 years ago as an example of how actor agents could be used in innovative ways as animated pedagogical agents. However, the focus of these simulations is somewhat structured, and the interactivity of the actor agent patients is very limited with little or no conversational ability. As such, we have placed a priority on the development of virtual patients who can “speak” to the students and engage in a natural conversation. Using conversational agent technology in Second Life, we have designed virtual patients that simulate the clinical interview between a doctor and patient. Our goal was to provide a realistic environment in which the students could focus on the development of their clinical interviewing skills. By increasing the fidelity of the simulated environment, we hope to deepen the immersiveness of the entire experience to better achieve the learning outcomes.

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Our current project is an extension of earlier research on historical figure applications of conversational agents. Freudbot is a conversational agent programmed to chat in the first person about Freudian theory, concepts and biographical events (Heller et al. 2005). Freudbot was developed using Artificial Intelligence Markup Language (AIML), an XML-based open-source programming language, developed by Richard Wallace. AIML is the language used to support ALICE (http://www.alicebot.org), an award winning chatbot and progenitor of thousands of other chatbots as hosted on Pandorabots (www.pandorabots.com). At its core, AIML relies on pattern matching and consists of "category" tags, which in turn contain a "pattern" and "template" tag. If the input matches the pattern, the template defines the action to be taken.

AIML also has recursion and wildcard functions which allow many inputs to match a single pattern. Creating content for Freudbot involved anticipating the questions users would ask of Freud and providing appropriate answers. However, adding content to AIML agents is an iterative and incremental manual process where user input is targeted for failed matches and new content is added. In addition to programming content, AIML can also be used to manage the dialogue and create strategies loosely consistent with Speech Act theory that direct the user to ask about content within each agent’s repertoire. In Freudbot’s case, when no input was recognized, the agent would default to one of several conditional strategies: ask for clarification, suggest a new topic for discussion, indicate that he had no response, ask the user for a suggested topic, or redirect with a unrelated question. Freudbot has been evaluated in two studies thus far (Heller et al. 2005; Heller & Procter, 2009) and although there is still room for improvement, the concept has proven to be generally positive among users.

More recently, Freudbot was successfully deployed in Second Life using an avatar connected to an AIML server (http://slurl.com/secondlife/Athabasca%20University/194/155/249) and served as focal point for the current project on virtual patients. The use of AIML agents in Second Life is well established. In particular, Dadeni Ltd., one of the premier providers of conversational agents, has used AIML to develop agents that assist in marketing, search functions, and help desk scenarios (http://www.daden.co.uk/chatbots.html). Daden’s agents are designed to provide flexible solutions for a variety of commercial applications. Our approach has been to focus specifically on creation of virtual patients for medical education with the goal of creating a dedicated yet scalable solution that can be implemented by physician and basic science educators for training basic interview skills for medical and nursing students.

The Virtual Patients The principal scenario underlying the Virtual Patient project is the initial doctor-patient visit. This could be for a routine annual exam, a prenatal visit with an OB/GYN, or a patient presenting to the physician’s office or emergency room with a chief complaint or illness (Figure 1).

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Figure 1. Typical setting with Student doctor and virtual patient.

The student then proceeds to interview the patient gathering appropriate patient and family histories, symptoms, complaints etc. The patient answers the questions with the preprogrammed responses for the questions asked. Once the student has gathered enough patient data they then develop a differential diagnosis list of likely causes for the symptoms described and order the appropriate lab tests, ultrasounds, x-rays, etc. Once they interpret the results provided, the students must develop a final diagnosis for the patient. The conversational components of the interaction are handled by AIML and the remainder is managed through scripting within the Second Life environment.

Our current visual design is a work in progress with plans to create more realistic hospital settings and improve the interface for creating differential diagnoses and selecting appropriate tests. We will model this on our existing electronic medical record so the students will have a common frame of reference. We hypothesize that as the fidelity increases between the simulation and the actual event, so does the level of immersion which in turn promotes positive learning outcomes.

The core component of the system is the relational database for creating and maintaining virtual cases. We had several design goals when developing the virtual patient database: 1. Flexibility â&#x20AC;&#x201C; As much as possible we wanted this to be platform independent. Thus, while the initial implementation is designed for a Second Life simulation using an AIML-based conversational agent, there are plans to increase flexibility by incorporating XML data which should, in principle, make it relatively easy to implement using other interfaces and conversational engines.

2. Ease of use â&#x20AC;&#x201C; Cases and patients should both be configurable without requiring scripting or programming skills. Once implemented, the system should be maintainable by the subject experts (medical students and faculty).

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3. Scalability – Within reason the only thing limiting how many cases, or how many patients would be expandable computing resources (clients and servers).

4. Portability – Ultimately we would like to define a standardized format for the conversational knowledge-base, allowing for easy sharing and use by other applications.

The system is composed of the following components: • • • • •

Case Repository Web interface AIML generator AIML server Second Life scripts

Case Repository The system is built around the concept of a "case repository", containing the content, or knowledge, that the virtual patient needs to perform its task, decoupled from AIML or any specific conversational engine. A single case defines the data for one type of patient condition, such as "endometriosis" or "ectopic pregnancy". This supports ease of use by allowing subject experts to work directly on the data without concern for the underlying AIML, through a variety of different tools. We achieve flexibility if the repository is constructed in a platform independent way that allows us to build tools that accomplish the following goals: • •

Maintain the dataset (web page, GUI applications, automated applications such as spellcheckers, syntax checkers, etc). We have concentrated initially on a web based tool.

Generate interfaces to the data (converters for AIML and other conversational agents).

An XML to AIML converter has been developed.

The case repository consists of two parts: 1) a questions database used by all cases; and 2) case answers which contain the answer elements linking back to the respective question elements.

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The questions database contains all common questions that might be asked for any patient condition. As new questions are identified, they need only be added to the questions database once, and then will become available for all cases. Generally a case will only need to have specific answers for a relatively small subset of these questions. Default answers will be defined for all questions, so that a patient is still able to respond to questions that are not particularly relevant to the case and have therefore not had case-specific answers defined. Sets of default answers (templates) will be created for different patient profiles (age, sex, marital status, etc). Building a case starts by choosing a template relevant to the patient and providing answers to only those questions relevant to the patientâ&#x20AC;&#x2122;s condition.

Web interface: The purpose of the web interface is to allow subject experts to build and maintain the questions and case datasets without having to understand or interact with the underlying database.

AIML Generator The AIML generator is a Java application that converts case files to AIML for the conversational agent. This content AIML is combined with common AIML files which handle generic conversation-related behaviors and avatar control.

AIML Server The AIML server is an open source program â&#x20AC;&#x201C; (Program D serve) with an HTTP server component. SL scripts access this service via typical HTTP request functions (similar to pandorabot.com).

Second Life scripts These scripts provide an interface between SL users and AIML server, avatar animation and other interaction with avatars and in world objects.

Future Development Although the existing application provides a rudimentary, usable virtual patient, the immersive experience will be further enhanced, and greater utility will be achieved, as the following are developed: Animation The virtual patient employs some fundamental animation, such as standing when someone enters the room, sitting and typing (a common method to indicate "speaking" in Second Life). Additional animations and movement, such as head turning, nodding, fidgeting and walking will help to make the patient appear more human-like.

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Emotional Expression By linking facial expressions to the conversational output, we take greater advantage of the bandwidth of communication available in a 3D world.

Patient Emotional State Allowing for variations in the virtual patient's emotional state allows us to mimic real life patient interviews to a greater degree. Confusion, levels of cooperation, fear and other emotions can affect the way in which questions are answered and the types of questions a medical professional would need to ask to get the necessary information.

Conclusion In summary, the creation of virtual patient simulations using the Second Life platform will provide truly unique learning opportunities for the next generation of future physicians. By fostering global, interactive, immersive collaborations, we can leverage existing and future technologies to maximize educational opportunities at home and around the world. The “Millennial Generation” of students will no longer be served by the passive approaches and technologies of the past. The traditional paradigm of didactic presentation and passive learning is rapidly being supplanted by novel approaches using new technologies designed to foster active learning and participation. Immersive Learning Environments such as Second Life offer unique opportunities to engage today’s students in innovative and exciting ways.

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Bibliography Beard, L.; Wilson, K.; Morra, D. & Keelan J. (2009) A Survey of Health-Related Activities on Second Life. Journal of Medical Internet Research, 11(2):e17. Retrieved from http://www.jmir.org/2009/2/e17 Brender, E .(2005). Standardized Patients. Journal of the American Medical Association 294:1172.

Danforth, D. (2009). Ohio State University College of Medicine Island – Second Life Ohio State University Medicine http://slurl.com/secondlife/OSU%20Medicine/69/94/302 Foster , A.L. (2008). Professor Avatar. Education Digest: Essential Readings Condensed for Quick Review. 73(5):12-17.

Gorini, A., Gaggiolo, A., Vigna, C. & Riva, G, (2008). A Second Life for eHealth: Prospects for the Use of 3-D Virtual Worlds in Clinical Psychology. Journal of Medical Internet Research. 10(3): e21. Published online on August 5.

Heller, R.B., Procter, M., Mah, D., Jewell, L., & Cheung, B. (2005). Freudbot: An Investigation of Chatbot Technology in Distance Education. Proceedings of the World Conference on Multimedia, Hypermedia and Telecommunications.

Heller, R.B. & Procter, M. (2009). Animated pedagogical agents: The effect of visual information on a historical figure application. Journal of Web-based Learning and Teaching Technologies, 4(1), 54-65.

Hansen, M. (2008). Versatile, Immersive, Creative and Dynamic Virtual 3-D Healthcare Learning Environments: A Review of the Literature. Journal of Medical Internet Research.

Jul–Sep; 10(3): e26. Published online on September 1.

Kamel Boulos, M., Hetherington, L., & Wheeler, S. (2007). Second Life: An overview of the potential of 3-D virtual worlds in medical and health education. Health Information and Libraries Journal, 24, 233–245.

Kamel Boulos, M., Ramloll, R., Jones, R & Toth-Cohen, S. (2008). Web 3D for Public, Environmental and Occupational Health: Early Examples from Second Life. International Journal of Environmental Research and Public Health, 5, 290-317.

Lok, B. (2006). Teaching communication skills with virtual humans. IEEE Computer Graphics and Applications. May-Jun; 26(3):10-3.

Payr, S. (2003). The virtual university’s faculty: An overview of educational agents. Applied Artificial Intelligence, 17, 1-19.

Play2 Train (2009). Retrieved on June 26 from http://play2train.us/wordpress/ Perryman, C. (2009). Health Info Island Blog. Retrieved on June 26 from http://healthinfoisland.blogspot.com/from Second Life - Healthinfo Island. http://slurl.com/secondlife/Healthinfo%20Island/184/61/22.

Second Life - Nutrition Game. http://slurl.com/secondlife/ohio%25university/161/175/25/

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Skiba, D. (2009). Emerging technologies center nursing education 2.0: a second look at Second Life. Nursing Education Perspectives, 30(2), 129-131. Retrieved June 17, from Cumulative Index to Nursing and Allied Health Literature Plus with Full Text database.

Stevens, A., Hernandez, J., Johnsen, K., Dickerson, R., Raij, A., Harrison, C., DiPietro, M., Allen, B., Ferdig, R., Foti, S., Jackson, J., Shin, M., Cendan, J., Watson, R., Duerson, M., Lok, B., Cohen, M., Wagner, P. & Lind, D.S. (2006). The use of virtual patients to teach medical students history taking and communication skills. American Journal of Surgery.

Jun;191(6):806-11.

Vital Lab. (2009). Second Life Development Service. From the VITAL Lab @ Ohio University.

Vital Wiki. Retrieved July 1, 2009 from http://vital.cs.ohiou.edu/vitalwiki/index.php/Nutrition_Game Yellowlees, P., Cook, J., Marks, S., Wolfe, D., and Mangin, E. Can Virtual Reality be Used to Conduct Mass Prophylaxis Clinic Training? A Pilot Program. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Vol. 6, N. 1, 2008 Š Mary Ann Liebert, Inc. i

NE.: Daden has already developed Virtual Patients Scenarios (see, for example, Virtual Patients In Second Life, David Burden Daden Limited http://www.medbiq.org/events/conferences/2009/presentations/20090429_Burden_D_PLENARY.pdf

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Volume 2, Number 2 3D Virtual Worlds for Health and Healthcare August 2009

Development and Evaluation of Health and Wellness Exhibits at the Jefferson Occupational Therapy Education Center in Second Life

by Susan Toth-Cohen, Thomas Jefferson University and Therese Gallagher

Abstract Virtual worlds such as Second Life are increasingly used for consumer health and higher education. The present paper describes the development and evaluation of public exhibits on health and wellness at the Jefferson occupational therapy education center in Second Life.

Keywords: occupational therapy; home adaptation; healthy aging; program evaluation.

This work is copyrighted under the Creative Commons Attribution-No Derivative Works 3.0 United States License by the Journal of Virtual Worlds Research.

Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 4

Development and Evaluation of Health and Wellness Exhibits at the Jefferson Occupational Therapy Education Center in Second Life

by Susan Toth-Cohen, Thomas Jefferson University and Therese Gallagher

Virtual worlds such as Second Life are increasingly used for educational endeavors ranging from consumer health education to graduate education (Skiba, 2007), and many universities incorporate virtual worlds into their curricula and research (Stott, 2007; Yellowlees & Cook, 2006). Virtual worlds also are employed to educate the public about health and health conditions; for example, organizations such as the American Cancer Society and the US Centers for Disease Control presently utilize Second Life to encourage health promotion and education to the public (Boulos, Ramloll, Jones, & Toth-Cohen, 2008; Woodford, 2007).

Delivery of health educational programs within virtual worlds may be conceptualized as a type of interactive health communication (IHC) extended into social web media. IHC consists of interactions between people and healthcare information that are mediated through electronic devices or communication technology (Office of Disease Prevention and Health Promotion, 1999). In studies focused on the flat internet, IHC has shown promising results in providing information on health and health conditions, promoting healthy behaviors, and providing information exchange and support (Murray, Burns, See, Lai, & Nazareth, 2005).

IHC projects within virtual worlds can be customized to fit the needs of various usersâ&#x20AC;&#x201D;a factor cited as critical to the success of IHCs (Ahern, 2007). One example of customization is HealthInfo Island, a project funded by the National Library of Medicine that provides consumers with individualized support and health information resources (Boulos, Hetherington, & Wheeler, 2007). IHC is just now entering Web 2.0 tools via virtual worlds such as Second Life, with a number of additional benefits related to their characteristics as virtual worlds. Specific benefits of the 3-D environment include features such as an enhanced sense of place and co-presence with others within the virtual environment (Jarmon, 2009). Further development of IHC within these virtual worlds is expected to capitalize on the increasing capacity to integrate virtual world and real-world experiences (Gorini, Gaggioli, Vigna, & Riva, 2008).

This paper describes the development and evaluation of exhibits on health and wellness at the Jefferson occupational therapy education center within the virtual world of Second Life.

The occupational therapy center (OTC) consisted of 4 main areas: 1) an adaptation home that displayed strategies for modifying the home environment to improve capabilities of persons facing challenges from decreased mobility, impaired cognitive functioning (memory), and low vision; 2) backpack safety awareness, which explored the dangers of improper backpack use; 3) carpal tunnel syndrome (CTS), which consisted of exhibits demonstrating the anatomy of the carpal tunnel, strategies for prevention, experiences of persons who had CTS, and current research about CTS; and 4) healthy aging, which provided education on ways to maintain cognitive and physical functioning through the lifespan. The OTC is shown in Figure 1.

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Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 5

Figure 1: Occupational Therapy Center The overall aims of the OTC were to: • • •

Provide interactive exhibits on health and wellness for residents of the virtual world and conduct ongoing evaluation and improvement of these exhibits Collaborate with health professionals and consumers/residents to create the content and format of the exhibits, and Provide a means by which graduate students in occupational therapy can learn to deliver health information for consumers that is engaging, accurate, and benefits everyday life.

The present paper reports results of the development and evaluation of the OTC exhibits, which were informed by an interactive process built into the development and evaluation of the exhibits. Exhibits were created by the faculty director of the OTC and graduate students in occupational therapy, and then modified in response to feedback from Second Life residents.

Program Development The OTC began in summer of 2007 with general exhibits about occupational therapy and the university sponsoring the OTC. Graduate student involvement began in September of 2007 with one student exploring a potential final Master’s project and two students serving as paid graduate assistants (GAs). The present paper reports the evaluation of the OTC in fall of 2008, when two students were completing their final Masters projects and five were serving as GAs. All seven students contributed to exhibit development. One student (the second author) took primary responsibility for the program evaluation as her final MS project. The other student completed her final project by developing and conducting a formative evaluation of the new Healthy Aging exhibit. A graduate student and a faculty member from Kent State University’s speech pathology and audiology provided feedback on initial development of the adapted home.

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Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 6

Several key areas of exhibit development were emphasized with graduate students involved in their creation. In particular, students were instructed to focus on providing exhibits that were as interactive as possible, while including other types of education such as in-world video and web resources. Another important focus was to ensure that all text-based materials had a reading level of either grade or lower and did not include professional jargon or terms likely to be unfamiliar to those not in the health professions. While beyond the scope of this evaluation, interviews with graduate students involved in the exhibit development indicated that these students found the process beneficial to understanding current course topics and providing a perspective on healthcare and disability (Toth-Cohen, 2009).

The backpack safety and carpal tunnel exhibits were fully completed before initiation of the evaluation. The adaptation home exhibit was revised and expanded just prior to the evaluation, to enhance existing content to include more displays and explanations as to how to adapt one’s home for various challenges.

In order to develop the new healthy aging and neuroplasticity exhibit, the MSOT (Master of Science in Occupational Therapy) student researched current literature and assisted in designing the specific exhibits. In doing so, she utilized guidelines for development that were established by the TechVirtual (http://slurl.com/secondlife/The%20Tech/197/159/38), a museum within Second Life that also has a physical museum in San Jose, CA, the Tech Museum of Innovation (http://www.thetech.org/about/).

The Tech Virtual guidelines for exhibit development consist of identifying the main idea behind the exhibit, specific interactive aspects, determining the look and feel of the exhibit, making the design intuitive, ensuring access, creating “wow” or “aha” factors that attract visitors, ensuring responsiveness, providing a context or story, and giving a reward and opportunity to revisit or reset their experience. Based on these guidelines, the MSOT student developing the Healthy Aging exhibit created displays and interactive experiences that included the benefits of learning a new language, dancing and playing musical instruments, yoga, and contrasting the effects of passive activity such as watching TV with active pursuits such as exercising.

All exhibits at the OTC included quizzes, videos about the specific topics accessed inworld, and evidence based resources in the form of notecards and a wiki designed for this purpose. The adaptation home illustrated selected universal design elements and types of adapted equipment that may be used to assist functioning of persons with disabilities. Three main types of disabilities were addressed: low vision, memory/cognitive issues, and limited mobility. The kitchen of the adapted home is shown in Figure 2.

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Figure 2: Kitchen of Adapted Home The adaptation home was set up as a small house within Second Life consisting of an entry way, living room, bathroom, kitchen, and bedroom. Each component of the home exhibit was labeled with a station number (see Figure 2) that provided information about the specific adaptation in local text chat when clicked by the visitor. The home also had objects corresponding to real-life adaptive equipment that visitors could try out, such as a tub seat.

Research Design and Methods The research design was a case study used to evaluate and provide descriptive detail about the OTC exhibits within the context of the virtual environment (Yin, 2003). Both quantitative and qualitative measures were used to collect program data. These data sources included an online survey, focus group, and interviews, which have been described previously as methods for determining impact of virtual world programs (Kamel Boulos & Toth-Cohen, 2009).

Institutional Review Board approval was obtained from the principal investigatorâ&#x20AC;&#x2122;s university prior to commencement of the study. All participants were residents of Second Life who agreed to take part in the program evaluation at the OTC. Participants were recruited through announcements made to education groups in Second Life and from lists of visitors to the OTC. Potential participants contacted the principal investigator by instant message while logged into Second Life or by touching a signup box outside the OTC. After the participants indicated their initial consent through this contact, they were given a notecard with information about the program evaluation.

After interacting with all exhibits at the OTC, participants were given the url address in which to complete the online survey, which had been created at http://www.surveymonkey.com/ The online survey was anonymous with only the participantâ&#x20AC;&#x2122;s avatar name recorded in the survey. Thirty-three surveys were completed. Participants were paid 100 Linden dollars (fifty cents) for finishing the survey. Upon completion of the survey, some participants elected to be interviewed by the researchers within Second Life. Those who participated in the interview received an additional 100 Linden dollars.

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Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 8

The survey questions included: 1) demographics (gender, age, employment status); 2) responses to the OTC exhibits overall; and 3) specific responses related to the more recently developed healthy aging exhibit. Interviews were performed in Second Life through face to face virtual chats with one of the researchers. Twenty-five of the 33 respondents agreed to participate in the follow-up interviews. Open-ended questions were utilized to elicit responses about the overall impressions of the exhibits at the OTC. Prompts were added as needed to extract greater detail from the respondents. Interviews ranged from approximately 15 minutes to one hour, with the average length of interview 20-30 minutes. The interview text was recorded verbatim on the chat logs in Second Life and transferred to Word documents for analysis. Each transcribed interview was coded for categories, and the common themes across transcripts were identified.

Results Demographics of the 33 survey participants are shown below in Table 1. Participant views of the exhibit features (application to real life, clarity of information, and preference for three-dimensional learning) are shown in Figure 3.

Table 1. Demographics Gender

Male

Female

Education

11 High school

20 Some college 8 Full-time worker 17 26-35 8

5 Employment Unemployed or retired 6 18-25 Age 4

Declined to say 2 Bachelorâ&#x20AC;&#x2122;s

Graduate

5 Part-time worker 6 36-45 8

15 Full-time student 3 46-55 9

Part-time student 3 56-65 3

> 65 1

60% 50% 40% Prefer 3-D Learning Real Life Benefit

30%

Clearly Presented

20% 10% 0% SA

A

N

D

SD

Figure 3. Participant response to exhibit features

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Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 9

Participants were also asked to identify the exhibit they considered most useful and why.

The largest number of participants (12) identified the home adaptations as most useful; the healthy aging exhibit was identified as most useful by 11 of the 33 participants. Sample responses for their choices are shown in Table 2.

Table 2. Reasons for choice of most useful exhibit

Home Adaptations I am dealing with aging parents at present and found the suggestions very helpful. We are thinking about re-modeling the bathroom, so it it was timely as well.

My dad has ALS and gave me insight on things to make it easier on him.

Just fascinating... plus we are renovating our house and thinking of these things as we grow older...

Some things that I could actually do at home.

Having to walk through the house made it more 'real' and helped with context.

So many of the suggestions were so good for either myself, or my mom, who suffers from macular degeneration (eyesight is almost gone).

I love the interactivity, and a great deal of information was provided that would be useful to someone trying to make adaptations for people with a disability.

Healthy Aging The whole ordeal of aging I hate it. But, we must go through it.

Because... I know how it is for older people to have to adjust their lifestyles as they age Being a student doctor, I already know much of the science, the aging exhibition was the most fun and engaging though I am in that age group, and knowing that certain things I do, like SL participation, are actually part of a healthy aging lifestyle - and other points - will keep me focused on proactive strategies Maybe it is just that the topic is most on my mind. I'll follow some of the resources.

Useful in the sense of experiences how others are structuring an interactive environment... it is useful to know about the Healthy Aging processes, because I think this could be a future field of activity in Second Life concerning every content.

I'll be retiring in a few years. It makes me think more about how to plan my retirement home for when I get much older.

After completion of the online survey, 25 follow-up interviews were conducted and analyzed. The following three common themes emerged: 1) the ways in which exhibits applied to everyday life; 2) recommendations for improving the exhibits; and 3) perspectives on the exhibits overall. The recommendations category was further divided into the subtopics of content and format. The content subtopic comprised suggestions for enhancements or new ideas as they related to the different exhibits. The format subtopic was further divided in terms of suggestions for resources, setup, or technical aspects for specific displays or the exhibits in general. The third category, perspectives/impressions of the exhibits, was separated into the subtopics of content and format. Examples of specific quotes for these themes are included in Table 3.

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Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 10

Table 3. Sample Interview Responses

Real Life Applications

Recommendations

“I thought the content was immediately applicable and practical…I think it is a great resource for the OT’s in the state…”

“I am a cake decorator in real life (retired cake decorator) I should say, and its due to extreme carpal tunnel in my right hand.”

“I never realized how hard it is for someone in a wheelchair to do basic tasks like get things out of the cabinet in the kitchen!” “…I am in education, and always intrigued by the latest brain research…” “the backpack display really helped me out because I carry a lot of weight in my backpack with all my books.”

Content “…suggestions about physical fitness…” “maybe a computer with some adaptive technology…” “…show child being offbalanced depending on where weight in backpack is placed…” “…go into seating, monitor positioning, posture, etc”

Perspectives/Impressions of Exhibits “pretty good – you have a lot of content and interactivity…” “…I thought both the aging and home area were quite good…I learned some things and it kept my interest”

Format “maybe a path to follow [in the garden]…” “the text was a bit long and presented visual clutter…” “…a more consistent style in terms of colours and fonts…” “here’s a trick for slideshows…“ “for inspiration try and visit some of [second life’s] really good content creators…”

“at first I didn’t think it would be all that interesting but the whole design work[ed] well and kept me interested…”

“I liked the presence of the little quizzes to reinforce the exhibits…” “very informative and being interactive helps you to think about the answers…”

Follow-up to Evaluation Feedback The evaluation team reviewed participants’ recommendations and approved changes to the exhibit as shown in Table 4. Decision to approve changes was based on relevance and congruence with the overall content and format and feasibility.

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Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 11

Table 4. Summary of Major Approved Changes

Exhibit Component Overall Exhibit Carpal Tunnel Syndrome

Changes in Content

Add information about computer setup and work stations to optimize functioning and prevent CTS

Include more about psychosocial factors in aging

Status of Change Completed Planned for future renovation

Condense information that appears in text chat when activated Make it easier to see/understand specific adaptation suggestions

Adapted Home

Healthy Aging

Changes in Design or Format Use consistent style and colors throughout exhibits

Use fewer posters, provide more interactivity Create a path showing how to proceed through exhibit

Completed

Redid adaptations using holodecks, with one scene per room for each type of challenge In process; exhibit undergoing major renovation Completed

Discussion The health and wellness exhibits at the OTC were positively received by evaluation participants, as shown by survey and interview responses. Participants became actively engaged with the exhibits, and many commented that what they learned would help them in their lives outside of the virtual world. This indicates that virtual worlds may provide a bridge for users that enable them to envision real-life possibilities. The evaluation also supported the choice of exhibit content, particularly the adaptation home and healthy aging exhibits that were rated “most useful.” Additionally, the evaluation revealed that participants were eager to provide feedback and discuss ways to improve existing exhibits, as shown by the high level of participation (25 of the 33 participants) in follow-up interviews.

One surprising finding from the evaluation was the high level of education that characterized participants. The majority (20) had earned a bachelor’s degree or higher. While the breakdown of educational level of Second Life residents is unknown, this calls into question the extent to which virtual worlds (and specifically Second Life) are able to serve health information needs of persons who have less education (and by extension, less income as the two factors are related). Are producers of this type of virtual world program serving the needs of only those fortunate enough to have access to a relatively high end computer and enough free time to explore these venues? At the present time, the answer is probably “yes.” This may change as greater numbers of people gain access to computers and the cost of computers decreases.

However, it is important for those involved in producing health-related programs in Second Life 11

Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 12

and other virtual worlds to realize that they may be serving the needs of a very small proportion of persons who could potentially benefit from information on health and wellness. Nevertheless, development of such programs in virtual worlds still may enable organizations to â&#x20AC;&#x153;go where people areâ&#x20AC;? and potentially reach new audiences (CDC, 2006).

It is also interesting to note that Second Life residents who participated in this evaluation consisted primarily of middle-aged to older adults, with most participants (21) over age 36 and many (13) over age 46. This may be related to several factors: the strategy used to recruit participants, the demographics of Second Life, and the specific topic areas covered in the OTC exhibits. First, participants were recruited primarily from education groups in Second Life comprising teachers, administrators, and technology specialists, who are expected to have a large proportion of members over age 36. Moreover, the greatest numbers of Second Life residents are in the middle and older adult range (46% over age 35) and account for 47% of total hours of usage (Second Life Wiki, 2008). Additionally, the most popular exhibits, home adaptation and healthy aging, may appeal to those over age 36 who are caregivers of older relatives or who might benefit personally from learning about options for adapting their homes and adopting lifestyle changes that promote healthy aging. Many of the comments listed in Table 2 support this focus for the home adaptation and healthy aging exhibits. Thus, the present evaluation, though drawing from a small sample of participants, may be viewed as a case example of Second Life content that is relevant and interesting to middle and older aged adults. This is consistent with Pearceâ&#x20AC;&#x2122;s (2008) finding that virtual worlds, especially those providing some type of intellectual challenge, are very engaging for middle aged and older adults.

Conclusion This paper reported a case study on the development and evaluation of exhibits on health and wellness at an occupational therapy education center in Second Life. Because of the small sample size (33 participants), results cannot be generalized to similar types of programs in Second Life or other worlds. However, findings indicate that the educational exhibits on health and wellness at the OTC were perceived as interesting and useful to participants, the majority of whom were middle aged or older and well educated. The evaluation also indicates that such exhibits may have practical applications beyond the virtual world experience and may provide resources for decision-making on home adaptation and lifestyle choices promoting healthy aging.

Evaluation of health and wellness programs by users may significantly enhance the content and/or format of these programs in virtual worlds. Additionally, it may be useful to explore development of individualized interventions focused on health promotion and disease selfmanagement for the large population of baby boomers who participate in Second Life and other virtual worlds.

Acknowledgements The Jefferson Occupational Therapy Center in Second Life is sponsored by the Department of Occupational Therapy, Jefferson School of Health Professions, Philadelphia.

Funding for the program evaluation was provided through a generous donation from Second Life resident Kathee Gibbs, through a grant from the USC-Annenberg Network Culture Project. The authors thank graduate students Lindsay Allan, Shanna Corbin, Suzanne Dimassa, Shyvonne Gallagher, Alison Geiger, and Sara Jasin for their assistance in creating and implementing exhibits at the OTC.

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Journal of Virtual Worlds Research- Development and Evaluation of Health and Wellness Exhibits 13

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