Journal of CyberTherapy and Rehabilitation, Volume 3, Issue 1, 2010

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Adolescent Internet Depression Prevention: Preferences for Intervention andPredictors of Intentions and Adherence

The Sense of Olfaction: Its Characteristics and Its Possible Applications in Virtual Environments

Can We Combine Learning with Augmented Reality Physical Activity?

Sex and Race Differences in Rating Others’ Pain, Pain-Related NegativeMood, Pain Coping, and Recommending Medical Help

The Effect of Activities in Virtual Worlds as a Communication Environmentto Understand Each Other

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Lessons Learned from VR Sessions with Warriors with Combat-Related PTSD

Behavioral Treatment of Earthquake Survivors

PTSD Due to Motor Vehicle Accident

Therapeutic Alliance in Telepsychotherapy

Virtual Reality in Iraq

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Journal of CyberTherapy &

rehabiliTaTion

Volume 3, Issue 1, Spring 2010

San Diego, California - Brussels, Belgium

ediTorial board

Mariano Luis Alcañiz Raya, Ph.D.Universidad Politécnica de ValenciaValencia, Spain

Rosa M. Baños, Ph.D.University of ValenciaValencia, Spain

A.L. BrooksAalborg UniversityEsbjerg, Denmark

Julian Dooley, Ph.D.Edith Cowan UniversityMount Lawley, Australia

Paul M.G. Emmelkamp, Ph.D.University of AmsterdamAmsterdam, Netherlands

Uri Feintuch, Ph.D.Hadassah-Hebrew UniversityMedical CenterJerusalem, Israel

Joshua Fogel, Ph.D.University of New YorkBrooklyn, New York

Tom Furness, Ph.D.University of WashingtonSeattle, Washington

Charles Hughes, Ph.D.University of Central FloridaOrlando, Florida

Wijnand IJsselsteijn, Ph.D.Eindhoven University of TechnologyEindhoven, Netherlands

Linda A. Jackson, Ph.D.Michigan State UniversityEast Lansing, Michigan

Sun. I. Kim, Ph.D.Hanyang UniversitySeoul, South Korea

Dragica Kozaric-Kovacic, M.D., Ph.D.University Hospital DubravaZagreb, Croatia

José Luis Mosso, M.D.Regional Hospital No. 25 of theIMSSMexico City, Mexico

Paul Pauli, Ph.D.University of WurzburgWurzburg, Germany

Heidi Sveistrup, Ph.D.University of OttawaOttawa, Ontario, Canada

Richard M. Satava, M.D., F.A.C.S.University of WashingtonSeattle, Washington

Mark D. Wiederhold, M.D., Ph.D., FACPVirtual Reality Medical CenterSan Diego, California

XiaoXiang Zheng, Ph.D.Zhejiang UniversityHangzhou, P.R. China

JCRJ o u r n a l o f C y b e r T h e r a p y & R e h a b i l i t a t i o n

ediTor-in-Chief

Brenda K. Wiederhold, Ph.D., MBA,BCIAVirtual Reality Medical InstituteBrussels, BelgiumVirtual Reality Medical CenterSan Diego, California

managing ediTor

Emily ButcherInteractive Media InstituteSan Diego, California

assoCiaTe ediTors

Cristina Botella, Ph.D.Jaume I UniversityCastelló de la Plana, Spain

Stéphane Bouchard, Ph.D.Université du Québec en OutaouaisGatineau, Québec, Canada

Luciano Gamberini, Ph.D.University of PadovaPadova, Italy

Giuseppe Riva, Ph.D., M.S., M.A.Istituto Auxologico ItalianoVerbania, Italy

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editorial

B. Wiederhold

“adolescent internet depression prevention: preferences for intervention and

predictors of intentions and adherence”

M. Marko, J. Fogel, E. Mykerezi & B. W. Van Voorhees

“The sense of olfaction: its Characteristics and its possible applications in

Virtual environments”

O. Baus & S. Bouchard

“Can We Combine learning with augmented reality physical activity?”

K.F. Hsiao

“sex and race differences in rating others’ pain, pain-related negative mood,

pain Coping, and recommending medical help”

A. Alqudah, A. Hirsh, L. Stutts, C. Scipio & M. Robinson

“The effect of activities in Virtual Worlds as a Communication environment to

understand each other”

H. Park

Cyberprojects

G. Riva

Cyberfocus

D. Stevens

Continuing education Quiz

A. Gorini

iACToR is the official voice and resource for the international community using advanced technologies in therapy, training, education, prevention, and rehabilitation.

MISSIONOur mission is to bring together top researchers, policy makers, funders, decision makers and clinicians, pooling collective knowledge to improve the quality, affordability, and availability of existing healthcare.

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Welcome, readers and researchers, to the Spring 2010issue of the Journal of CyberTherapy & Rehabilitation(JCR). Our peer-reviewed quarterly academic journalcontinues to explore and support the uses of advancedtechnologies for therapy, training, education, preven-tion and rehabilitation. JCR is unique in the fact that itfocuses on the rapidly expanding worldwide trend ofapplying ground-breaking technology towards the fieldof healthcare, with an emphasis on the fields of psychi-atry, psychology, physical medicine and rehabilitation,neurorehabilitation, oncology, obesity, eating disordersand autism.

With a growing international base of readers and sup-porters driven by a similar goal of advancing the useof technology in the healthcare sector, JCR has re-ceived positive attention from peers, international in-stitutions and international conferences. To keepreaders abreast of new developments, within this issueof JCR we present comprehensive articles submittedby preeminent scholars in the field, featuring such top-ics as combining physical activity with learning in anaugmented reality setting, including the sense of ol-faction more commonly in VR, and how communica-tion is used in virtual worlds like Second Life.

In the first article Voorhees et al. study the relationshipbetween attitude and adherence to treatment in adoles-cents with sub-threshold depression in order to improvepublic health strategies to prevent depressive disorders.

Next, Baus and Bouchard address the sense of olfactionand ways in which it can further and enrich VR any ad-vocate the growth of the field while discussing possibleapplications in virtual environments.

In an attempt to merge learning and physical activity inthe classroom, Hsiao next looks at using augmented re-ality and VR applications to provide more effectiveteaching methods and increase retention, while provid-ing much-needed exercise to the younger population atthe same time.

In the fourth article, Alquda et al. use Virtual Humansto look at how race and sex can affect how people inter-

pret others’ pain, pain coping skills, related mood, andother factors.

Lastly, Park discusses the use of Second Life as an ex-ample of how activities in virtual worlds might be usedas a communication environment to better understandeach other, with an emphasis in this study on gender.

As well as continuing to provide our readers with thelatest studies presented in an informative and engagingmedium, we will be offering one Continuing Educationquiz per issue as a further added service to our sub-scribers and others interested in supporting their educa-tion. For more information, see page 95.

I would like to sincerely thank the contributing authorsfor their inspiring work and dedication to this field ofresearch. I also want to thank JCR’s Associate Editors– Professor Botella, Professor Bouchard, ProfessorGamberini and Professor Riva for their leadership andhard work, as well as or internationally renowned Edi-torial Board for their contributions. I would also like totake this opportunity to welcome new Board members –Linda A. Jackson of Michigan State University, JulianDooley of Edith Cowan University, Wijnand IJsselsteijnfrom the Eindhoven University of Technology, JoshuaFogel from the University of New York, and XiaoXiangZheng of Zhejiang University – whose diverse back-ground and placement around the globe will bring addedrichness to our board. We encourage readers and sub-scribers to contact us with ideas and we welcome sub-missions. Your input continues to enrich our publication.

With the start of a new year, new possibilities aboundand we will continue to promote the growth of the di-verse field of advanced technologies for healthcare inEurope and worldwide. We are happy to count you as apart of this movement and thank you for your continuedsupport.

Brenda K. Wiederhold, Ph.D., MBA, BCIAEditor-in-Chief,

Journal of CyberTherapy & Rehabilitation

Virtual Reality Medical Institute

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J o u r n a l o f C y b e r T h e r a p y & R e h a b i l i t a t i o nS p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1© Vi r tua l Rea l i ty Med ica l In s t i t u t e

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adolesCenT inTerneT depression preVenTion:

preferenCes for inTerVenTion and

prediCTors of inTenTions and adherenCe

Monika Marko1, Joshua Fogel2, Elton Mykerezi3, and Benjamin W. Van Voorhees1, 4, 5

Adolescents in primary care with sub-threshold depression (not reaching criteria for disorder) symptomsmay be candidates for early intervention to prevent the onset of major depressive disorder. However,we know little about their attitudes toward such interventions or what may predict motivation or ad-herence for preventive interventions. We also describe preferences for different types of interventionsand conduct exploratory analyses to identify predictors of motivation to prevent depression and subse-quent adherence to an Internet-based intervention. Adolescents with sub-threshold depressed mood fa-vored novel behavioral treatment approaches, such as Internet-based models for depression prevention.Adolescent beliefs about the intervention and perceived social norms predicted intention to participatein depression prevention. The most important significant predictors of adherence were beliefs aboutthe intervention. Careful attention to the specific beliefs and attitudes of users toward interventionshould be incorporated into intervention design as well as evolving public health strategies to preventdepressive disorders.

Keywords: Depressive Disorder, Adolescents, Attitudes, Intervention, Internet

inTroduCTion

Twenty-eight percent of adolescents in the United Statesreport their current mood as depressed, while only 2-5%meet the symptom threshold for major depressive disor-der at any given time (Kessler & Walters, 1998; Rushton,Forcier, & Schectman, 2002). The great majority havesub-threshold depression symptoms, which do not cur-rently meet criteria for major depression but often willprogress to major depressive disorder (Andrews, 1994).By the age of 24, one-quarter of adolescents in the U.S.will develop a depressive disorder, with a substantial ad-verse impact on the individual and society and with costsin excess of 100 billion dollars per year (Cicchetti &Toth, 1998; Kessler & Walters, 1998; Weissman et al.,1999). However, even sub-threshold depressive symp-toms at the levels of minor depression (two symptoms

for greater than one week) are associated with consider-able cost and impairment of social and academic func-tions (Asarnow et al., 2005). Early or preventiveinterventions targeting individuals with sub-thresholdsymptoms (20% of primary care attendees) (B. W. VanVoorhees et al., 2005, 2006) have been recommended toreduce the burden of depressive disorders (Garber, 2006;B. W. Van Voorhees et al., 2009). Unfortunately, someindividuals with mild depressive symptom levels, whoare the primary targets of indicated prevention strategies,demonstrate negative attitudes and beliefs toward de-pression, which make them reluctant to consider an in-tervention (Druss, Hoff, & Rosenheck, 2000; Fortney,Rost, & Zhang, 1998; Jaycox et al., 2006; Leaf, Bruce,Tischler, & Holzer, 1987; Lin & Parikh, 1999; Sihvolaet al., 2006).

Corresponding Author:Benjamin Van Voorhees MD, MPH, Section of General Internal Medicine, Department of Medicine, The University of Chicago 5841 South Mary-land Blvd, Chicago, Illinois, 60637 USA, Tel: 773.702-3835, Fax: 773.834-2238, Email: [email protected]

1Department of Medicine, The University of Chicago, Chicago, Illinois, USA2Department of Economics, Brooklyn College of the City University of New York, Brooklyn, New York, USA3Department of Applied Economics, University of Minnesota, Twin Cities, St. Paul, MN, USA4Department of Psychiatry, The University of Chicago, Chicago, Illinois, USA5Department of Pediatrics, The University of Chicago, Chicago, Illinois, US

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Pediatricians and family physicians are taking on an ex-panded role in screening for depressed mood, and also inidentifying and treating adolescents with depressive disor-ders (Christensen, 2009; Grant, 2009; Kaltenthaler, 2008;Waller, 2009). The Internet offers a potentially more ac-ceptable form of intervention in primary care settings forearly intervention or prevention of mental disorders (Gar-ber et al., 2009; B. Van Voorhees et al., in press). Motivatedadolescents visit self-improvement Web sites to managealcohol use, smoking, obesity, sexual risk and HIV/AIDSrelated issues, and show positive behavior change as a re-sult(Kirk et al., 2003; Lou, Zhao, Gao, & Shah, 2006; C.A. Patten et al., 2006; Ybarra, 2006). For adults, Internetinterventions may be helpful in increasing levels of exer-cise, adopting a more favorable diet, stopping smoking,and reducing depressed mood (Van den Berg, Schoones,& Vliet Vlieland, 2007; Walters, Wright, & Shegog, 2006;Wantland, Portillo, Holzemer, Slaughter, & McGhee,2004). However, only 20% of the general population ap-pears interested in Internet-based lifestyle changes, and asfew as 10% actively visit such Web sites (Evers, 2005; Ver-heijden, Jans, Hildebrandt, & Hopman-Rock, 2007). Theuse of mental health related Web sites by adolescents issimilarly low (G. Clarke et al., 2002; S. B. Patten, 2003;Santor, Poulin, LeBlanc, & Kusumakar, 2007) Determin-ing preferences for intervention, and which attitudes andbeliefs are associated with motivation to use a depression-prevention Web site, could facilitate the development ofmore acceptable public health interventions to prevent de-pression in community settings.

The Competent Adulthood Transition with Cognitive-be-havioral, Humanistic, Interpersonal Training (CATCH-IT),(B. W. Van Voorhees et al., 2007) primary care based pre-ventive intervention was developed to target adolescentswith sub-threshold depressive symptoms and provide anacceptable, low-cost, and broadly availableintervention/prevention model of depressive disorders(Garber et al., 2009). This intervention/prevention modelsought to overcome barriers to deployment of preventiveinterventions for depression by offering the interventionwithin the framework of primary care with an initial en-gagement interview by the primary care physician (Land-back, 2009; B. W. Van Voorhees et al., 2007). Arandomized clinical trial was conducted, comparing twoforms of physician engagement (both groups having accessto the Internet site), a motivational interview (MI) versusbrief advice (BA) to determine whether the “patient cen-tered” MI approach (adolescents develop their own ration-ale for participation) was superior to the one which relies

on physician authority of recommendation (BA) (B. W.Van Voorhees, 2009). In this trial, both groups actively en-gaged in exploring the Internet site and demonstrated fa-vorable changes in vulnerability and protective factors fordepressive disorder. However, the MI group demonstratedhigher levels of adherence to the Internet intervention andfewer depressive episodes (B. W. Van Voorhees, Fogel, J.,Pomper, B. E., & Domanico, R., 2009; B. W. Van Voorheeset al., 2008).

A variety of predictors has been identified for adherenceto Internet-based interventions. We know that females,school-based settings, living in a rural area and lowerpretest anxiety scores predict greater adherence to Internetbased depression interventions in youth (Neil, Batterham,Christensen, Bennett, & Griffiths, 2009). We also knowthat, for older adults, psycho-education is the least pre-ferred option for preventing depression compared to exer-cise or vitamin supplementation (Grant, 2009). A fewstudies have reported varied levels of acceptability and sat-isfaction with computer-based cognitive behavioral psy-chotherapy (Kaltenthaler, 2008), but little is knownregarding the influence of specific attitudinal factors onadherence (Waller, 2009). In contrast, we do know whatadolescents in primary care think about depression preven-tion interventions and how such attitudes might influencemotivation and adherence. The use of theoretical modelsof behavioral change has been proposed as a method to de-velop a more systematic understanding of motivation andadherence to Internet-based mental health interventions(Christensen, 2009).

Organizing items according to the theory of planned behav-ior framework has been previously demonstrated to predictadolescent and emerging perceived need for treatment andintention in order to accept a physician’s diagnosis of majordepression (B. W. Van Voorhees et al., 2005, 2006). TheTheory of Planned Behavior provides a theoretical frame-work for understanding motivation, intention and adher-ence. According to this theory intention is the closestprecedent of behavior, which is directly influenced by atti-tudes and beliefs toward a behavior (e.g., attitudes towardintervention), subjective norms (e.g., concerns with regardto family, peer or employer opinions) and perceived behav-ioral control (e.g., self-efficacy), as a probability that onecan perform the specific behavior (e.g. adhering to the in-tervention) (Ajzen, 2002). In these analyses, beliefs and at-titudes toward the intervention and behavior, rather thansocial norms, were the most important predictors of inten-tion (B. W. Van Voorhees et al., 2005, 2006). Primary care

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physicians, health policy planners, and prevention re-searchers would benefit from a sound understanding ofpreferences for intervention and the attitudinal predictors ofgreater motivation for prevention and adherence to a pri-mary care/Internet-based intervention.

The purpose of this study is to provide an attitudinal de-scription and to identify predictors of passive and activeadherence within a sample of adolescents with sub-thresh-old depressed mood enrolled in a randomized clinical trialof a primary care/Internet-based depression intervention(B. W. Van Voorhees et al., 2009; B. W. Van Voorhees,Fogel, J., Pomper, B. E., & Domanico, R., 2009). We focuson adolescents with sub-threshold depressed mood in pri-mary care because are the likely targets of preventive in-terventions for major depression (Garber, 2006; Garber etal., 2009; Landback, 2009). We provide an attitudinal de-scription of this sample in the study and explore how spe-cific attitudes, measured at baseline, within the frameworkof the theory of planned behavior may influence motivationand adherence. Based on the framework of the theory ofplanned behavior, we hypothesize that (1) attitudes/beliefsabout intervention effectiveness would be the most impor-tant predictors of motivation for preventive interventionand participation in such an intervention in primary care.We also hypothesize that (2) adolescent primary care pa-tients with sub-threshold depressive symptoms would ex-hibit ambivalence toward established traditionalinterventions (medications, group and individual counsel-ing) similar to earlier studies of adolescents and adults withmajor depressive disorder (Cooper-Patrick et al., 1997; Jay-cox et al., 2006).

meThods

sTudy design

This study is based on a survey of adolescents enrolled toparticipate in a randomized controlled trial in primary careof an Internet-based depression intervention and preventionprogram (CATCH-IT). We conducted a phase-2 clinicaltrial of a primary care/Internet-based depression preventionintervention for adolescents at 13 U.S. primary care sites(B. W. Van Voorhees et al., 2009; B. W. Van Voorhees etal., 2008). Eligible adolescents were assigned randomly toeither a primary care physician (PCP) motivational inter-view plus the use of a Internet Web site or to PCP brief ad-vice and use of a Internet Web site. Those eligible andwilling to enroll completed a baseline questionnaire relat-ing to attitudes and beliefs, as well as motivation for pre-vention before they received their randomizationassignment. The responses to these questions, together with

the passive and active adherence to the Web site, are thesubject of our analysis. The passive and active adherenceof the intervention was approximated by time spent on theWeb site and number of characters typed in, respectively.Both measures were obtained by using simple algorithmsin the Web site. The randomized controlled trial methodshave been fully described in prior publications (B. W. VanVoorhees et al., 2009; B. W. Van Voorhees et al., 2008).The University of Chicago Institutional Review Board, aswell as those with responsibility for each site ,approvedthis study.

sTudy sample and eligibiliTy

Participants were adolescents (N=83) between the age of14-21, recruited from 13 primary care sites throughout theSouthern and Midwest U.S., and reported at least one coresymptom of depression at both the initial screening and theat the full eligibility assessment administered one to twoweeks after the initial screening. Potential participants wereidentified by completing a two-item screening question-naire based on the Patient Heath Questionnaire Adolescent(PHQ-A-2) core depression symptom items in the routineprocess of care (all adolescents visiting the clinic) (John-son, Harris, Spitzer, & Williams, 2002). Adolescents re-porting any core depressive symptom lasting longer than afew days in the two weeks prior to the screening were con-sidered “positive.” Those with “positive” screens and whoconsented to be contacted by study staff were called byphone for eligibility assessment. Inclusion criteria includedaged between 14-21, presence of one core symptom of de-pression, but below the level of major depression (four orfewer symptoms, “sub-threshold depressed mood”). Ex-clusion criteria included meeting criteria (or getting treat-ment) for minor or major depression, expressing frequentsuicidal thought or intent, bipolar disorder, conduct disor-der, substance abuse, generalized anxiety disorder, or anytype of eating disorder. Consent from adolescents and par-ents (if adolescents were under 18 years old) was collectedby study staff at the clinic. A full description and the criteriaof the recruiting method have been previously reported(Johnson et al., 2002).

demographiCs

Information on age, gender, race/ethnicity, and educationlevel was recorded. Furthermore, family’s history of de-pression or any depressive disorder pertaining to the indi-vidual was assessed by asking, “Have you ever beentreated for depression (via medication or counseling)?” and“Have any of your family members (mother, father,sister(s), brother(s)) ever been treated for depression that

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lasted at least four weeks?” For the participant’s dimen-sional measures of depressed mood we report Center forEpidemiologic Studies Depression Scale 10 items(CESD10), scored as double to create the 60-point scale.

preferenCes for inTerVenTion

Preferences for treatment (get over it naturally, medication,one-on-one or group counseling) were developed from theQuality Improvement in Depression study, which showedthat among primary care adult patients viewing treatmentsas unacceptable, there is an association with a lower like-lihood of seeking treatment (Rost, Nutting, Smith, &Werner, 2000). Responses were recorded in a Likert-typescale ranging from “1=definitely acceptable” to “4=defi-nitely not acceptable,” where participants rated statementssuch as “I will wait and get over it naturally,” “Use anti-depressant drugs,” “Seek one-on-one counseling from amental health specialist,” and “Seek group counseling…led by a mental health specialist.” We added several optionsthat were not included in the original scale, represented bystatements such as “Talking with primary care physician(PCP) about what you can do to prevent depression,”“Talking with PCP and agreeing to set up a regular sched-ule,” “Talking with PCP about your feelings and situation,”“Talking with PCP and agreeing to complete an e-pro-gram,” “Talking to a counselor through the phone aboutyour feelings,” “Complete a questionnaire with your PCP,”“Complete a questionnaire Online,” “Start an exercise pro-gram with thirty minutes of aerobic activity, individually,”“Start an exercise program with thirty minutes of aerobicactivity with a group,” “Participate in a religious youthgroup,” “Take a health class to learn about feelings andcoping skills,” and “Group meeting with 6-10 peers fromyour school.” All items were scaled in accordance to theoriginal scale, as mentioned above.

depression preVenTion iTems based upon Theory of

planned behaVior

We adapted the items from a previous questionnaire, whichwas modified based on the preventive health model (Myerset al., 1996; B. W. Van Voorhees et al., 2006). The originalinstrument, developed for prostate cancer, was adapted toprimary care based depression prevention. The reliability(Cronbach alpha =0.89) and validity of the instrument wasevaluated during a pilot study of the CATCH-IT interven-tion in 2004. Validity is supported by several items demon-strating a trend toward predicting intervention performance(predictive validity) and post-study qualitative interviewssuggested that the concerns/themes identified were consis-tent with items on the scale (face validity). The participants

indicated a level of agreement based on a Likert-type scaleranging from “1=strongly disagree” to “5=strongly agree.”Beliefs about the intervention were defined by such state-ments as “depression intervention makes sense to me,”“protecting yourself from depression through interven-tion,” “participating in intervention is important,” “if de-pression is found early it can be prevented,” “depressionintervention could prevent further depression,” “depressionintervention will help me to get healthy,” and “would bebetter off without the intervention.” Attitudes toward thebehavioral intervention were measured by the statements“going through depression intervention is too much trou-ble,” “the benefits of the prevention outweigh any diffi-culty,” and “going through a depression intervention is tooembarrassing.” Subjective social norms were measured bysuch statements as “members of my family support megoing through intervention,” “I want to please family,” “Iwant to do what the doctors want me to do about depres-sion,” “I think physicians want me to do a depression in-tervention,” “my close friends support my going througha depression intervention,” and “I want to please my closefriends.” Perceived behavioral control was measured byself-efficacy and had items of “going through this depres-sion intervention would be easy” and “arranging the sched-ule for the intervention will be easy.” We had previouslyadministered this questionnaire in a pilot study and foundit acceptable and easily understood.

moTiVaTion ToWard preVenTiVe inTerVenTion

These items were adapted from Miller and Rollnick’sthree-item assessment of motivation (Miller & Rollnick,1991). The measures of motivation toward treatment or in-tervention were constructed from the responses to the fol-lowing statements measured with a Likert-type scaleranging from “1=not important” to “10=very important”:“rate your ability to learn coping skills to reduce your riskof clinical depression,” “rate your readiness to reduce yourrisk of clinical depression by learning coping skills,” and“rate the importance of preventing an episode of clinicaldepression over the next year.”

ouTCome Variables

BEhavioral iNtENtioN

Behavioral intention was measured by the stage of chang-ing ways to deal with problems in order to prevent depres-sion. It was measured by the response to the question,“Please indicate which statement best fits your current po-sition with regard to changing the way you think about andsolve everyday problems to reduce your risk of developingclinical depression.” Participants indicated their responses


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using a Likert-type scale, consisting of “1=I have not givenany thought to changing...”, “2=I am giving some thoughtto changing...”, “3=I am preparing to change...”, “4=I havedecided to change...but do not have a plan...” and “5=I havedecided to change...and I have a plan...” where higherscores indicate a more active adherence towards changingthe behavior.

PassivE adhErENcE

We measured passive adherence on the Web site by calcu-lating the total amount of time participants spent onlinethroughout the intervention. This variable was constructedby a simple algorithm, which subtracted the first page loadtimestamp from the last page load timestamp in a givensession. The length of time for each session was capped atseven minutes, since that is the approximate maximumamount of time required to review the materials on eachpage. In cases when sessions lasted more then seven min-utes, we assumed the participant was not reviewing mate-rial and the page was still loading. The length of all sessionswas then added together to generate the total amount oftime spent online. We chose to calculate time spent on theWeb site because this is a broad measure of willingness toat least review material related to depression preventionand its ease of measurement (B. W. Van Voorhees et al.,2009). Visitation of the Internet Web site was done entirelyat the adolescents’ discretion and occurred completely sep-arate from the physician encounter.

activE adhErENcE

Active adherence was measured by a proxy measure of thetotal number of characters typed throughout the interven-tion. The variable was constructed by counting the totalnumber of characters typed by each participant as a part ofcompleting exercises and writing notes at the end of eachmodule, and then adding the characters together across allmodules to generate the total number of characters typed.This outcome variable was used to measure the active be-havior of the participants. It was selected because of itsease of measurement and its relationship to choosing to ac-tively participate in a behavior change process (B. W. VanVoorhees et al., 2009). This is similar to “homework” incognitive behavioral psychotherapy.

statistical aNalysEs

Descriptive statistics were calculated for the demographicvariables, preferences for treatment variables, and depres-sion prevention items based upon the theory of planned be-havior. Separate linear regression analyses were performedfor the three outcome variables of intention, passive adher-

ence, and active adherence. As passive adherence and ac-tive adherence were both skewed data, they were logarith-mically transformed to allow for a normal distribution.There were four models for each analysis. Model 1 was aunivariate analysis. Model 2 adjusted for age, race/ethnic-ity (white/non-white), and gender. Model 3 adjusted for theitems from the same category/block. Model 4 simultane-ously adjusted for all items that were significant or ap-proached significance for each outcome (p-value<0.10) inmodel 3 in order to understand the strongest correlates fromthe category/block in a multivariate framework. Motivationitems were added as predictors to the passive adherenceand active adherence outcome analyses. They were not in-cluded for the intention outcome analysis, as the theory ofplanned behavior does not typically include motivation asa predictor for the intention outcome. STATA 10 was usedto conduct the analyses ("Stata Statistical Software: Re-lease 10," 2009).

resulTs

demographiCs

The total number of participants screened reporting at leastone core depressive symptom in the two weeks prior to thescreening comprised 21% (N=293) of the entire sample,with participants aged from 14-21 years. One hundred andsixty-two participants were contacted to participate in thefull assessment, (N=131 were not able to be contacted). Ofthe 162 participants, 71.6% (N=116) agreed to a full assess-ment and 13 were ruled ineligible (i.e., due to major depres-sion, conduct disorder, or suicide intent). The remaining 103participants were found eligible and 80.6% (N=83) en-rolled. Fifty-seven percent were females (N=47). Race/eth-nicity varied and included, 61% (N=49) whites and 24%African American (N=19), followed by 6% Asians (N=5),5% Hispanics (N=4), and 4% of other racial composition(N=3). Average age was 17.5 years old (SD=2.04). Twenty-seven percent of the adolescents (N=20) sampled were cur-rently attending college, with one individual who hadalready completed college, while over half of the teens hadfinished at least 10 years of education (N=43) and 14%(N=10) had completed 12 years of education. The meanhousehold income of the sample measured by zip code in-formation obtained from the U.S. Census 2000 was $40,249(SD=$14,500). More than half of the screened adolescentsin the sample had a family history of depression (N=43),while 31% (N=21) of the adolescents had received priorcounseling, and 18% (N=13) had been previously treatedwith medication. The demographic profile of this samplehas been reported in greater detail in the primary clinicaltrial publication (B. W. Van Voorhees et al., 2009).

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As shown in Table 1, most adolescents preferred primarycare based interventions, such as talking to their primarycare doctor about what to do to prevent depression

(86.95%, N=60 chose definitely acceptable and probablyacceptable). Other popular preferences endorsed by morethan 75% included talking with PCP and agreeing to set upa regular schedule of pleasurable activities, starting an in-

Table 1Preferences for Treatment

Note. ** Adjusted for similar items in the block


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dividual aerobic exercise program for thirty minutes a day,talking with PCP about feelings and situation, completingInternet questionnaires, seeking one-on-one counselingfrom a mental health specialist, starting a group aerobic ex-ercise program for thirty minutes a day, and completingquestionnaires with a PCP. The least preferred preferencesfor treatment that were endorsed by less than 40% includedtalking to a counselor by phone about their feelings, and a

group meeting with 6-10 peers from your school. Almostthree-fifths endorsed “waiting and getting over it naturally”(i.e., no treatment) as acceptable.

depression preVenTion iTems based upon Theory of

planned behaVior

As shown in Table 2, most adolescents endorsed favorablebeliefs toward a primary care Internet-based depression

Table 2Depression Prevention Based on Theory of Planned Behavior

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Table 2 cont.


Table 2 cont.

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prevention intervention program, indicating that it makessense to them (68%, N=53 chose strongly agree and agree)and believing it will help them be healthy (70%, N=53chose strongly agree and agree). Additional beliefs favoredby more than 64% (N=50) included beliefs that depression,if detected early, can be prevented, prevention interventioncould prevent further depression (65% N=51), and stronglydisagree/disagree with being better off without a depressionprevention intervention (68% N=54). For the attitudeitems, 60% (N=46) favored that the benefits of a depressionprevention program outweigh any difficulty. Similarly,adolescents (62.83% N=49) generally disagreed with theconcept that the intervention was “too much trouble” butonly a minority reported favorable social norms toward theintervention. In terms of self-efficacy, while most felt itwould be easy to arrange their schedule to participate (59%N=45) only less than half the adolescents in the sample feltthat completing such an intervention would be “easy”(42% N=32).

prediCTors of inTenTions

As shown in Table 3, with regard to beliefs, the belief of“participating in an intervention like this is important” sig-nificantly predicted intentions for changing ways to dealwith problems in order to prevent depression for Models 1and 3 and approached significance in Model 2. Also, thebelief of “a depression prevention intervention could pre-vent further depression” was significant in Model 1 and ap-proached significance in Model 2. None of the attitudessignificantly predicted intentions. Social norms had signif-icance in Model 3 for the family item of “I want to pleasemy family,” the physician item of “I want to do what thephysicians want me to do about depression prevention” inModel 1 and Model 3, and approached significance forfriends for the item of “My close friends support my going

through a depression prevention program” in Models 1 and3. No self-efficacy items were significant. The demograph-ics item of male gender significantly predicted lower inten-tion in Model 1 and 3, but depressed mood (CES-D score)did not predict intentions. In Model 4, only the social normsitem of family was significantly associated with intentions.

prediCTors of passiVe adherenCe

As shown in Table 4 with regards to beliefs, the belief of“participating in an intervention like this is important” and“a depression prevention intervention could prevent furtherdepression” all significantly predicted total time spent on-line as a measure of passive adherence to prevent depressionfor Models 1 and Model 2. Also, there was a significantnegative association with “being better off without a depres-sion prevention intervention” and total time spent online inModels 1, 2, and 3. The attitude item of “the benefits of adepression prevention intervention outweigh any difficulty”significantly predicted total time spent online in Models 1and 2. None of the perceived social norms significantly pre-dicted total time spent online. The perceived behavioralcontrol item of “arranging my schedule for depression pre-vention intervention will be easy” significantly predictedtotal time spent online in Model 3. Motivation item of “rateyour ability to learn coping skills to reduce your risk of clin-ical depression” significantly predicted total time spent on-line for both Models 1 and 2 and the motivation item of“readiness” approached significance in Model 1 and wassignificant in Model 2. The motivation item of “preventingan episode” approached significance in Model 2. Depressedmood did not predict total time spent online in any of themodels with which it was included. In Model 4, only thebelief about “being better off without a depression preven-tion intervention” was significant with a negative associa-tion with total time spent online.

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Table 3Predictors of Intention

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prediCTors of aCTiVe adherenCe

As shown in Table 5 with regards to beliefs, the beliefs of“protecting myself from depression through a depressionprevention intervention,” “participating in an interventionlike this is important,” and “when depression is found earlyit can be prevented” all significantly predicted the total

numbers of characters typed, as a measure of active adher-ence in preventing depression in Models 1 and 2. The beliefof “depression prevention intervention could prevent fur-ther depression” for Models 1 and 2, and also “depressionprevention intervention will help me to be healthy” forModel 1, all approached significance. With regard to atti-


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Table 3 cont.

tudes, the item of “the benefits of a depression preventionintervention outweigh any difficulty” significantly pre-dicted number of characters typed in Models 1, 2, and 3.The social norm item of “I want to do what the physicianswant me to do about depression prevention” significantlypredicted the dependent variable only in Models 1 and 2

and approached significance in Model 3. Also, there was anegative association of “immediate family support” for sig-nificantly predicting number of characters typed in Model3. None of the perceived behavioral control items weresignificant predictors. Male gender approached signifi-cance for a negative association with number of characters

typed in Model 3. The motivation item of “readiness” sig-nificantly predicted the total number of characters typed inModels 1, 2, and 3. Depressed mood did not predict num-ber of characters typed in any of the models with which itwas included. In Model 4, only the belief item of “protect-ing myself from depression through a depression preven-tion intervention” significantly predicted total numbers ofcharacters typed.

missing daTa ConCerns

Participants and those eligible to participate did not differbased on PHQ-A -2 scores. Similarly, participants did notvary based on PHQ-A-2 scores from those we identifiedin screening but whom we either did not reach or did notconsent to a phone interview. We examined reasons fornon-participation in the phone assessment (N=177). Ofthose who did not participate in the initial phone assess-

ment, 46 answered the phone for the follow-up study. Ofthose who answered the phone, the most common reasonfor declining an interview was that they were not interested(50.0%, N=23), followed by being too young (21.7%,N=10). There was no significant difference in the level ofdepressed mood between those who participated in thestudy and those who chose not to participate.

disCussion

Adolescents endorsed favorable attitudes and prefer-ences toward primary care Internet-based interventionsand more ambivalent attitudes toward more traditionaldelivery forms such a group counseling program. Whilethe majority of the sample participants found conven-tional approaches to depression prevention, such as talk-ing to their primary care doctors about depressionprevention and feelings and setting up a regular schedule

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Table 3 cont.


Self efficacy

Demographics

Table 4Predictors of Passive Adherence

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with their family practitioners acceptable, a great numberof the adolescents found novel forms of intervention ac-ceptable, such as completing an Internet questionnaireand starting an individual exercise program. Further-more, most of the adolescents we assessed agreed thatintervention programs were important and relevant andmore than half believed that an intervention program

could help prevent further depression. The most impor-tant predictors were family social norms for intentions,disagreeing with the belief about “being better off with-out a depression prevention intervention” for passive ad-herence, and the belief of “protecting myself fromdepression through a depression prevention intervention”for active adherence.

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Table 4 cont.


This is the first study to consider preferences for interven-tion of adolescents with sub-threshold symptoms. As hy-pothesized, (hypothesis 2) we found that adolescents withsub-threshold symptoms in primary care preferred novelapproaches such as personal exercise or completing Inter-net questionnaires. The preference for primary care and In-ternet-based approaches might be congruent to thepreference reported for an autonomous-supportive envi-ronment from patients’ health practitioners (Sheldon, 2003;Vansteenkiste & Sheldon, 2006; Wisdom, Clarke, &Green, 2006) and methods under personal control such asexercise or vitamin supplementation (Grant, 2009). Thefindings that a majority of adolescents preferred no treat-ment (57%) (“Waiting and getting over in naturally”) andpreferred individual counseling (79%) to group counseling

(43%) are new and important. The most effective preven-tive intervention to date have used the group counselingapproach (G. N. H. Clarke, M., Lynch, F., et al., 2001; Gar-ber et al., 2009). This is consistent with preference ex-pressed by older adults for less psychologically-orientedapproaches such as those including exercise and vitamins(Grant, 2009). In contrast, Jaycox and colleagues demon-strated that most adolescents in primary care settings diag-nosed with major depressive disorder preferred activetreatment (72%) with face-to-face counseling or anti-de-pressants, rather than watchful waiting (28%) (Jaycox etal., 2006). This difference might be explained by the find-ings that symptom severity substantially predicts perceivedneed for intervention and willingness to accept treatment(B. W. Van Voorhees et al., 2003; B. W. Van Voorhees etal., 2005, 2006) and in our study participants had low levels


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of depression symptom severity. Our study findings in anadolescent sample may differ due to the greater concern ofadolescents with regard to opinions of peers compared toadults.

aTTiTudes ToWard depression preVenTion

Prior studies have assessed the influence that attitudes andbeliefs of adolescents with varying levels of symptomshave on their intent to seek treatment (B. W. Van Voorheeset al., 2007; B. W. Van Voorhees et al., 2006) or preferencesfor treatment (Jaycox et al., 2006). However, to our knowl-edge this is the first study that reports specific attitudes andbeliefs towards depression prevention on adolescents withsub-threshold depressive symptoms (Christensen, 2009;Neil et al., 2009). Our study also departs from the previousstudies in that it assesses perceived behavioral control inaccordance with the theory of planned behavior framework(Ajzen, 2002). The participants appeared to endorse pri-mary care/Internet-based prevention, which is consistent

with prior work demonstrating that the lay public and ado-lescents view primary care physicians as their first sourcefor care (Highet, Hickie, & Davenport, 2002; Joffe, Radius,& Gall, 1988) and that they desire psychosocial interven-tions despite the reported growing acceptance of the “bio-logical model” for treating depression (Blumner & Marcus,2009).

prediCTors of inTenTions

The significant relationship for both beliefs about the in-tervention and perceived social norms with the intentionsoutcome is a new finding consistent with prior work thatshows attitudes/beliefs toward an intervention predict bothintention and service use (Jaycox et al., 2006; Leaf et al.,1987; Lin & Parikh, 1999; B. W. Van Voorhees et al., 2003;B. W. Van Voorhees et al., 2005, 2006). However, the rel-atively greater importance of social norms for predictingintention to prevention surprised us because our prior workwith predicting treatment suggested that beliefs toward the

Table 4 cont.

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Table 5Predictors of Active Adherence


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Table 5 cont.

intervention demonstrated a primacy in decision-making(B. W. Van Voorhees et al., 2005, 2006). Similarly, self-ef-ficacy and/or attitudes toward the behavior did not predictintention or use as it has in other studies (Leaf et al., 1988;B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al.,2005, 2006). Perhaps for new or novel preventive inter-ventions such as our Internet-based intervention and also

when the perceived need for treatment is low since theseindividuals had sub-threshold depressive symptoms, anadolescent turns to family, such as parents, and friends forguidance (DeBar, 2009). The inverse relationship betweenmales and intention is consistent with prior work demon-strating greater use by females of the Internet-based pro-grams (Christensen, 2009; Neil et al., 2009).

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prediCTors of passiVe and aCTiVe adherenCe

The findings that beliefs about the intervention, attitudestoward behavior, self-efficacy and motivation predict pas-sive and active adherence for the prevention interventionis a new finding. Conversely, demographic factors such asage, gender, depressed mood severity or non-white ethnic-ity, did not influence adherence as has been noted in priorstudies (Christensen, 2009; Neil et al., 2009). The findingsthat beliefs concerning the intervention were the most im-portant predictors support our first hypothesis that beliefsabout intervention effectiveness would be the most impor-tant predictors of motivation for preventive intervention.These findings are consistent with an extensive amount ofliterature linking attitudes to help seeking and/or intentions(Jaycox et al., 2006; Leaf et al., 1987; Lin & Parikh, 1999;B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al.,2005, 2006). These findings are also consistent with thetheoretical models of the Theory of Planned Behavior(Hagger, Chatzisarantis, Biddle, & Chatzisarantis, 2002)and Transtheoretical Model of Change (Miller & Rollnick,1991). Similarly, we have previously established that mo-

tivational interviewing before Web site use increases bothtime on the Web site and also number of characters typed(B. W. Van Voorhees, Fogel, J., Pomper, B. E., & Doman-ico, R., 2009). Neil and his team have previously demon-strated that symptom severity influences adherence (Neilet al., 2009). We were surprised that symptom severity didnot influence adherence in our study. This may reflect thatthe perceived need for “intervention” was deliberately con-structed around a “prevention and resiliency model” ratherthan an illness model (B. Van Voorhees et al., in press). Per-haps the adolescents discounted their current symptomswhen determining whether or not to engage in the InternetWeb site activities (B. Van Voorhees et al., in press; B. W.Van Voorhees et al., 2007).

limiTaTions

The primary strength of this study was the recruitment ofa sample of adolescents in varied primary care settings intwo U.S. regions, which resulted in a diverse sample (40%ethnic minority). Limitations of this study include thesmall sample size and possible selection bias toward ado-

Table 5 cont.


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lescents who may be more favorably disposed toward pri-mary care, Internet-based interventions and possibly allmental health interventions than adolescents who chose notto respond to the study after the initial screening identifiedthem as “at risk.” Similarly, we omitted individuals whodid not visit the Internet site from the adherence analysesin order to convert the outcome variable to a natural logand attain a normal distribution. Also, the small sample sizelimited the capacity to complete multivariate analyses andconsequently may have underestimated the number of po-tentially significant relationships in the multivariate mod-els. Conversely, the adolescent participants that consentedto a relatively “low burden” study and were found eligibleto participate in the study were not originally “seeking”treatment for depression or any other mental-health relateddisease. As such, they might have represented a “snap shot”of primary care attendees in these practices. Given the lim-itations of the sample size, we must characterize these find-ings as exploratory in nature.

ConClusion

Adolescents in primary care are open to the idea of earlypreventive intervention to avert developing depressiveepisodes. They seem to prefer novel forms of interventionsuch as Internet-based types and primary care-based pre-scriptions for exercise. Clinicians should recognize that ado-lescents might be persuaded to take more proactiveapproaches to preventing depression based on their recom-mendations. Clinicians should consider the potential valueof novel interventions such as adherence to daily exercisesor use of cognitive behavioral therapy through Internet Websites. Researchers should consider the value of embeddinginterventions into the normative framework of primary carewhere physicians’ persuasive influence can be exercised andcontrolled. Policy makers should consider primary care asan acceptable environment to intervene to prevent depres-sive disorders in adolescents and consider how such effortscan be supported with adequate reimbursement from thehealthcare and health insurance systems.

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The sense of olfaCTion: iTs CharaCTerisTiCs

and iTs possible appliCaTions in

VirTual enVironmenTs

Oliver Baus1,3 and Stéphane Bouchard1,2,3

Virtual environments (VE) aim to reproduce life-like experiences, but despite indications that the ol-factory sense plays a significant role in everyday life, the integration of olfactory stimuli in VEs is rare.The aim of this paper is to review the literature on olfaction and its potential applications in VirtualReality (VR). Indications supporting the integration of odorants in VR include the privileged connec-tions between the olfactory system and the brain regions involved in the processing of virtual stimuliused in clinical applications, as well as the interaction between odors, the other senses, and variouspsychological processes. Presently, smells are mostly integrated in VR applications for post-traumaticstress disorder and drug addiction, but further uses of odorants in VEs could include pain distraction,various training scenarios, such as emergency response and relaxation, and investigations of multi-sen-sory integration.

Keywords: Olfaction, Smell, Odor, Virtual Environment, Virtual Reality

“Of all the ways of getting sensory information to thebrain, the olfactory system is the most ancient and perhapsthe least understood” (Ratey, 2001, p. 62). The sense ofsmell is believed to have been a major catalyst in the evo-lution of the primitive brain, and it is suspected that theentire limbic system actually evolved from its originalfunction of interpreting odorants and emitting pheromones(Ratey, 2001). Its significance for animals is readily rec-ognized (Ache & Young, 2005). It plays a role in theirsearch for food, navigation and orientation, reproductivebehavior, and social organization (Albrecht & Wiesmann,2006). Although many of these aspects also apply to hu-mans (Albrecht & Wiesmann, 2006), many tend to con-sider olfaction of minor importance (Shepherd, 2006).

The relatively minor interest in the olfactory sense is alsoreflected in the field of virtual reality (VR), and variousfactors may contribute to the underutilization of olfactorystimuli in virtual environments (VE). According to Sad-

owski (1999), these factors include the perception that in-corporating olfaction stimuli would neither enhance thevirtual experience, nor be useful in concrete applications.Most importantly, the primary obstacle to a generalizedintegration of olfactory stimuli in VEs may be the diffi-culty in dispensing and controlling the odorants in the en-vironment (Sadowski, 1999).

To date, relaxation techniques (Kawai & Noro, 1996),posttraumatic stress disorder (PTSD) treatment (Gerardi,Rothbaum, Ressler, Heekin, & Rizzo, 2008), and drug ad-diction research (Bordnick et al., 2008; Ryan, Kreiner,Chapman, & Stark-Wroblewski, 2009) belong to the rareapplications integrating olfactory cues in clinically perti-nent VR scenarios. More specifically, Kawai and Noro(1996) coordinated olfactory cues with the content ofstereoscopic 3-D images, for example, using the fragranceof a forest with 3-D images of a green forest, in order toexperiment with the relaxation effects of such combina-

Corresponding Author:Stéphane Bouchard, Dept de Psychoéducation et de psychologie, Université du Québec en Outaouais, C.P. 1250 Succ "Hull", Gatineau, Québec,J8X 3X7, E-mail: [email protected].

1University of Ottawa, Ottawa, Ontario, Canada2Université du Québec en Outaouais, Gatineau, Quebec, Canada3Laboratory of Cyberpsychology, Gatineau, Quebec, Canada

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tions. The results of this experiment suggest that such as-sociations can lead to a psychological effect as measuredin three psychological factors–depressive mood, anxiousmood, as well as tension and excitement–that differs ac-cording to the type of fragrance (forest, marine, or laven-der). In the field of PTSD treatment in VR, Gerardi andcolleagues' (2008) protocol calls for exposure to visual,auditory, tactile (i.e., vibration), and olfactory stimuli(burning rubber, diesel fuel, weapons fire and spices).During treatment, the patient is exposed to multi-sensorycombat zone stimuli while driving a Humvee in eitherurban or non-urban "Iraq-like" scenes. The intensity ofthese stimuli increases gradually across sessions. The re-sults of this brief, single case VR exposure treatment in-cluded clinically and statistically significant changes inscores on the Clinician Administered PTSD Scale (Blakeet al., 1990) and the PTSD Symptom Scale Self-Report(Foa, Riggs, Dancu, & Rothbaum, 1993), thereby suggest-ing preliminary promise for this type of intervention (Ger-ardi et al., 2008). In the field of substance abuse andaddictions, Bordnick and colleagues' (2008) VR alcoholcue reactivity assessment system incorporated visual, au-ditory and olfactory stimuli. These stimuli included thescents of vanilla, pizza, coffee, the preferred drink of theparticipant (such as whiskey, beer, brandy, tequila, gin,scotch, red wine or white wine), beer, cigarette smoke, andpine trees. During trials involving non-treatment seekingindividuals with alcohol use disorders, the exposure of thesubjects to multi-sensory alcohol related cues generatedhigher subjective alcohol cravings than when these cueswere absent. Furthermore, the multi-modal VE appears tobe associated with high levels of presence in VR (Bord-nick et al., 2008). In an interesting variation on the previ-ous experience, Ryan et al. (2009) found that, whenexposed to multi-sensory alcohol related cues, bingedrinking college students reported significantly highercravings for, and thoughts of, alcohol than non-bingedrinkers.

Yet, considering that the sense of smell plays a significantrole in everyday human life (Drummond, Douglas, &Olver, 2007), and that its loss or impairment has signifi-cant chances of adversely affecting an individual’s qualityof living and emotional experience (Pollatos et al., 2007),it would seem that the successful integration of olfactorystimuli in VEs should be pursued more actively. Thus, thepurpose of this paper is to provide VR researchers anoverview of the olfactory system, and its involvement inpsychological reactions, in the hope that this informationmay contribute to an increased use of olfactory cues in VR

clinical applications. To this end, the information is struc-tured into six sections, the first of which briefly addressesthe neuroanatomy of the olfactory system. The next twosections cover the capabilities of the olfactory sense, andthe characteristics of odors. Next, the potential interactionsinvolving the olfactory sense are covered. The fourth sec-tion presents various factors that influence olfactory pro-cessing and the fifth section presents some of theinfluences of odors on physiological state, perception andmental processes. Lastly, the present status of the researchinvolving the sense of olfaction, and the use of olfactorystimuli in VEs will be discussed. This discussion will in-troduce some of the present, and some of the potential, ap-plications of exposure to olfactory stimuli in VEs.

neuroanaTomy of The olfaCTory sysTem

Olfaction is the “sensation of odors that results from thedetection of odorous substances aerosolized in the envi-ronment” (Simpson & Sweazy, 2006, p.377), and thus, itis categorized as a chemical sense, as in the sense of taste.In addressing olfaction, it is important to distinguish be-tween the terms “odor” and “odorant” (e.g., Hudson, 2000;Hudson & Distel, 2002a,b). While an odorant, or olfactorystimulus, is a physicochemical entity of molecules in theenvironment (Hudson & Distel, 2003), an odor is the per-cept created by a subject’s nervous system, in reaction tothe contact between the olfactory receptors and the mole-cule patterns of the odorant (Hudson & Distel, 2003).

An odorant commences its transformation into an odor ei-ther from the outside (orthonasal) or from the inside(retronasal) of the subject’s body. Whereas orthonasalstimulation results from sniffing the ambient air, retronasalstimulation results when the odorants of ingested foodtravel up from the back of the oral cavity and through thenasopharynx into the nasal cavity (Shepherd, 2006). In ei-ther case, the odorant ends up in the olfactory mucosa, it-self located in the superior and posterior part of the nasalcavity (Mackay-Sim & Royet, 2006). There, the odorant,which must be hydrophilic or lipophilic in order to dis-solve in the mucus (Stockhorst & Pietrowsky, 2004),comes into contact with the olfactory receptors of the ol-factory epithelium (Ratey, 2001). The axons of the sensoryneurons fasciculate to form the fila olfactoria (Mackay-Sim & Royet, 2006), which traverses the skull basethrough the cribriform plate, to then enter the olfactorybulb. The left and right olfactory bulbs are interconnectedvia the anterior commissure (Mackay-Sim & Royet,2006), and axons leave the olfactory bulb via the olfactorytract, to then project onto a group of structures collectively

The Sense of Olfaction

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referred to as the primary olfactory cortex (Mackay-Sim& Royet, 2006). These structures include the amygdalawhich seems to play critical roles in odor processing(Jones-Gotman & Zatorre, 1993; Zald & Pardo, 2000),conditioned fear and attention (Bremner et al., 1999), aswell as aversive and negative emotional states (Hamann& Mao, 2002). There exist important differences in neu-roanatomical connections between the olfactory sense andother senses. The various connections of the olfactory sys-tem are illustrated at Fig.1. While other senses go througha series of cortical relays before reaching the limbic sys-tem, the olfactory bulb projects uncrossed (Ratey, 2001),and without being mediated by the thalamus (Simpson &Sweazy, 2006), onto the amygdala. There seems, however,to exist an additional indirect and less prominent link be-tween the primary olfactory cortex and the secondary ol-factory area via the thalamus, (Djordjevic &Jones-Gotman, 2006). In addition, the connection to theorbitofrontal cortex provides olfaction with the “fastestroute between perception and action” (Malaspina et al.,2006, p. 222).

In summary, an odor is the result of complex interactionsbetween the molecular pattern of an odorant, the olfactoryreceptors, the olfactory bulb, the primary olfactory cortexand the secondary olfactory area. Most importantly, whencompared to the other senses, the sense of olfaction enjoysa more direct, and thus, faster and less filtered, uncrossedconnection with the amygdala. It is this privileged relationwith the limbic system, as well as that with the or-bitofrontal cortex, that speak in favor of the use of olfac-tory cues in VR. Indeed, many of these brain regions areinvolved in the processing of virtual stimuli used in clin-ical applications, including anxiety disorders (Phillips,Drevets, Rauch, & Lane, 2003), addictions (Everitt &Robbins, 2005) and eating disorders (Beckman, Shi,Levine, & Billington, 2009).

CapabiliTies of The olfaCTory sense

Differentiable behavior and physiological changes ex-pressed by newborn in reaction to odorants suggest that,unlike the visual system, the olfactory system is remark-ably mature at birth (Schaal, Marlier, & Soussignan, 1998,2000). However, other than “an aversion to decaying, pu-trid or bitter things” (Morean, 2007, p. 157), the only in-born olfactory preference seems to be that for the mother’samniotic fluid (Schaal, Marlier, & Soussignan, 1998). Itseems that the right hemisphere is involved in the elabo-ration of odors (Zatorre, Jones-Gotman, Evans, & Meyer,1992; Zucco & Tressoldi, 1989), and that they are acquired

as a whole entity (Zucco, 2007). Unlike vision or hearing,olfaction needs to be activated (Köster, 2002), and its ol-factory bulb-produced “images” are subconscious (Shep-herd, 2006). This latter point is supported by the absenceof a significant relay in the thalamus (Shepherd, 2006).Furthermore, it seems impossible for a subject to conjureup an olfactory image (Moeran, 2007). Concerning this dif-ference form the other senses, Zucco (2003) offers the ex-planation that, unlike olfactory representations, visual andverbal representations are conceptual, and thus, can giverise to conscious representations. Alike the other sensorymodalities, the olfactory system habituates to a prevailingstimulus (Morean, 2007). This phenomenon is observablethrough a rapid decline in the pyriform cortex activationduring constant exposure to a particular olfactory stimulus(Poellinger et al., 2001; Sobel et al., 2000).

In humans, the development of different cognitiveprocesses for socialization seems to have led to loss offunction mutations in the olfactory receptor genes(Rouquier, Blancher, & Giorgi, 2000), and the human’s ol-factory acuity is inferior to that of most animal species(Malaspina et al., 2006). A person’s ability to localize thesource of an odorant–based on olfaction alone–is relativelypoor (Kobal, Van Toller, & Hummel, 1989), and humansare anomic to certain odorants (Albrecht & Wiesmann,2006). Nevertheless, an individual can detect up to 10,000odorants (Albrecht & Wiesmann, 2006) with less than10,000 receptors (Ratey, 2001). Hudson and Distel (2003)propose three ways the olfactory system is able to meet thischallenge: the combination of wide spectrum receptors andneurons, the ability to learn, and the ability to adjust thesensitivity of the receptors according to the environment,the individual experience and the situation. However, de-spite its still impressive detection spectrum, the human isonly able to discriminate between up to four separate com-ponents of an odorant (Laing & Francis, 1989). Further-more, unless it is exposed to certain odorants early indevelopment, the olfactory system may never develop theability to recognize them. Conversely, one’s olfactory sensecan be improved through training (Ratey, 2001).

An odor incorporates a potentially great number ofodorants into a single percept, for example, about 800in the case of coffee (Deibler, Acree, & Lavin, 1998).According to Albrecht and Wiesman (2006), each indi-vidual is equipped with a different set up of receptors,and they qualify one’s olfactory world to be as individ-ual as a fingerprint. It also appears that individual sub-jects encode one same odorant differently during

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34 The Sense of Olfaction

Figure 1. Major projections of the olfactory cortex (Simpson & Sweazy, 2006).

consecutive presentations (Engen, 1983). In addition, itseems that the individuality of one’s olfactory world isfurther defined by contextual contributions. Indeed,Hudson and Distel (2003) suggest that individuals shar-ing the same sensory-chemical niche–the home, theneighbourhood, the city, etc.–will respond to an olfac-tory stimulus in a more similar manner than those notsharing that same olfactory niche. In support of this sug-gestion, Stockhorst and Pietrowsky (2004) found thatthe perceived intensity of an olfactory stimulus de-pended on its concentration, as well as on the level ofeveryday experience with the odorant. Hence, an odoris a subjective percept produced by the combination ofan olfactory stimulus and a context, it is modulated viathe nervous system (Hudson & Distel, 2003), its mean-ing is probably acquired by individual experience (Hud-son, 1999), its perceived intensity depends oninterpretation and cognitive appraisal, and therefore, itcan be modified through learning (Stockhorst &Pietrowsky, 2004).

In summary, the olfactory sense is remarkably matureat birth. It can detect up to 10,000 odorants, but the non-exposure to some odorants in early development maylead to an inability to detect them. Olfaction must be ac-tivated, habituates to prevailing stimulus, and it is im-possible for a subject to conjure up an olfactory image.An odorant may be encoded differently during consec-

utive presentations, and its resulting odor is influencedby a variety of contextual contributions and personal ex-periences. Of particular interest to the integration of ol-factory cues in VEs is the finding that the localizationof the source of an odorant, based on olfaction alone (i.e.without the support of the other senses), is relativelypoor. For the purpose of integrating odors in a VE, theimplication of this characteristic could be three-fold. Forone, it allows, within certain limits, the use of a singleremote source to release the olfactory cues (instead ofusing multiple sources and activating one, or the other,depending on the position and/or orientation of theuser). The second implication may be that, in order totrigger the user's association between the odor and theintended virtual source of that odor, the visual (and po-tentially auditory as well as haptic) details need to "sup-port" the intended odor. For example, the odor of alemon should be matched with a virtual object that looksand, if applicable, feels like a lemon. Lastly, the syn-chronization between the user's virtual position and thetiming of the releases of the olfactory cues need to con-trolled precisely, perhaps through a three dimensionalmodel creating an increasing odorant intensity as oneapproaches the intended virtual source.

CharaCTerisTiCs of odors

dimensions of an odor

Hedonicity, or the measure of pleasantness, familiarity and

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intensity are the dimensions mostly used to qualify anodor, and they are not totally independent of another(Delplanque et al., 2008). Hedonicity, also referred to asvalence (Schiffman, 1974), is the most salient (Engen &McBurney, 1964; Harper, Land, Griffiths, & Bate-smith,1966) of these dimensions. Hedonicity is not quantifiedvia a continuum of pleasantness, but via two opposingclusters of pleasantness and unpleasantness (Godinot,Sicard, & Dubois, 1995; Schiffman, 1974), and the effectof a pleasant olfactory stimulus seems to be more persist-ent than that of an unpleasant one (Weber & Heuberger,2008). As proposed by the mere exposure effect (Cain &Johnson, 1978; Sulmont, Issanchou, & Köster, 2002),pleasantness and familiarity of odors seem to be positivelycorrelated (Engen and Ross, 1973; Bensafi, et al., 2002).While Henion (1971) had suggested that, generally, an in-crease in intensity leads to decreased pleasantness,Moskowitz, Dravnieks, and Kiarman (1976) later sug-gested that, depending on the odorant used, the correlationcould be positive, negative, complex or nonexistent. It hasalso been suggested that the path for neutral or pleasantodors is slower, and cognitively more complex, than thatfor unpleasant odors (Rouby & Bensafi, 2002). As the for-mer would be associated with higher order associations,it may also be more influenced by familiarity (Royet etal., 1999; Larsson, 2002). As proposed by Delplanque andcolleagues (2008), the existence of two distinct paths forpleasant and unpleasant odors is in line with models sug-gesting the existence of different evaluative channels forthe processing of positive and negative stimuli (Cacioppo,Garner, & Bernston, 1999; Sander, Koenig, Georgieff,Terra, & Franck, 2005). Furthermore, the existence ofthese two distinct paths is supported by neuroimaging(Fulbright et al., 1998; Zald & Pardo, 1997) and electro-physiological (Hummel & Kobal, 1992) results of cerebralactivations during odor processing.

The dimensions qualifying an odor are hedonicity, famil-iarity and intensity and certain correlations seem to existbetween these dimensions. In order to improve the VR ex-perience, it may be useful to consider each of these threedimensions. For example, it is conceivable that the hedo-nicity of an odor could contribute to the determination ofits intended virtual source (e.g., during immersion, the de-tection of a pleasant but non-specific odor, while the useris positioned equidistantly from an overflowing garbagecan and a bouquet of flowers, is likely to result in an as-sociation between the pleasant odor and the flowers). Fur-thermore, the level of familiarity is likely to lead to a morerapid, and stronger, association with the cues presented

via other modalities. For example, the level of presence ina virtual kitchen may differ between users, depending ontheir familiarity with the type of food odorant use, whichin turn, may be associated with cultural background. Fi-nally, varying odorant intensities may be useful in cueingthe user about the position, and rate of position change,relative to the intended virtual source of that odor.

faCTors influenCing olfaCTory proCessing

gender

Herz (2004) reports that women are more sensitive to ol-factory stimuli than men, and although the results are notunequivocal, consistent replications suggest that womenoutperform men in olfactory tests (Good & Kopala, 2006;Pause, Sojka, Krauel, Fehm-Wolfsdorf, & Ferstl, 1996).These differences appear at an early age (Dorries,Schmidt, Beauchamp, & Wysocki, 1989), and apply morespecifically to discrimination, recognition and identifica-tion abilities (Doty, 1997; Wysocki & Gilbert, 1989), aswell as the accuracy of higher order olfactory processing,such as naming or memory tasks (Good & Kopala, 2006).The effect size of this difference increases with age (Shipand Weiffenbach, 1993), and is consistent across cultures(Barber, 1997; Doty et al., 1985). Although women detectpleasant and unpleasant odors faster than neutral ones, thisis not the case for men (Pollatos et al., 2007). Neither Chenand Dalton (2005), nor Pollatos et al. (2007) found a dif-ference in perceived pleasantness and arousal betweenmen and women. In general, women are more sensitive tobiologically relevant olfactory stimuli, such as thepheromone androsterone (Wysocki & Gilbert, 1989). Thislast point, when combined with women’s peak sensitivityto olfactory stimuli during the pre-ovulatory period (Good& Kopala, 2006), and the passive communication of matequality through body odor (Sergeant, Davies, Dickins, &Griffiths, 2005), supports the biological relevance of thesuperior sensitivity of the woman’s olfactory system.

emoTional sTaTes

Current emotional states also seem to influence olfactoryprocessing (Pollatos et al., 2007). While an individual’scurrent emotional state does not seem to affect olfactorydiscrimination, it seems that across both sexes, negativeemotional states are associated with an increase in judgedodor intensity. For men, this increase in judged odor in-tensity is observed across all emotional conditions (Chen& Dalton, 2005; Pollatos et al., 2007). Viewing pleasantand unpleasant pictures, respectively, increases and de-creases the pleasantness ratings of a neutral suprathresholdodor judged according to intensity and pleasantness (Pol-

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latos et al., 2007). The viewing of unpleasant pictures isfollowed by significantly reduced olfactory sensitivity(Pollatos et al., 2007). This result is congruent with the ef-fect of negative emotional states on the ”primary sensorylevel of stimulus processing as measured by thresholdtasks” (Pollatos et al., 2007, p. 587-588), as previouslydemonstrated with depressive patients (Serby, Larson, &Kalkstein, 1990; Pause et al., 2003). Song and Leonard(2005) suggest that, considering the projection of the ol-factory system onto the limbic system (in particular, theorbitofrontal cortex and the amygdala), there could be alink between the dysfunction of a depressed patient’s lim-bic system and the reduced olfactory sensitivity. Interest-ingly, Vasterling, Braily, and Sutker (2000) found thatpatients with PTSD suffered from olfactory identificationdeficits–an observation which Doop, Mohr, Folley,Brewer, and Park (2006) report as consistent with PTSDrelated dysfunction of the fronto-limbic system. Thesefindings could be considered contradictory to the use ofolfactory cues in the treatment of PTSD. This apparentcontradiction will be addressed in the next section.

Visual sTimuli

Multisensory integration is a “process by which inputsfrom one sensory modality influences processing of infor-mation from another modality and leads to either en-hanced or dampened neural responses depending on thevariety of factors, such as context and temporal or spatialconcordance” (Small, 2004, p. 120). This process impliesthat “when two or more sensory cues occur at the sametime and in approximate spatial correspondence, the firingrate of a multisensory neuron to a stimulus in one modalitycan be measurably altered by the presence of a secondstimulus in another modality” (Österbauer et al., 2005, p.3434). Anatomical and physiological evidence suggeststhat the multisensory integration of olfactory and visualstimuli involves the orbitofrontal cortex and the amygdala(Thesen et al., 2004). There seem to exist compellingcolor-smell associations (Österbauer et al., 2005). Indeed,color not only facilitates odorant identification, but it canalso influence judgments of odor intensity and pleasant-ness (Zellner, Bartoli, & Eckard, 1991). The mere pres-ence of color in an odorant-less solution increases thelikelihood that subjects will report an odor (Engen, 1972),and a seemingly impossible color-smell combination(such as red colored white wine) can create perceptual ol-factory illusions (DuBose, Cardello, & Maller, 1980; Mor-rot, Brochet, & Dubourdieu, 2001). So far, however, theliterature offers little evidence whether odors can, in turn,influence visual perception (Thesen et al., 2004).

In summary, women’s olfactory processing seems moresensitive than that of men, and negative emotional statesare associated with an increase in judged odor. Althoughthe gender-related difference in olfactory processing maynot necessarily warrant the development of gender-spe-cific olfactory environments, it may need to be taken intoconsideration during the analysis of the effect of odorantsduring immersion. Most importantly for the integration ofolfactory cues in VEs, visual stimuli seem to influence andenhance olfactory processing.

The influenCe of odors on

perCepTion and menTal proCesses

A variety of studies demonstrate that olfactory cues canexert a cross-modal influence on the judgement of a vari-ety of non-olfactory stimulus attributes or qualities (De-mattè, Österbauer, & Spence, 2007).

odors, emoTions, and arousal

Pleasant and unpleasant odor cues have the power to leadto, respectively, positive and negative affective states(Ehrlichman & Halpern, 1988) and moods (Alaoui-Ismaïliet al., 1997; Goel & Grasso, 2004). Specifically, it hasbeen demonstrated that pleasant odors decrease arousal,whereas unpleasant odors have the opposite effect(Knasko, 1992; Alaoui-Ismaïli et al., 1997). Furthermore,arousal seems to be positively correlated with the strengthof an odor (Royet et al., 2003; Heuberger, Hongratana-worakit, & Buchbauer, 2006).

odors and pain

Odors seem to have the potential to increase and decreaseperceived pain. Familiar odors, such as maternal milkodorant (Mellier, Bézard, & Caston, 1997; Rattaz, Gou-bet, & Bullinger, 2001), can soothe up to moderate painin infants, thereby limiting or even preventing crying andthus, limit the energy expended during somewhat painfulmedical procedures (Goubet, Rattaz, Pierrat, Bullinger,& Lequien, 2003). Conversely, in the presence of alreadyexisting pain, certain odors seem to superimpose addi-tional pain, and slowly increase the level of backgroundpain (Villemure, Wassimi, Bennett, Shir, & Bushnell,2006). Neurophysiologically, the intensification in per-ceived pain can be observed by increased neural activa-tion in several areas associated with pain (Villemure etal., 2006). However, although the unpleasantness of theodor predicts the increase in pain intensity and unpleas-antness, it is the changes in mood evoked by the odorsthat correlates best with the perceived level of pain (Ville-mure et al., 2006).

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odors and soCial inTeraCTion

The perceived masculinity/femininity of photographedfaces can be influenced by the presence of human sex hor-mone-like chemicals (Kovács et al., 2004). These findingsare in line with results suggesting the influence of humanpheromones on people’s judgements of the written de-scriptions of others (Cowley, Johnson, & Brooksbank,1977), and on the ratings of the sexual attractiveness ofpictures of women (Kirk-Smith, Booth, Carroll, & Davies,1978; Kirk-Smith & Booth, 1990). Pheromones, whichhumans emit in all body fluids (Ratey, 2001), are alsoprocessed via the olfactory system (Stockhorst &Pietrowsky, 2004). Even though they may carry no con-sciously perceptible odor, they can cause measurablechanges in the autonomic nervous system and, dependingon the pheromone, they can induce mild impressions ofcontentment or uneasiness (Ratey, 2001). Evidence sug-gests that pheromones affect human sexual behavior, notthrough sexual activity per se (Stockhorst & Pietrowsky,2004), but through the modification of socio-sexual mat-ing preference, attractiveness and mood (Cutler, Fried-mann, & McCoy, 1998). More specifically, they “facilitatethe perception of species members for reproduction (Cow-ley & Booksbank, 1991; Wyatt, 2003), they lead to an en-trainment of the menstrual cycle (Stern & McClintock,1998), change the physical attraction of possible sexualpartners (Kohl, Atzmüller, Fink, & Grammer, 2001;Grammer, 1993) and mood (Jacob & McClintock, 2000),and they are correlated to physical attractiveness(Rikowsky & Grammer, 1999)” (Stockhorst &Pietrowsky, 2004, p.5).

Research results also suggest a tendency to rate other peo-ple more positively when in the presence of a pleasant fra-grance (Kirk-Smith & Booth 1990). In turn, there is asignificant positive correlation between the rated sexinessof a man’s body odor and his facial attractiveness to fe-males (Rikowski & Grammer,1999). However, Demattèet al. (2007) suggest that odors do not affect the actual per-ception of the visual characteristics of a subject, but thatinstead, they change the affective reaction to them.

odors, learning, and CondiTioning

Indicators supporting the role of learning in olfaction in-clude an improving ability to discriminate between twopreviously unfamiliar odorants with exposure (Rabin,1988; Jehl, Royet, & Holley, 1995), and the ability to ac-quire the qualities used to describe an odor (Stevenson,2001). Olfactory learning appears to take place as early asthe olfactory bulb and the pyriform cortex (Brennan &

Keverne, 1997; Haberly, 2001). This process permits thefine tuning, amplification and storage of the particularlyimportant odors, thus allowing the subject to distinguishthem from the multitude of olfactory stimuli in the envi-ronment (Hudson & Distel, 2003). Learning greatly affectsthe perception and processing of odors, and it allows anorganism to associate a specific situation with a particularsmell (Stockhorst & Pietrowsky, 2004). It may be theprocesses of amplification and storage of odors (identifiedas particularly important through "learning" during a trau-matic event) that, despite the previously mentioned find-ings of olfactory identification deficits in PTSD patients,make the use of trauma-related odorants pertinent in thetreatment of this category of clientele. As demonstratedby one trial exploring aversions to smells and tastes asso-ciated with nausea-inducing substances, olfactory learningcan take place in the form of one classical conditioningtrial (Stockhorst & Pietrowsky, 2004).

Olfactory conditioning appears to first have been demon-strated on humans by Kirk-Smith, Dodd and Van Toller(1983), and by Marinkovic, Schell, and Dawson (1989),as well as by Moore and Murphy (1999). Respectively,these researchers successfully paired an odorant with anelevated level of anxiety, physiological arousal, and aneye-blink response. Olfactory stimuli may also, by virtueof an association with unconditioned drug stimuli, elicitconditioned responses in the form of increased craving,skin responses and heart rate changes (Bordnick et al.,2008). Olfactory conditioning seems to contribute to thephenomena of sick building syndrome and multiple chem-ical sensitivities (Magnavita, 2001). Various investigations(Van den Bergh et al., 1999) suggest that the somatic neg-ative symptoms in reaction to certain chemicals are mostlikely linked to conditioned increases in olfactory sensi-tivity to those same chemicals (Chu, 2008), potentiallyleading to reactions such as pre-chemotherapy nausea(Siegel, 1999). Olfactory conditioning has also emergedas an influence in drug administration (Stockhorst et al.1999) and cigarette smoking behavior (Lazev, Herzog, &Brandon, 1999).

Herz, Schlanker, and Beland (2004) have suggested thatambient odorants, initially paired with seemingly easy butactually impossible to complete tasks, could have an in-fluence on behavior. In one of their experiments, they ex-posed their participants to an unfamiliar ambient odorantduring a frustration mood induction. When the participantslater worked on puzzle tests in a room scented with eitherthe same odorant, a different odorant, or no odorant, par-

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ticipants in the same odorant condition spent significantlyless time working on the tests than participants in the otherconditions. Herz, Schlanker et al. (2004) suggest the ex-istence of an emotional conditioning mechanism–the re-duction in the time spent on the task in the presence of theconditioned odor is the result of a reduced motivation, it-self resulting from the odor-triggered re-emergence of thenegative emotional reaction initially experienced duringthe failure to complete seemingly easy tasks. But the op-posite also seems to be true. Indeed, Chu (2008) demon-strated that, by classically conditioning an odorant withpositive task-related experiences, subsequent perform-ances of underachieving schoolchildren could be manip-ulated to significantly improve on subsequent tasks. Anolfactory stimulus can also act as a conditioned stimulusin fear conditioning (Engen, 1973), and Chu (2008) sug-gests that stronger emotions increase the likelihood of ef-fective olfactory associative links.

odor and memory

Lehrner et al. (1999) report evidence supporting the exis-tence of a discrete olfactory memory system branchinginto component subsystems. Olfactory memory is inde-pendent of, and different from, other modalities of mem-ory (Vermetten & Bremner, 2003). Common and complexodorants are encoded and remembered as poorly as ab-stract meaningless geometrical shapes (Lawless, 1978);Lawless (1978) and Engen (1991) suppose that the lackof structural information in olfactory stimuli could con-tribute to the poor immediate recognition of odors (incomparison to visual and verbal stimuli). Odor memoryseems strongly affected by proactive interference (Engen,1987; Lawless & Engen, 1977), barely affected by the ef-fect of learning strategies (Zucco, 2007), and very resistantto retroactive interference (Lawless & Engen, 1977; Zucco2007). As such, it may well be the absence of attributesthat contributes to its resistance to interference (Schab,1991). Although Engen and Ross (1973) had proposed thatodors are encoded in relation to perception and independ-ent of semantic networks, Royet et al. (1999) found thatsemantic and perceptual subsystems interacted duringodor processing (Doop et al., 2006).

According to Engen and Ross (1973), there seems to beno difference between the recognition rates of intention-ally and incidentally learned odor. In addition, the memoryof an odor seems unaffected by higher order abilities(Danthiir, Roberts, Pallier, & Stankov, 2001). AlthoughEngen and Ross (1973), as well as Lawless and Cain(1975), had found no link between familiarity and odor

memory, more recent sources have suggested that familiarodors are easier to remember and discriminate than unfa-miliar ones (Savic & Berglund, 2000; Schab & Crowder,1995). Royet et al.’s (1999) finding that odor familiaritystrongly predicted odor naming further supports the linkbetween familiarity and odor memory. Anatomical supportto this result includes the observation that the judgementof odor familiarity involves the left inferior frontal gyrus(Royet et al., 1999), an area normally linked to semanticassociation (Ricci et al., 1999; Vandenberghe et al., 1996).Thus, familiar and unfamiliar odors may be mediated byseparate neuronal circuits (Savic & Berglund, 2004). Fur-thermore, if familiarity and pleasantness are indeed cor-related (as suggested by Bensafi et al., 2002; Sulmont etal., 2002), then odor pleasantness may also affect odormemory.

While the memorization of a new odor seems more diffi-cult than that of visual and auditory stimuli, if it is suc-cessfully stored, the memory of that odor is particularlypersistent (Herz & Engen, 1996; White, 1998). Duringrecognition tasks immediately after exposure to stimuli,visual and auditory stimuli are recognized at a rate of 90%(Zucco, 2007), while olfactory stimuli are recognized at arate of only 70% (Herz & Engen 1996; Zucco 2003,2005). However, over an entire year, unlike the case forverbal and visual stimuli, the forgetting curve of an ac-quired odor is relatively flat (Engen & Ross, 1973; Nick-erson & Adams 1979). In fact, Engen and Ross (1973)observed that after one year, over and above the 30%recognition rate lost during initial memorization, therecognition rate of odorants only decreases by an addi-tional 5%.

Odor memory is excellent for odors associated withsignifi cant autobiographical experiences (Engen, 1973).This is supported by the ability of certain adults to nameodors they had not smelled since childhood (Goldman &Seamon, 1992), and may be influenced by the aforemen-tioned strong resistance to retroactive interference. Auto-biographical memories are “episodic memories:recollected events that belong to an individual’s past. Theevents that are recalled as autobiographical memories aretypically multimodal (involving vision, hearing, smell,taste, touch, and body sense or kinesthesis); they vary inspatial, temporal, emotional, and narrative content andcontext; they have personal relevance” (Rubin, 2005), andthey are usually encoded passively (Chu & Downes,2000a). Thus, the systems that play a role in autobiograph-ical memory are the individual senses, a multi-modal spa-

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tial system that notes the location of people and objects,emotion, language, a non language narrative system whichtracks causal relations (Rubin, Schrauf, & Greenberg,2003; Schrauf & Rubin, 2000), and “an explicit memorysystem that coordinates or binds information from theother systems” (Rubin, 2005, p. 79). When autobiograph-ical and semantic memory retrievals are compared, theamygdala, the hippocampus and the right inferior frontalgyrus were found to be more active (Rubin, 2005), andworking more closely together (Greenberg et al., 2005)during the former.

Autobiographical memory retrieval is enhanced by expo-sure to events associated with odors (Doop et al., 2006).In an autobiographical memory recall task, twice as manymemories were recalled when accompanied with the ap-propriate odorant than without (Maylor, Carter, & Hallett,2002). Odor-evoked memories seem different from othermemory experiences (Willander & Larsson, 2006). Al-though they are no more accurate than those evoked byother senses (Herz, 2004), odorant-triggered memories arerated as more pleasant, and recalled less frequently(Rubin, Groth, & Goldsmith, 1984). Odor representationscan be recalled after longer periods of time than verbal orvisual ones. While visually and verbally-triggered mem-ories generate a reminiscence bump between the ages of10 and 30 years at event (Conway & Haque, 1999; Rubin,Rahhal, & Poon, 1998), olfactory-triggered memorieshave been localized to the first decade of life (Chu &Downes, 2000b; Willander & Larsson, 2006). These re-sults are in agreement with research suggesting that asso-ciative olfactory learning begins very early in life (Schaal,Marlier, & Soussignan, 2000; Van Toller & Kendal-Reed,1995), and earlier than the formation of autobiographicalmemories consisting of verbal or visual information (Wil-lander & Larsson, 2006). The strength of the relationshipbetween the olfactory cue and the autobiographical mem-ory is directly correlated to the emotional charge and sig-nificance of the remembered event (Vermetten &Bremner, 2003). The remarkable ability of olfactory stim-uli to evoke very old autobiographical memories may beattributed to weak retroactive interference (Lawless &Engen, 1977), strong proactive interference and, whencompared to visual or auditory stimuli, a low probabilityof subsequent exposure interference (Herz, 2004). Conse-quently, the first odor/event association is very hard to un-learn, a subsequent association to the same odor is difficultto form (Herz, 2004), and hence, exposure to event-con-gruent olfactory information can give access to very oldpersonal experiences (Willander & Larsson, 2006).

In addition to being more potent autobiographical memorycues than stimuli presented to other senses (Chu &Downes, 2000), research suggests that olfactory-triggeredmemories generate a stronger feeling of being broughtback in time than verbally or visually-triggered ones(Herz, 2004; Willander & Larsson, 2006). Indeed, cross-modal laboratory and autobiographical studies of episodicmemory have shown that olfactory-triggered memoriesare more vivid than memories evoked by correspondingwords (Chu & Downes, 2002), and more emotional thanthose triggered by alternate sensory variants, including au-ditory stimuli (Royet et al., 2000) of the same item (Herz,2004; Herz, Eliassen, Beland, & Souza, 2004). In fact,specific trauma-related olfactory cues can lead to anxiety,fear-related memories, flashbacks (Vermetten & Bremner,2003) and panic attacks (Hinton, et al., 2004) in PTSD pa-tients. These reactions may, in turn, lead to avoidance be-havior. In the case of PTSD, the conditioned responsesrooted in the autobiographical memory do not extinguishwith time (Vermetten & Bremner, 2003). These observa-tions are congruent with the direct synapsing from the ol-factory area to the amygdala-hippocampal complex– theneural substrate of emotional memory (Cahill, Babinsky,Markowitsch, & McGaugh, 1995; Herz, Eliassen, et al.,2004)–and the greater activation in the amygdala-hip-pocampal complex in reaction to personally relevant odors(Herz, Eliassen, et al, 2004).

effeCT of sub-ConsCiously proCessed odors

The research presented above suggests that olfactoryprocessed signals can affect organisms, but it is importantto recognize that these signals need not be consciouslyprocessed to create an effect. Indeed, subliminal odors, aslittle as seven ppt, (Shepherd, 2004) can influence implicitodor memory (Degel & Köster, 1999; Köster, Degel, &Piper, 2002), social likeability judgements, and autonomicresponses in a valence-consistent manner (Li, Moallem,Paller, & Gottfried, 2007). In fact, contrary to autonomicresponses which are independent of the level of awarenessof an odor, the effects on social likeability emerge best whenthe odor is subliminal (Li et al., 2007). As bottom-up sen-sory input often induces top-down regulation, thereby re-sulting in synthesized processes (Schneider & Chein, 2003),it has been suggested that it is the absence of the consciousawareness of the odor, and thus, the absence of a top-downregulation, that allows the subliminal odor to exert a greatereffect than supraliminal odors (Li et al, 2007).

In summary, the presence of an odorant is associated withnumerous effects, and some of the ways these effects

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could be exploited in VEs will be addressed in the discus-sion section. While pleasant odors seem to lead to positiveaffects and decrease arousal, unpleasant ones seem to in-crease arousal and lead to negative affects. Furthermore,arousal is inversely related to pleasantness, but positivelyrelated to odor strength. The presence of odors can in-crease or decrease the pain perceived by an individual. Theindications that an odor can influence how another personis perceived are of particular interest to social presence ina VE. These results seem to speak in favor of assigningindividual olfactory signatures to each virtual human in aparticular VE. Olfactory learning enables the discrimina-tion of odorants in the environment, and this ability canbe improved through exposure. Olfactory conditioning–the association between an olfactory stimulus and a par-ticular situation–can not only elicit physiological andphysical responses, but it can also affect performance. Theolfactory system seems to have its own memory system,and although the establishment of the memory of an odoris more difficult than that of a visual stimulus, if it is suc-cessfully established, it becomes particularly persistent.There seems to be no difference between the recognitionrates of intentionally and incidentally learned odors, andthe memory of an odor seems unaffected by higher orderabilities. Odor memory is excellent for odors associatedwith significant autobiographic experiences, and the re-trieval of an autobiographical memory is enhanced by ex-posure to event-associated odors. The strong resistance toretroactive interference allows olfactory cues to triggermemories originating in the first 10 years of life. Thesememories are vivid, and result in a strong feeling of beingbrought back in time. The conscious awareness of the odoris not necessarily required to enable its potential effects.

disCussion

The sense of olfaction is used constantly and often subcon-sciously (Drummond et al., 2007). It contributes to per-sonal safety by helping to test the quality of the air(Drummond et al., 2007), detect the presence of food andindividuals (Drummond et al., 2007), determine the edibil-ity of food (Holland, Hendriks, & Aarts, 2005), sense theflavors of food (Ratey, 2001; Shepherd, 2006), to the pleas-ures of eating (Simpson & Sweazy, 2006), and thus, it alsoinfluences future consumption. The olfactory sense’s sig-nificant role in human social behavior is supported by theobservation that, contrary to congenitally blind, mute ordeaf people, individuals with congenital anosmia do nothave intact reproductive–social behavior (Naftolin, Harris,& Bobrow, 1971). The olfactory sense contributes to theidentification of, not only an individual, but also his/her

gender (Russel, 1976), as well as certain emotional states(Stockhorst & Pietrowsky, 2004). Subconsciously, it affectsmating behavior (Herz & Inzlicht, 2002; Sergeant et al.,2005). Specifically, it influences attraction and sexual part-nering by affecting mood states (Jacob & McClintock,2001), detecting immune system characteristics (Jacob,McClintock, Zelano, & Ober, 2002; Thornhill & Ganges-tad, 1999), genetic similarities (Eggert, Müller-Ruchholtz,& Ferstl, 1999), and female fertility (Poran, 1995). As pre-sented earlier in this document, research results suggestthat through the association of an olfactory cue with anemotion (the more intense the emotion, the stronger the as-sociation), that same olfactory cue can later evoke the con-ditioned emotion, thereby affecting the abilities andbehavior of the subject. Thus, it could be expected that theuse of olfactory cues would be common in experimentalas well as in clinical psychology–yet, it isn’t so.

Several factors may have contributed to this situation. Firstand foremost, as olfaction often acts subliminally, its im-portance in day-to-day life may be underestimated (Al-brecht & Wiesmann, 2006). Secondly, due to theircomplex composition and transient character, controlledexposure to olfactory stimuli is more complex than that tovisual or acoustical stimuli (Stockhorst & Pietrowsky,2004) and it is still impossible, from one exposure to an-other, to stimulate the exact same combination of olfactoryreceptors (Hudson & Distel, 2003). Thirdly, the odor per-ceived by each subject is highly subjective, and thus, gen-eralization involving one particular odorant is likely to bedifficult. These factors may have contributed to the knowl-edge gap between olfaction and the more researchedsenses such as vision and audition. This knowledge gapalso applies to the technology behind devices reproducingand dispensing olfactory stimuli.

More recently, however, due to the potential of this rela-tively neglected sense and, in particular, its ability to evokevivid memories, this trend has begun to change (Chu &Downes, 2000a). Today, in the field of scent machines,dispensing and controlling odorants in VEs (previouslyidentified, as the primary obstacle to a generalized inte-gration of olfactory stimuli in VEs; Sadowski, 1999) arebeing addressed by a variety odor delivery systems, suchas the SDS100 by Biopac Systems Inc., the Scent Collarby the Institute for Creative Technologies in collaborationwith AnthroTronix Inc., and the Scent Projector by ATRMedia Information Science Laboratories. These systemsallow exposure to a variety of orthonasally-delivered ol-factory stimuli. In the field of applied research, the interest


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in aromachology, the study of the influence of odors onbehavior, now grows annually, and the topics covered bythis research include the effect of odorants on emotions,physiology, cognitive abilities and behavior (Chu &Downes, 2000a). It has been suggested that a jasminescent can enhance individuals' performance on problem-solving tasks, as well as lead to higher levels of interestand motivation to a task (Rottman, 1989), and that thescents of rose and mustard seed differentially modulate at-tention to brightness (Michael, Jacquot, Millot, & Brand,2003). A stimulating peppermint fragrance seems to con-tribute to increased pain tolerance (Raudenbush, Koon,Meyer, & Flower, 2002), to enhance athletic performance(Raudenbush, Meyer, & Eppich, 2002; Raudenbush, Cor-ley, & Eppich, 2001), to induce physiological arousal(Raudenbush, Koon, et al., 2002), and to enhance attentionto visual stimuli. The latter also seems true for muguet(Warm, Dember, & Parasuraman, 1991). Finally, a rose-mary scent seems to contribute to, at the cost of slowerperformance, increased memory recall accuracy (Moss,Cook, Wesnes, & Duckett, 2003), while a cinnamon scentseems to contribute to enhanced cognitive performancessuch as attention processes, virtual recognition memory,working memory, and visual-motor response speed (Zo-ladz & Raudenbush, 2005). Some of the physiologicalchanges resulting from pleasant ambient scents may, inturn, contribute to behaviors such as increased gamblingin casinos (Hirsch, 1995), increased time spent on a deci-sion task (Bone & Ellen,1999; Mitchell, Kahn, & Knasko,1995), and intentions to visit a store (Spangenberg, Crow-ley, & Henderson, 1996). At the opposite end of the spec-trum, the persistent scents of air pollution seem tocontribute to aggression in school-aged children (Ratey,2001). Other results indicate that odors can impair thememory for faces that are presented simultaneously withan odorant (Walla et al., 2003), and that when an odor issemantically (Platek, Thomson, & Gallup, 2004) or hedo-nically (Ehrlichman & Halpern, 1988) congruent with apicture or a word, it facilitates the detection of that picture,or the production of that word. Furthermore, stimulatingodorants seem to have the ability to increase alertness(Goel & Lao, 2006; Weber & Heuberger, 2008).

In clinical applications, aromatherapy aims to capitalizeon the ability of olfactory stimuli to elicit specific emo-tional responses. It relies on the hypothesis that, due to therapid connection between the olfactory system and thelimbic system, the appropriate olfactory stimulus couldcalm or stimulate an individual, assist sleep, influence eat-ing habits, reduce pain (via the release of enkephalins), or

heighten sexual arousal (via the release of endorphins)(Ratey, 2001). For example, the natural scent of bloomingplants seems to be able to increase calmness, alertness,and mood (Weber & Heuberger, 2008), while a lemonscent seems to lead to fewer reports of health symptoms(Knasko, 1992).

Whether in clinical or experimental research, VEs have,so far, failed to fully integrate the potential of olfactorystimulation, but there are exceptions. In clinical scenarios,some interesting VR research utilizing olfactory stimuliis being pursued in the field of behavioral and physiolog-ical reactivity to drug and alcohol triggers/cues (Bordnicket al., 2008). In such scenarios, the power of combiningvisual and olfactory cues to induce drug cravings and un-desired behavior can be employed as a tool for behaviormodification. Clinical scenarios for treating PTSD utilizethe tendency of prevailing olfactory cues to becomestrongly associated to a highly emotional event occurringat the same time, such the odor of burning human fleshduring a Rocket Propelled Grenade attack on a convoy.In these virtual world scenarios, olfactory cues, alongwith visual and acoustic ones, are meant to ease accessto, and thus facilitate the processing of, traumatic mem-ories (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo,2008).

However, the use of olfactory cues in VEs is more oftenthe exception than the rule, and more extensive applica-tions of olfactory cues seem possible. For example, VEsare presently used for pain distraction (Hoffman, Patter-son, & Carrougher, 2000), and odors seem to have the po-tential to decrease perceived pain. It would be interestingto verify the effect of integrating them in these types ofapplications. Furthermore, Kawai and Noro (1996) havesuggested that odorants, combined with stereoscopic 3-D images may, through their ability to affect arousal andemotions, be useful in relaxation procedures. It seemsthat, as an extension of this application, the investigationof the use of olfactory cues as an element of treatingmood disorders in VEs would also be pertinent. In train-ing scenarios, VR olfactory conditioning could turn outto be useful in triggering more appropriate responses toemergency situations–for example, the use of the smellof smoke during the practice of a fire drill in a VE maylead to more appropriate behavior, including better con-trol of emotions, in the presence of this stimulus duringan actual fire. Olfactory cues in a VE may also turn outto be useful to establish an association between a distinctodorant and “virtually-evoked” positive emotions. Such

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an association may possibly find use in relaxation train-ing, or the treatment of certain mood and anxiety disor-ders. Furthermore, the ability of a VE to expose a greatnumber of users to a complex, yet perfectly identical sce-nario, would seem to make it a good tool for investigatingthe fundamental interactions between olfactory cues, per-ception, cognition, emotion, and behavior. The results ofsuch investigations are of major interest, because theycould reveal whether the integration of olfactory stimuliin training devices, such as combat simulators, would en-hance the virtual experience, and if so, how and to whatdegree.

In sum, research has demonstrated the importance of ol-factory stimuli in the human experience, and the results

suggest that until olfactory cues are properly integratedin VEs, the gap between real world and virtual world ex-periences will remain significant. It is likely that theproper integration of olfactory cues in VEs will bring sce-nario simulation, whether for training or therapeutic pur-poses, to a previously unattainable level of realism.

Acknowledgement

The writing of this paper was supported by scholarshipsfrom the Fonds de la Recherche en Santé du Québec(FRSQ) and the Natural Sciences and Engineering Re-search Council of Canada (NSERC) awarded to the firstauthor, as well as by grants from the NSERC, the CanadaFoundation for Innovation (CFI) and the Canada Re-search Chairs awarded to the second author.

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Can We Combine learning WiTh augmenTed

realiTy physiCal aCTiViTy?

Kuei-Fang Hsiao1

Augmented Reality (AR) technology is being applied in an increasingly large range of applications forimproved educational efficiency. In this study, a new approach to the implementation of AR in the edu-cational environment was taken by creating a Chemistry Augmented Reality Learning System (CARLS),using the existing teaching curriculum, together with physical activity. This system combined learningwith three types of physical activity–aerobic fitness, muscle strength and flexibility fitness. A large sam-ple of students (n=673) from five high schools was divided into four groups. The first three groups usedthe CARLS learning system while a control group used a keyboard and a mouse to operate the computer.We explored changes in academic achievement, as well as attitudes towards learning about science, re-sulting from the implementation of CARLS. This study reveals that the students using all three types ofphysical activity together with CARLS result in significantly higher academic performance comparedto the traditional Keyboard-Mouse CAI (KMCAI). The improvement is most evident for the non-mem-orized knowledge component of science. Moreover, the students in the AR group with "muscle strength"physical activity had a significantly more positive learning attitude change toward science than those inthe KMCAI group. An additional benefit of our approach is that students also obtained better physicalfitness while learning.

Keywords: Augmented Reality, Physical Activity, Information Technology, Academic Achievement, Learning Attitude

inTroduCTion

Numerous researchers have reported the importance ofphysical activity not only for physical and mental health,but such studies have also indicated a potential positiveimpact on intelligence (Chomitz et al., 2009; Hillman, Er-ickson, & Kramer, 2008), and cognitive development(Neubauer, 2008; Sibley & Etnier, 2003). Further, physicalactivity was even proven to positively correlate to stu-dents’ academic performance (Hillman, Erickson, &Kramer, 2008; Castelli et al., 2007; Coe et al., 2006). Re-cent research done on fourth-eighth grade students re-vealed that both mathematics and English test scoresincreased as the passed number of fitness tests increased(Chomitz et al., 2009). Other research conducted on thirdand fifth grade students (Castelli et al., 2007), found that"aerobic fitness" was positively associated with total aca-demic achievement, including reading and mathematics.

Moreover, students’ body mass index (BMI) was nega-tively associated with their total academic achievement.Therefore, Chomitz et al. pointed out that “promoting fit-ness by increasing opportunities for physical activity dur-ing Physical Education (PE), recess, and out of schooltime may support academic achievement” (Chomitz et al.,2009).

While the importance placed on standardized testing is in-creasing, many schools in the United States have tried todiminish or even eliminate PE programs, although no em-pirical evidence suggests that this elimination could resultin higher academic performance (Hillman, Erickson, &Kramer, 2008). A similar situation is also apparent in Tai-wan. Contrary to the "Health Related Physical Fitness" poli-cies of the Ministry of Education in Taiwan (Ministry ofEducation, 2007a, 2007b), many schools have diminished

Corresponding Author:Dr. Kuei-Fang HSIAO, Department of Information Management, Ming-Chuan University, No. 5, Teh-Ming Rd., Gwei-Shan,Taoyuan County 333,Taiwan, Tel: +886-933-981105, Fax: +886-3-3294449, E-mail: [email protected]

1Department of Information Management, Ming-Chuan University, Taiwan

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non-academic programs in order to maximize the time foracademic programs in order to meet parents’ expectations.In Taiwan, most parents expect their children to spend mostof their time on academic programs instead of other non-academic endeavors, though, as mentioned above, spendingmore time on academic programs does not guarantee higherscores. Nonetheless, many Chinese parents are profoundlyinfluenced by the Chinese philosophy that says, “Regardlessof the result, just throw all your endeavors into studying”(Hsiao, 2005). Because of their parent’s high expectationswith respect to studying, students may feel it is inappropri-ate to spend time on physical activity instead of studyingacademic subjects. This old Chinese philosophy has trig-gered the innovative idea of "learning while exercising" thatwill be discussed in this study.

One of the main research objectives of this study was todevelop a learning system that can facilitate students'"learning while exercising." A new information technol-ogy termed "Augmented Reality" (AR) was employed toachieve this objective. Most previous studies involvingAR learning systems used 3-D features to assist studentsto learn in a way that is more realistic than 2-D instruc-tional tools (Yee, Ning, & Lipson, 2009; Chen & Wang,2008). Kaufmann reported that AR is a variation of VirtualReality (VR) (Kaufmann, 2002). Recent research providedfruitful results by using VR, MR or AR to help sufferersof mental (Muhlberger et al., 2008; Manzoni et al., 2008)or physical health disorders. Regarding mental healthcare,a recent study reported exciting results using VR applica-tions for patients with schizophrenia (Kim et al., 2008).Concerning physical health, Schaik et al. reported that par-ticipants strongly preferred virtual augmented physical ac-tivity over traditional physical exercise and the adherencerate was 100% (Schaik et al., 2008). Wiederhold andWiederhold pointed out that VR has made a significantimpact on behavioral healthcare with its multiple effectiveuses over the past decade (Wiederhold & Wiederhold,2008). In addition to healthcare by the applications of VR,MR or AR, Schaik et al. also found that fitness level wasnot associated with the performance of solving simplepuzzles and hitting targets in the game. Further, the corre-lation of preference for type of games with performancein the game was not significant. In this study, a new ap-proach was taken by creating an AR system for educa-tional purposes using the current-day curriculum, not onlyfor simple puzzles or simple arithmetic puzzles, togetherwith three types of physical activity. Moreover, the poten-tial of AR environments would be explored for adolescenthigh school students.

In addition to creating an AR learning system includingexercise, another objective of this study was to comparethe academic performance and learning attitude towardsscience between high school-age groups using CARLSand a group using KMCAI. In terms of assessment for ed-ucational objectives, Bloom classified six categories ofcognitive domains–Knowledge, Comprehension, Appli-cation, Analysis, Synthesis and Evaluation (Bloom et al.,2009). Among these six categories, "Knowledge" was de-fined as “recalling or remembering something withoutnecessarily understanding, using, or changing it.” The re-vised taxonomy of the cognitive domains by Anderson andKrathwohl included Remembering, Understanding, Ap-plying, Analyzing, Evaluating and Creating (Pickard,2007; Anderson & Krathwohl, 2001). The subject special-ists involved in the research divided the assessment for theunit of chemistry in high school science into two cate-gories–memorized type and non-memorized type. Thememorized type referred to the content, which studentsonly needed to recall or remember without necessarily un-derstanding. The memorized type corresponded with thebasic level "Knowledge" in Bloom’s classification of cog-nitive skills and "Remembering" in Anderson’s & Krath-wohl’s Revised Bloom’s Taxonomy (RBT). For the restof the assessment, the non-memorized type was identifiedwith the other five categories of cognition domains exceptremembering knowledge. Our final goal in this study wasto compare the impact of the three types of physical ac-tivity in CARLS on the memorized type and non-memo-rized type of knowledge in high school science.

meThods

subJeCTs

In this study, the participants consisted of 687 seventh andeighth grade students, aged between 13-14 years old, from22 classes in five high schools located in Northern Taiwanduring the spring term of 2009. Approximately half of theparticipants were male and the other half were female. Atotal of 673 valid data samples were collected. All studentswere divided into four groups–Group AR-Jump, GroupAR-Stretch, Group AR-Box and Group KMCAI. In thesefour groups, only the first three groups used the AR learn-ing system. Each group used a different type of AR phys-ical activity. Group AR-Jump practiced aerobic fitness,Group AR-Stretch practiced flexibility fitness and GroupAR-Box practiced muscle strength. The reference GroupKMCAI used a keyboard and a mouse to operate the com-puter. The gender distribution ratios, male versus female,among the above-mentioned four groups are 84 (53.5%)versus 73 (46.5%), 77 (48.4%) versus 82 (51.6%), 79

Learning with AR Physical Activity

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(49.4%) versus 81 (50.6%), and 99 (50.3%) versus 98(49.7%) for Group AR-Jump, Group AR-Stretch, GroupAR-Box, and Group KMCAI respectively. The initial ac-ademic performance of the students for the subject of sci-ence or other subjects was not available. Due to theInformation Protection Act of students’ personal informa-tion, only the class tutors and students’ parents are allowed

to obtain students’ initial academic performance. Studentsfrom all four groups followed the conventional instruc-tions, using textbooks and CAI materials to implement thefirst part of the teaching activity, then adopted four differ-ent approaches to carry out the second part, "practice."Table 1 presents the different features of the learning ac-tivities for students in the four groups.

insTrumenTs

In order to explore academic achievement in high schoolscience, pre-test and post-test paper-and-pencil examina-tions were designed to be used in this study. There wereeight items pertaining to the memorized type and sevenitems pertaining to the non-memorized type for each ex-amination. Among these 15 items, eight items were thesame in both of the pre-test and post-test examinations andthe other seven items were different, but of the same levelof difficulty. The examination items were identified byfour subject teachers from four high schools and by onedirector of Teaching Affairs.

In addition, the scale for measuring attitude towards lean-ing science was revised from the previous studies of Ger-mann and also of Osborne et al. (Germann, 1988;Osborne, Simon, & Collins, 2003). After the Factor Analy-

sis in this study, there were 13 items left in the revisedscale. All items were measured using a five-point Likert-type scale, ranging from 1 meaning "strongly disagree" to5 meaning "strongly agree." Regarding the content valid-ity, the questionnaire was refined by a pilot study, whichfocused on question wording, clarity and validity. In thepilot study, the four subject teachers and director men-tioned above provided comments on the questionnaire asa basis for revisions. The reliability (alpha) coefficient forthe scale was 0.925.

In this study, all teachers and students using the AR learn-ing system received two 50-minute training lessons to be-come familiar with the operations of CARLS. During thetraining week, the students in the three AR groups and thecontrol group KMCAI spent approximately 20 minutesfor the pre-test and 15 minutes for the pre-attitude test to-

Table 1The different features of learning activity in the four groups

group ar-Jump group ar-stretch group ar-box group KmCai

numbers 157 159 160 197

Teach textbooks and CAImaterial

textbooks and CAImaterial



practice CARLS- Jump system CARLS- Stretch sys-tem

CARLS- Box system A keyboard andmouse

interactions with

materials

By body movementlike jumping

By body movementlike stretching

By body movementlike boxing

By wrist movement

media delivery Text, graphics, soundeffects and AR tech-nology (with aerobic

fitness function)

Text, graphics, soundeffects and AR tech-nology (with flexibil-ity fitness function)

Text, graphics, soundeffects and AR tech-nology (with muscle

strength function)

Text, graphics, soundeffects

Hsiao

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ward learning about science. Afterwards, all students inthe four groups received one 50-minute lesson for con-ventional instruction using textbooks and CAI materialsand the other 50-minute lesson for the second part, "prac-tice," by using four different approaches in the followingthree weeks. After the completion of learning the unit ofElements and Compounds, all students in the four groupsspent 20 minutes for the post-test and 15 minutes for thepost-attitude test toward learning about science. The post-test and post-attitude test were applied a week after fin-ishing all activity with AR in order to examine students’learning retention. Thus, in addition to a four-week inter-vention with AR, the fifth week was used for the examand the questionnaire.

In order to avoid anxiety and resistance towards the newAR technology from parents and teachers, the four-weekintervention using AR technology and one week for theexam and questionnaire in this study were authorized bythe schools. Relating to the intervention time of this study,the following realistic and practical problems did exist atthe beginning stage of designing the experiment: (1) ARis new to most schools in Taiwan so there are a great num-ber of doubts and resistance towards new technology. (2)This study involves a large sample of students (n= 673)from 22 classes in five high schools. To avoid uncertainacademic results for students, most schools would notallow the long-term experiment to be conducted on theirstudents, particularly for the pioneer or exploratory study.To examine the differences in students’ academic achieve-ment including both memorized and non-memorizedtypes, as well as students’ attitude change towards learn-ing, a series of statistical analyses was conducted among

the five groups. Since the group means differed both pre-test and post-test in academic achievement and learningattitude, covariance analysis was applied to the followingstatistical analyses. Furthermore, in order to explore aricher, in-depth context of students’ learning with AR, ex-tensive interviews and observations were also carried outin this study.

ChemisTry ar learning sysTem (Carls)

In this study, AR technology was employed to facilitatestudents "learning by exercising." By modifying the con-tent of chemistry for seventh and eighth grade high schoolstudents, CARLS was developed as an assisted tool forstudents’ science learning. Thus, CARLS can be viewedas another type of a Computer Assisted Instruction (CAI)tool, but differentiated from conventional KMCAI.

In terms of AR technology, the most well-known defini-tion of AR was provided by Milgram and Kishino, whodefined it as “a continuum of real to virtual environmentsin which AR is one area within the general area of MixedReality (MR)” (Milgram et al., 1994). In Azuma’s work,AR was defined as a system with three characteristics: (1)a combination of real and virtual environments; (2) inter-active in real time; and (3) registered in 3-D (Azuma,1997). However, Malik et al. argued that AR uses virtualobjects, including text, 2-D images or 3-D models, to en-hance users' insight into the real world (Malik, Roth, &McDonald, 2002). Kaufmann reported that AR is a varia-tion of VR (Kaufmann, 2002). VR immerses a user in avirtual environment but, in contrast, AR allows a user tosee the real world combined with virtual objects in thesame space at the same time.


Figure 1. Equipment setup and user’s location in CARLS.

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In this study, CARLS adopted a webcam to capture stu-dents’ gestures and body movements from the real worldand combined them with designed virtual images to createan interactive image. These virtual interactions were dis-played onto a screen by a projector (see Figure 1, previouspage). In CARLS, when students touch the "answer area"in the virtual environment, their positions and gestures canbe captured by the webcam and CARLS will generate re-

actions according to the students’ intended answers. Theresults and feedback from CARLS will be displayed on alarge screen-wall in the real world.

CARLS combined learning with three types of physicalactivity–aerobic fitness or jumping (see Figure 2a), flexi-bility fitness or stretching (see Figure 2b) and musclestrength or boxing (Figure 2c).

Figure 2. AR Physical activity including jumping, boxing and stretching in CARLS.

Hsiao

non-memorized memorized learning attitude changes

pre-test= 3.10 3.48 3.11

group ar-Jump

group ar-stretch

group ar-box

group KmCai

Mean S.E. n

3.697 0.114 139

3.726 0.113 141

3.649 0.114 139

3.246 0.096 197

Mean S.E. n

3.504 0.144 139

3.887 0.143 141

3.519 0.144 139

4.121 0.121 197

Mean S.E. n

3.391 0.058 97

3.277 0.059 93

3.432 0.060 90

3.248 0.048 144

Table 2The descriptive data of non-memorized, memorized science knowledge and learning attitude changes toward sci-

ence for four groups (ANCOVA)

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CARLS allowed the students to have direct interactionswith the system through their body gestures, such as wav-ing their hands to "catch" the answer in the virtual envi-ronment. For instance, in the boxing physical activity, thestudents have to wear "boxing gloves" to hit the correctanswers a certain number of times instead of only hittingonce. The system designer programmed the number of hitsrequired from the user in order to reach particular physicalexercise levels in CARLS. For the other types of physicalactivity, like jumping, CARLS can be programmed to re-quest students to jump to reach a certain height, and a cer-tain number of times, in order to reach the desired exerciselevels. In Taiwan, most high schools have at least onecomputer and a projector in each classroom, making it isfeasible to implement CARLS in any high school. All thatis required in addition is a low-cost webcam.

With regards to the curriculum design in CARLS, a con-ventional high school science teacher in Taiwan wouldnormally be expected to teach by presenting fundamentalconcepts from textbooks, and then providing practice ex-ercises to students. The first part of the teaching activityis a one-way instruction. However, the practice compo-

nent contains interactive communication and discussionbetween a teacher and the students. In this study, CARLSwas used for students as an assisted learning tool in thesecond part of teaching activity, "practice." All studentsreceived conventional instruction using textbooks andCAI materials on the fundamental concepts of chemistry,in particular the unit dealing with elements and com-pounds. The content in the CARLS segment corre-sponded with the National Curriculum in Science inTaiwan (Ministry of Education, 2003) and consisted of216 items from the elements and compounds unit. Allitems were identified as memorized or non-memorizedtypes by four subject teachers involved in this study.

resulTs

In terms of examining the differences in students’ aca-demic achievement including memorized and non-mem-orized types of learning, as well as students’ attitudetowards learning change, since the group means differedboth pre-test and post-test in academic achievement andlearning attitude, a series of ANCOVA test analyseswere applied. Table 2 shows students’ estimated mar-ginal means and standard errors of non-memorized,

Covariates appearing in the model are evaluated at the following value:


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Table 4 shows the differences in the memorized type aca-demic achievement between the four groups, F (3, 615)=5.170, p<0.01. The table was integrated from a series ofPairwise Comparisons based on estimated marginal meansin the ANCOVA test analysis as well. The results shownin Table 4 indicated that there were significant differences

in the memorized academic achievement between GroupAR-Jump and Group KMCAI (p<0.01) and betweenGroup AR-Box and Group KMCAI (p<0.01) after stu-dents studied. It revealed that the students in GroupKMCAI have a better performance than those in bothGroup AR-Jump and Group AR-Box.

memorized science knowledge and learning attitudechanges toward science from four groups (by AN-COVA). In term of the non-memorized type academicachievement, the students in all three AR groups, AR-Jump, AR-Stretch, and AR-Box (mean = 3.697, mean =3.726, and mean = 3.649, respectively), have higher av-erage scores than those in the control group KMCAI(mean = 3.246). Regarding the memorized scienceknowledge, the students in the control group KMCAI(mean = 4.121) scored higher than those in the AR-Jump, AR-Stretch, and AR-Box groups (mean = 3.504,mean = 3.887, and mean = 3.519, respectively). Con-cerning the learning attitude changes towards science,the students in the AR-Box group scored highest on therelevance scale (mean = 3.432), indicating that theyhave the highest positive learning attitude changes to-

wards science.

non-memorized and memorized sCienCe

KnoWledge

Table 3 presents differences in the non-memorized portionof science academic achievement between the four groups,F (3, 615) =4.921, p<0.01. The table was integrated froma series of Pairwise Comparisons based on estimated mar-ginal means in the ANCOVA test analysis. It revealed therewere significant differences in the non-memorized typeachievement between the students in Group AR-Jump andGroup KMCAI (p<0.01), Group AR-Stretch and GroupKMCAI (p<0.01), and Group AR-Box and GroupKMCAI (p<0.01). The results also clearly showed that allstudents in the three AR groups have better academicachievement in science than those in Group KMCAI.

Table 3The differences in non-memorized science knowledge between four groups

F (3, 615)= 4.921, ** p< 0.01

group

ar-Jump

(mean=3.697)

group

ar-stretch

(mean=3.726)

group

ar-box

(mean=3.649)

group

KmCai

(mean=3.246)

group

ar-Jump

group

ar-stretch

-0.029

group

ar-box

0.049 0.078

group

KmCai

0.451** 0.480** 0.403**

Hsiao

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learning aTTiTude Change ToWard sCienCe

In terms of the learning attitude change toward sciencefollowing the course study, there was a significant differ-ence between the students in Group AR-Box and Group

KMCAI, F (3, 423) =2.581, p<0.05 (Table 5). The stu-dents in Group AR-Box had a more positive learning atti-tude change toward science than those in Group KMCAI(p<0.05).


Table 4The differences in memorized science knowledge between four groups

F (3, 615)= 5.170, ** p< 0.01

group

ar-Jump

(mean=3.504)

group

ar-stretch

(mean=3.887)

group

ar-box

(mean=3.519)

group

KmCai

(mean=4.121)

group

ar-Jump

group

ar-stretch

-0.382

group

ar-box

-0.014 0.368

group

KmCai

-0.616** -0.234 -0.602**

Table 5The differences in learning attitude change toward science between four groups

F (3,423)=2.581, * p< 0.05

group

ar-Jump

(mean=3.391)

group

ar-stretch

(mean=3.277)

group

ar-box

(mean=3.432)

group

KmCai

(mean=3.248)

group

ar-Jump

group

ar-stretch

0.115

group

ar-box

-0.041 -0.155

group

KmCai

0.143 0.028 0.184*

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disCussion

This study developed an AR learning system, CARLS, tofacilitate students learning about science by includingthree types of physical activity–aerobic fitness, flexibilityfitness and muscle strength–at the same time. Further, theperformance in academic achievement in science, includ-ing both memorized and non-memorized types of knowl-edge and learning attitude change toward science betweenthe four groups, Group AR-Jump, Group AR-Stretch,Group AR-Box and Group KMCAI, have been com-pared.

In comparison to the previous research which reportedthat "aerobic fitness" was positively associated with totalacademic achievement, including reading and mathemat-ics (Castelli et al., 2007), the findings derived from thisstudy support the notion that students combining all threetypes of physical activity in CARLS obtained signifi-cantly higher scores of the non-memorized type knowl-edge of science than those in the control group KMCAI.The findings concur with those revealed by previousstudies that there was no negative link between distrac-tion from physical exercise and performance of cognitiveactivity (Schaik et al., 2008). This study also found evi-dence for the benefits of AR physical activity with cog-nitive activity, irrespective of physical activity type.Meanwhile, the students in the control group KMCAItended to attain significantly better performances on thememorized type of knowledge than those in Group AR-Jump and Group AR-Box. These results imply that bothconventional KMCAI and our new AR technology ap-proach were both helpful to students’ learning, but in dif-ferent types of knowledge. In terms of memorizedknowledge, based on the revised taxonomy of the cog-nitive domain by Anderson and Krathwohl (Anderson &Krathwohl, 2001), "remembering" is the basic level ofcognitive domain where students "do not need to under-stand, use or change" knowledge. However, non-memo-rized knowledge includes other cognitive domains suchas understanding, applying, analyzing, evaluating or cre-ating. All of these could be seen as very essential abilitiesin the field of science.

In addition to quantitative evidence on academic achieve-ment, qualitative interviews and observations were car-ried out to obtain a better picture of the educational settingand learning process. Relating to higher-level learning be-yond memorizing of the concepts of chemistry, especiallythe unit dealing with elements and compounds, studentsfrom all three types of physical activity in CARLS ex-

pressed their personal experiences about the new ap-proach using AR:

“After learning with the use of CARLS, I know the fun-

damental concepts of Elements and Compounds better

now.” (Interviews, June 2009, opinions from Student 2-81020-C).

“After learning with the use of CARLS, I could clearly un-

derstand the differences between Elements and Com-

pounds and the characteristics of Elements and

Compounds.” (Interviews, June 2009, opinions from Stu-dent 2-81035-A, 3-80332-A, 4-71001-A,2-80215-B, 2-80426-B, 2-80609-B, 2-81013-C, and 2-80235-C).

In terms of the change in attitude toward learning aboutscience, this study revealed that the students in Group AR-Box using the "muscle strength" physical activity obtaineda significantly more positive attitude change than those inthe control group KMCAI. Thygerson and Larson (Thyger-son & Larson, 2006) suggested that muscle fitness couldimprove the peoples' ability to manage and function wellunder pressure or anxiety. Further, it also promoted peo-ple’s intention and willingness to carry out their tasks. Thefindings of Thygerson and Larson imply that muscle fitnessmight improve peoples' attitude toward certain objects orsituations since Loyd and Loyd suggested that attitude in-cludes four components–anxiety, confidence, liking andusefulness (Loyd & Loyd, 1985). Moreover, Gibson et al.defined attitude as the positive or negative mental state to-ward objects or situations (Gibson, Ivancevich, & Don-nelly, 1991). Thus, the findings in this study correspondedwith previous studies and also explained why the studentsin the muscle fitness exercise group had the highest posi-tive learning attitude change toward science.

In addition to quantitative evidence on learning attitude,the qualitative interviews also provided some clues.Among three groups with AR physical activity, the stu-dents in both Group AR-Box and Group AR-Jump ob-tained higher scores in learning attitude change thanGroup AR-Stretch, though only the students in Group AR-Box obtained significant results in comparison with thosein the control group KMCAI. Based on the analysis of col-lected data between the quantitative survey and qualitativeinterviews, we provide outlines to explain this situation.Firstly, the design of three types of physical activity inCARLS might cause students to progress less concerninglearning attitude. The physical activity design for both AR-Box and AR-Jump is quite "simple" and "straightforward."

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The students only need to jump a certain height to touchthe answer, or to box the answer there is only a "short"distance between their hands and the answer. However,the physical activity design for AR-Stretch is slightly morecomplicated than the other two. Students have to move thecorrect answer from location A to location B carefully andstretch their body in a difficult manner. The students fromGroup AR-Stretch which resulted in less progress regard-ing positive attitude change towards learning stated:

“It is a bit difficult to move the answer to the target loca-

tion. Even though I know the answer, I am not able to move

the answer to reach the assigned location.” (Interviews,June 2009, opinions from Student 2-81003-B, 3-80322-B, and 3-80419-B)

“The system should be improved to be easier for user and

the route for moving should be re-designed.” (Interviews,June 2009, opinions from Student 2-80831-B and 3-80110-B)

However, in order to reach the aim of the "stretch" exer-cise, the route between location A and location B was de-liberately designed to be longer and more winding incomparison with the other two types of physical activity.Future research may look more closely at the relationshipbetween the precise functions of exercise and the effecton learning.

ConClusions

This study provides a new approach to increasing students’physical activity without diminishing students’ academicperformance since many schools have tried to decreasePE programs in many countries due to a variety of reasons.In addition, better academic achievement in non-memo-rized knowledge of science and a more positive attitudetoward learning about science were also promoted byusing CARLS. In this study we have shown that by usingCARLS it is possible to promote better academic achieve-ment in non-memorized knowledge in science, and a morepositive attitude toward science while students also par-ticipated in extra physical fitness exercises while learning.

In spite of the above findings, as the exploratory study thatpioneers in combining learning with AR and physical ac-tivity, some suggestions and research constraints areneeded for future researchers and teachers adopting newAR technology in the classroom. First, the content used

in the AR learning system was taken from a certain unitin high school science so that the findings could not begeneralized to other fields or subjects. Moreover, the stu-dents who were involved in this study only used theCARLS system to specially learn the unit dealing with el-ements and compounds for a relatively short period oftime. One week of training was used to provide familiaritywith the AR system and three weeks were spent learningwith CARLS. There may possibly have been a novelty ef-fect effecting students’ performances or behaviors, whichis partially in response to increased interest in, or attentionto, the AR technology, instead of the curriculum. The find-ings might vary when CARLS is used in learning for alonger period of time. Therefore, instead of drawing toomuch attention to the novelty of the new technology, fu-ture researchers and teachers should be encouraged to em-phasize more valuable characteristics of AR, i.e. exploringlearning material through the combinations of the real andvirtual objects in the 3-D space so that it would help todisplay more concrete demonstrations to learners. Further-more, students obtain more physical activity while learn-ing compared to the sedentary learning style. Finally,although this study revealed that the students participatingin all three types of physical activity in CARLS obtainedhigher scores on the non-memorized science knowledge,this study did not directly prove that any specific physicalactivity in CARLS promoted any specific students’ abili-ties in the above-mentioned five non-memorized cognitivedomains. Future studies might prove fruitful in providingmore details of the likely causes of the results by utilizingmore sophisticated medical equipment.

For teachers adopting the new AR technology in the class-room, we suggest that they pay close attention to the safetyof students since physical activity typically takes place inthe classroom. Further, the amount of physical activityshould be individualized for different students’ health con-ditions. Physical activity should ideally take place withina normal school schedule, however, if student exercise hasbeen limited by school budgets or any variety of reasonsas has happened in different countries, an AR learning sys-tem with physical activity functions, like CARLS, mightprovide an alternative solution.

Acknowledgements

This research work has benefitted from the technical sup-port by Professor SY Huang and an AR work team inMing-Chuan University, Taiwan.


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sex and raCe differenCes in raTing oThers’

pain, pain-relaTed negaTiVe mood, pain Cop-

ing, and reCommending mediCal help

Ashraf F. Alqudah1, Adam T. Hirsh2, Lauren A. Stutts3, Cindy D. Scipio3, and Michael E. Robinson3

This study examined the influence of Virtual Humans' (VH) sex and race on participants’ ratings of painintensity, pain unpleasantness, pain-related negative mood, pain coping, and recommendations for med-ical help. Seventy-five undergraduates viewed a series of VHs and provided computerized visual analogscale (VAS) ratings for the five domains listed above. Mixed model ANOVA analyses showed that par-ticipants of both sexes and races viewed female VHs as experiencing greater pain intensity, greater painunpleasantness, a greater number of pain-related negative moods, poorer coping skills, and a greaterneed to seek medical help for their pain. Participants of both races rated Caucasian VHs as experiencingmore negative moods and poorer coping skills do deal with their pain. The novel computerized VH tech-nology used herein allowed for the standardization of pain expression across sexes and races of VH stim-uli, thus allowing us to remove the influence of biases when creating the study stimuli. This is a notableadvantage over other research methodologies in this line of inquiry. Several future research and educationapplications of this VH technology are discussed.

Keywords: Pain Assessment, Virtual Technology, Mood, Coping, Medical Help

inTroduCTion

Empirical investigations support the presence of sexdifferences in pain (Dao & LeResche, 2000; Ellemeier& Westphal, 1995; Frot, Feine, & Bushnell, 2004;Hawthorn & Redmond, 2000; Robinson, Riley, Myers,Papas, Wise, Waxenberg et al., 2001; Robinson & Wise,2003; Robinson & Wise, 2004; Unruh, 1996; Vallerand& Polomano, 2000). Some studies have shown that fe-males perceive and express higher levels of pain thanmales in clinical settings (Hawthorn & Redmond,2000). Sex-related differences in pain perception havealso been found in experimental pain settings (Frot, etal., 2004). These sex differences extend to the observa-tion of pain in others, with one study finding that par-

ticipants rated female subjects as experiencing greaterpain intensity in an experimental pain task compared tomales (Robinson & Wise, 2004).Sex-specific relationships between pain and negativeaffect have been reported in both community and clin-ical samples (Riley, Robinson, Wade, Myers, & Price,2001). In the National Health and Nutrition Examina-tion Survey, pain and depression were more prevalentin females than in males (Magni, Caldieron, Rigatti-Lu-chini, & Merksey, 1990). In clinical pain samples, theprevalence of depression and anxiety is typically higherfor females (Unruh, 1996). Although little is knownabout the differences between males and females incoping with pain, Unruh, Ritchie, & Merskey (1999)

Corresponding Author:Michael E. Robinson, P.O. Box 100165, Gainesville, FL 32610-0165, Tel: +1 352-273-6153, Fax: 352-273-6156

1University of Jordan, Department of Psychology, Amman, Jordan2University of Washington, Department of Rehabilitation Medicine, Seattle, Washington, U.S.A.3University of Florida, Department of Clinical and Health Psychology, Gainesville, Florida, U.S.A.

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found that females use a wider range of coping strate-gies than men do. However, Keogh & Herdenfeldt(2002) suggested that the use of a wider range of strate-gies could reflect the failure of coping strategies to ef-fectively reduce pain.

A number of studies have also suggested that there areracial differences in pain perception, pain-related neg-ative affect, and pain coping. In one study, AfricanAmericans with rheumatoid arthritis reported signifi-cantly higher use of distraction and praying/hoping ascoping strategies, whereas, Caucasians reported greateruse of ignoring pain and coping statements (Jordan,Lumley, & Liesen, 1998). Campbell, Edwards, & Fill-ingim (2005) examined racial differences in responsesto multiple experimental pain stimuli, including heatpain, cold pressor pain, and ischemic pain and foundthat African Americans reported greater use of passivepain coping. Moreover, research on pain-related moodhas shown that African Americans with chronic painhad higher pain-related depression and disability whencompared to Caucasians (Carmen, Green, Ndao-Brum-blay, Nagrant, Baker, & Rothman, 2004). Riley, Wade,Myers, Sheffield, Papas, & Price (2002) also found thatAfrican Americans experience greater emotional suf-fering compared to Caucasians with similar levels ofpain intensity.

Most research studies investigating sex and race differ-ences in pain perception and evaluation focused on howboth sexes and different races perceive and evaluatetheir own pain. The current study focuses on the differ-ences in perceiving and evaluating others’ pain. Fur-thermore, studies investigating differences inperceiving and evaluating pain in others relied mainlyon recorded videos and still pictures of actual pain pa-tients expressing pain. This methodology, however, isnot sensitive to the possible variance that might alreadyexist amongst video-taped pain patients. The currentstudy controls this possible variance through a novelcomputerized technology which reduces the varianceto almost zero. The purpose of this study was to employa novel computer-generated virtual human (VH) tech-nology to investigate sex and racial differences in theobservation of pain, pain coping, pain-related negativeaffect, and recommendations to seek treatment. The useof a VH technology allows for the standardization ofthe amount of pain expression independent of the sexand race characteristics that are of interest as dependentvariables. This level of experimental control is not pos-

sible with traditional research methodologies, such asthose that involve historical chart reviews. It was hy-pothesized that a VH stimulus would elicit the same sexand race differences previously published in traditionalself-report and observational studies.

meThods

parTiCipanTs

Seventy-five University of Florida undergraduate stu-dents (53 females, 22 males) were recruited throughfliers and posters requesting volunteers to participatein this study. The participant sample was 83% Cau-casian and 17% African American.

inClusion/exClusion CriTeria

Eligibility requirements for participation were being atleast 18 years old, English speaking, and of AfricanAmerican or Caucasian background. Participation wasalso contingent upon ability to give consent.

proCedure

Each participant was asked to read a description of thestudy including the time required to complete the studyand a reminder that the study is voluntary. After readingthe study description, all participants read and signed acomputerized consent form acknowledging that thestudy procedures were explained and that they couldwithdraw, without prejudice, from the study at anytime. Next, they completed a brief demographic ques-tionnaire that collected participants’ age, race, and sex.Participants then read a set of instructions that providedinformation on how to approach the task and how touse Visual Analogue Scales (VASs) to give ratings.

A series of 16 vignettes were produced using comput-erized VH technology via a commercially availablesoftware package (People Puttytm). A novel feature ofthis approach was the ability to standardize the amountof pain expressed in the VH face across different sexesand races of VHs. This was accomplished by employ-ing the Facial Action Coding System (FACS). TheFACS is based on an anatomic analysis of facial musclemovements and distinguishes 44 different action units(AUs). An abbreviated version of the FACS was usedin this study focusing on the four primary action unitsthat are involved in the facial expression of pain andproduced validated facial expressions showing pain–brow lowering, tightening of the orbital muscles sur-rounding the eye, nose wrinkling/upper lip raising, andeye closure.

Sex and Race Differences in Rating Pain

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Each stimulus the participants observed consisted of avignette and a VH patient. Each VH contained threecues–sex (two levels: male or female), race (two levels:Caucasian or African American), and pain (two levels:low amount or high amount of pain) which was re-flected on the VHs facial expressions.

Participants were instructed to completely respond toVHs in the order presented, complete the ratings for oneVH before going on to the next, and they were not al-lowed to revisit a previously viewed VH. For each VH,participants used computerized VASs to rate the levelof pain intensity observed, the level of pain unpleasant-ness observed, the level of pain-related negative moodobserved, how well the observed VH was coping withthe pain experience, and the extent to which they wouldrecommend the observed VH to seek pain-related med-ical help. Participants also completed a computerizedversion of the Gender Role Expectations of Pain ques-tionnaire (GREP) (see appendix A) using computerizedVASs to assess the degree to which gender role expec-tations of pain may contribute to their ratings.

The Gender Role Expectations of Pain questionnaire(GREP) consists of visual analog scales to assess par-ticipants’ view of the typical male and female regardingpain sensitivity, pain endurance, and willingness to re-port pain. It also assesses the participants’ personal at-tribution of his/her pain sensitivity, pain endurance, andwillingness to report pain relative to the typical maleand female. The psychometric properties of the GREPfactor structure are close to the theoretical formulationof the scales, accounting for 76% of the variance inscores. The questionnaire has good test–retest reliabilitywith individual item correlations ranging from 0.53 to0.93. The sex differences in the endorsement of itemson the GREP were large, with the largest differences(46% of variance) shown for willingness to report painitems. Wise, Price, Myers, Heft and Robinson foundthat the GREP was a significant predictor of experimen-tal pain ratings in undergraduate males and females, andthat a significant proportion of sex differences in painreport was accounted for by gender role expectations.

Task duration for the current study was approximatelyone hour. Following the completion of the task, partic-ipants were asked to respond, in writing, to a task valid-ity probe, in which they were asked to guess the studyhypotheses. Then, participants were briefed regardingthe variables of interest and the study hypotheses.

analysis

All data analyses were performed using SPSS for Win-dows (Version 15). Mixed model ANOVA analyseswere performed where sex and race of participants andVHs served as independent variables, and ratings ofpain intensity, pain unpleasantness, pain-related nega-tive mood, pain coping, and the extent to which theVHs were recommended to seek medical help for theirpain served as dependent variables. We had no a priorihypotheses regarding a number of the interaction terms(e.g. sex of participant, by race of participant, by sexof video, by race of video), therefore, we approachedthe analyses by looking at only the main effects andspecified two-way interactions for which a priori hy-potheses were available.

Willingness to report pain and pain endurance, takenfrom the GREP, were investigated to determine whetherthey met the criteria to serve as covariates in the analy-ses involving participants’ ratings of pain intensity andpain unpleasantness.

resulTs

CoVarianCe analysis

Willingness to report pain and pain endurance are twofactors of the GREP that were considered for inclusionin the models as covariates. Correlation analyses wereconducted on these two factors as well as male and fe-male participants’ ratings of pain intensity and pain un-pleasantness for male and female VHs. Results of thecorrelation analyses were not significant, thereby indi-cating that the two GREP factors did not meet the as-sumptions of covariance analysis. Therefore,willingness to report pain and pain endurance were notincluded in the following models.

assoCiaTions among The dependenT Variables

A correlation analysis was conducted between the de-pendent variables. All dependent variables in this study(ratings of pain intensity, pain unpleasantness, pain-re-lated negative mood, pain coping, and recommendingmedical help) were significantly correlated. The mag-nitude of the correlations ranged from 0.35 (pain copingand recommending medical help) to 0.87 (pain intensityand pain unpleasantness.) See Table 1 below.

analysis of pain inTensiTy raTings

sEx EffEcts

Both male and female participants rated pain intensityfor female VHs as significantly higher than that for

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male VHs, F (1, 73) = 4.92, p < 0.05. Both Caucasianand African American participants rated pain intensityfor female VHs significantly higher than that for maleVHs, F (1, 73) = 6.93, p < 0.05.

racE EffEcts

There was no main effect of race of VHs on ratings ofpain intensity. Table 2 below summarizes the results ofthe pain intensity ratings.

analysis of pain unpleasanTness raTings

sEx EffEcts

Both male and female participants rated pain unpleas-antness for female VHs significantly higher than thatfor male VHs, F (1, 73) = 7.61, p < 0.01. Both Cau-casian and African American participants rated pain un-pleasantness for female VHs as significantly higherthan that for male VHs, F (1, 73) = 4.17, p < 0.05.These results mirrored the pain intensity effects pre-sented above.

racE EffEcts

There was no main effect of race of VHs on ratings ofpain intensity. Table 3 below summarizes the results ofthe pain unpleasantness ratings.

analysis of pain-relaTed negaTiVe

mood raTings

sEx EffEcts

Both male and female participants rated pain-relatednegative mood for female VHs as significantly higherthan that for male VHs, F (1, 73) = 6.76, p < 0.05. A


pain intensity pain

unpleasantness

pain-related

negative mood

pain coping recommending

medical help

pain intensity 1 – – – –

pain

unpleasantness

0.87 1 – – –

pain-related

negative mood

0.72 0.82 1 – –

pain coping 0.68 0.75 0.71 1 –

recommending

medical help

0.53 0.51 0.42 0.35 1

Table 1Correlations between the dependent variables

Table 2Means and standard deviations of pain intensity

ratings

* < .05 significant difference between participants onpain intensity ratings

Vh pain intensity

male 38.65* (14.54)

female 41.14* (13.87)

Caucasian 39.94 (13.98)

african american 39.72 (14.45)

main effect was found for race of participants whereCaucasian participants’ ratings for both male and femaleVHs pain-related negative mood (M=40.59, SE=1.84)were significantly higher than African American partic-ipants’ ratings (M=31.75, SE=4.02), F (1, 73) = 3.99, p= 0.05. An interaction of the sex of the VHs by race ofparticipants was also found–Caucasian participants' rat-ings for female VHs (M=42.17, SD=14.28) were signif-icantly higher than African American participants' ratingsfor female VHs (M=31.02, SD=16.16), F (1, 73) = 4.11,p < 0.05.

racE EffEcts

Both Caucasian and African American participantsviewed Caucasian VHs as having significantly higherlevels of pain-related negative mood (M=39.84,SD=14.97) compared to African American VHs(M=38.12, SD=16.02), F (1, 73) = 5.34, p < 0.05. Table4 above summarizes the results of the pain-related neg-ative mood ratings.

analysis of pain-Coping raTings

sEx EffEcts

Both male and female participants viewed female VHsas coping more poorly than male VHs, F (1, 73) = 6.37,p < 0.05. No significant main effect for sex of VHs onthe race of participants was found.

race Effects

Both Caucasian and African American participantsviewed Caucasian VHs as coping more poorly withtheir pain (M=34.47, SE=13.56) than African AmericanVHs (M=32.79, SE=14.07), F (1, 73) = 6.86, p < 0.05.Table 5 below summarizes the results of the pain-cop-ing ratings.

Table 5Means and standard deviations of pain-coping ratings

Vh Coping

male 32.47* (13.63)

female 34.76* (13.80)

Caucasian 34.47* (13.56)

african american 23.79* (13.07)

* < .05 significant difference between participants onpain-coping ratings

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Table 3Means and standard deviations of pain unpleasantness

ratings

Vh pain unpleasantness

male 32.42* (15.17)

female 44.77* (14.54)

Caucasian 44.30 (14.28)


* < .05 significant difference between participants onpain unpleasantness ratings

Table 4Means and standard deviations of pain-related nega-

tive mood ratings

Vh negative mood

male 37.87* (15.44)

female 40.23* (15.11)

Caucasian 39.84* (14.97)

african american 38.12* (16.02)

* < .05 significant difference between participants onpain-related negative mood ratings

analysis of reCommending mediCal help raTings

sEx EffEcts

A main effect for sex of VHs on sex of participants wasfound. Both male and female participants’ ratings for rec-ommending medical help were significantly higher for fe-male VHs than that for male VHs, F (1, 73) = 5.98, p <0.05. The sex of participants was also found as a main ef-fect, indicating that male participants’ ratings for recom-mending medical help (M=52.86, SE=4.31) weresignificantly higher than female participants’ ratings(M=42.50, SE=2.78), F (1, 73) = 4.02, p < 0.05. Race ofthe participant did not have an effect on ratings of recom-mending medical help.

racE EffEcts

Male participants’ ratings for both Caucasian and AfricanAmerican VHs (M=52.86, SE=4.31) were significantlyhigher than that of female participants (M=42.50,SE=2.78), F (1, 73) = 4.06, p < 0.05. Table 6 below sum-marizes the results of recommending medical help ratings.

summary of resulTs

In summary, male and female participants both rated fe-male VHs’ pain intensity, pain unpleasantness, pain-re-lated negative mood, and poorer pain coping, as higherthan male VHs. Male and female participants were alsomore likely to recommend that female VHs seek medicalhelp than male VHs. However, Caucasian and African

American participants’ ratings for female VHs were higherthan that for male VHs only on pain intensity and pain un-pleasantness. Caucasian VHs were viewed as havinghigher pain-related negative mood and as coping morepoorly with their pain than African American VHs.African American VHs’ pain intensity was rated higheronly by African American participants. Ratings made bymale participants tended to be higher than ratings madeby female participants.

disCussion

Although pain levels–as expressed by the faces of theVHs–were digitally controlled to be equivalent across dif-ferent sexes and races, results indicated that participantsof both sexes and races still viewed female VHs’ pain,both the sensory (intensity) and affective (unpleasantness)components, as significantly higher than that for maleVHs. This is consistent with other research findings. In astudy of experimentally-induced pain, Robinson et al.found that viewers rated females’ pain as higher thanmales’. One explanation for why female VHs were viewedas having higher pain is the difference in pain expecta-tions. Females are expected to report higher levels of painthan males in general. Although willingness to report painand pain endurance (as measured by the GREP) did notcorrelate significantly with pain ratings in this study, a siz-able literature shows that both males and females expectfemales to experience greater amounts of pain (Robinsonet al., 2001; Unruh, 1996). Additional research is neededto determine whether such expectations are also elicitedby computer-generated VH characters.

The International Association for the Study of Pain’s def-inition of pain highlights the importance of understandingthe emotional experiences of pain. It is important to notethe effects of negative mood accompanying pain. Al-though all facial expressions of pain were digitally con-trolled to be similar for males and females in this study,female VHs’ pain-related negative mood was rated as sig-nificantly higher than that for male VHs’ by participantsof both sexes. This result could be explained by the posi-tive relationship between pain and negative mood and isconsistent with the findings of the National Health andNutrition Examination Survey, where pain and depressivesymptoms were more evident in females than in males(Magni et al.,1990).

Caucasian VHs were rated by both African American andCaucasian participants as experiencing greater pain-re-lated negative moods. These results suggest that assess-

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Table 6Means and standard deviations of recommending med-

ical help ratings

* < .05 significant difference between participants onrecommending medical help ratings

Vhrecommending

medical help

male 44.05* (21.16)

female 47.15* (20.94)

Caucasian 45.80 (21.35)



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ment of the pain-related negative mood is, at least, partlydetermined by the race of the individual experiencing pain.Consistent with the pain-related negative mood results,participants of both sexes rated female VHs as copingmore poorly with their pain, and participants of both racesrated Caucasian VHs as coping more poorlywith theirpain. These results mirror those for pain-related negativemood, and suggest that when females and Caucasians areviewed as having higher pain than males and AfricanAmericans, respectively, they are also more likely to beviewed as experiencing higher levels of pain-related neg-ative mood and poorer pain-related coping.

When an individual’s pain level, pain-related negativemood, and maladaptive pain coping is rated as high, it isexpected that he/she is more likely to be recommended toseek medical help for his/her pain. In this study, femaleVHs were rated higher on all these variables than maleVHs. They were also recommended to seek medical helpfor their pain significantly more often than male VHs.However, it was not expected for male participants’ rec-ommendations to be higher than female participants’.Male participants recommended that VHs of both sexesand races should seek medical help for their pain signifi-cantly more than female participants. This is consistentwith studies showing sex differences in health-seeking be-haviors. Males have been found to request more drugsthan females after surgery when given access to patientcontrolled analgesia (Macintyre & Jarvis, 1995). Burns,Hodsman, McLintock, Gillies, Kenny, & McArdle (1989)and Stinshoff, Lang, Berbaum, Lutgendorf, Logan &Berbaum (2004) also found that males tend to seek moremedication for their pain compared to females. Based onthe current findings, it also appears that males are morelikely to recommend that others seek care for their ownpain complaints. Several other interpretations are possible.For example, perhaps males consider themselves to be lessequipped than females to help others with their medicalconcerns. Males may also be less tolerant of expressionsof distress from others, which results in them being morelikely than females to encourage that medical care besought. These speculations could be investigated in futurestudies.

The ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending

medical help showed significant intercorrelations. Rela-tionships between these dependent variables have a patternthat might add to the explanation of some of the currentresults. For example, the high correlation between pain in-tensity, pain unpleasantness, pain-related negative mood,and pain coping might add to the explanation of why fe-male virtual videos were rated higher on all variables, ifpain ratings influenced the other ratings.

The results of this study have several implications that areworth noting. First, the use of computerized VHs with dig-itally controlled facial expressions of pain across sexesand races is an innovative technique that enabled greaterstandardization of pain expression than real humans wouldallow. This standardization allows for greater confidencein interpreting the results as being determined by the sexand race biases that participants brought to the ratings.Furthermore, the VH technology used in this study has thepotential to be an educational assessment and interventiontool. Students, healthcare providers, and other individualscan use this technology to assess their own biases in in-terpreting pain or other emotions expressed by others. Thistechnology can also be accessible to almost anyone in theworld via the Internet.

This study did have some limitations, however. First, therewas only one African American male participant in thesample. Future investigations with more diverse sampleswould be necessary to provide additional evidence of thesex and race findings of the present study. Second, the par-ticipants in this study were undergraduate students and itwould be important to replicate these findings in otherpopulations. Finally, the VH characters only showed thehead region and, thus, did not address the many other non-verbal expressions of pain that are communicated through-out the entire body. Future work could examine whetherthe sex and race effects observed herein are also foundwhen full body characters are used and other nonverbalexpressions are manipulated.

Acknowledgement

The present work was supported by grants from the Na-tional Institute of Dental and Craniofacial Research(R01DE013208), National Institute of Neurological Dis-orders and Stroke (F31NS049675), and National Centerfor Rehabilitation Research (T32HD007424).

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The effeCT of aCTiViTies in VirTual Worlds

as a CommuniCaTion enVironmenT To

undersTand eaCh oTher

Hyungsung Park1

The purpose of this study is to explore the possibility of using virtual worlds such as Second Life as atool to develop an understanding of male and female gender roles in the classroom and in social life.Specifically, virtual worlds offer possibilities for users to experience role playing with other people, ofdifferent ethnicities and gender roles, which may allow them to better recognize characteristics ofmale/female gender roles and give them a different perspective of men and women in the real world.Through these activities in Second Life, we found that users had positive attitudes about gender iden-tification and developed an increase in respect towards other people. At the same time, also exploredthe benefits of using virtual worlds for educational applications.

Keywords: Virtual World, Communication, Learning Environment, Second Life, Role Playing

inTroduCTion

Our future society is an age of knowledge and informa-tion. In this new period, entrenched stereotypes and prej-udices may yield to a more balanced sense of social valuesbased on rationality and dignity. This will be a direct resultof empowering the individual, without the distinction ofsexual, ethnic, or class discrimination. Talented individu-als who may otherwise be stifled will have a better chanceto be realize their own potential and become socially rec-ognized.

Jonassen et al. (1999) argues that technologies can be ap-plications of human knowledge to solve real-world prob-lems. Such technological tools can support human needsand expand the individual’s functional capacities. Thisknowledge can be constructive, aid in informational re-source management, and requires producing communica-tion connectivity. In the same context, Second Life is asocial virtual environment tool and new media for explor-ing communication environments may improve mutualunderstanding between men and women concerning gen-der roles. Virtual worlds continue to grow as a significantcomponent of many children’s and adults’ leisure time.They are being used in education worldwide, and they

play an increasingly important part of our culture as awhole.

Different societies reflect cultural values that vary, alterand evolve with given social, political and environmentallocations. Male and female gender roles, and the interac-tion between the two, have long been a key determinantof social-cultural values. In other words, expectations ofmale and female behavior are set according to gender dif-ferences and variance. However, such expectant interpre-tive analysis is within accordance to age modificationvariants. A gender role is set within a particular social, po-litical, and environmental context shared between maleand female subjects. However, such expectant interpretiveanalysis is within accordance to age modification variants.This is social science and humanity’s framework for thedesired analysis. Gender is the primary component of thegender system in human society, which refers to the set ofarrangements by which a society transforms biologicalsexuality into products of human activity, and in whichthese transformed needs are satisfied (Reiter, 1975).

Thorne (1999) classified four kinds of meaning for genderplaying. Of the gender playing used in this research, one

Corresponding Author:Hyungsung Park, LG Apt. 103-2002, Dangjeong-dong, Gunpo-si, Gyeonggi-do, Tel: 82-10-5602-0122, E-mail: [email protected]

1Kyonggi University, Republic of Korea, San 94-6 Iui-dong, Paldal-gu, Suwon-si, Gyeonggi-do, 443-760, Republic of Korea

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is community activity through role playing with genderclassifications, gender identities, and gender areas. He ar-gued that gender role playing is an important activity tounderstand one's own gender identity and to understandthe opposite gender role. It has been determined that gen-der roles are decided by social and cultural factors morethan biological factors. This makes online communitiesan interesting site to explore how gender is perceived invirtual spaces. The online player community serves thefunction of interaction and socialization for many players,and one virtual world in particular, is the so-called SecondLife. This Second Life is rich in scenery with players in-teracting with other characters through text-based chat,virtual environment and social activities.

Virtual Reality (VR) is an emerging computer interfacethat strives to make simulations believable and realistic.Highly realistic and believable simulations are accom-plished using high-speed supercomputers and three-di-mensional graphic accelerators (Ken & Teixeira, 1995).The important distinguishing features of VR is that it ishighly immersive, interactive, colorful and visually ori-ented, fun and generally exciting. VR technology is in-creasingly being recognized as a potential tool for theassessment and rehabilitation of cognitive and functionalprocesses in humans (Foreman et al, 1997; Pugnetti et al,1995; Rizzo & Buckwalter, 1997; Rose, 1996). Virtual en-vironments (VE) allow the creation of dynamic stimulusenvironments in which all responding behaviors can ver-ifiably be recorded. Such advanced technology could po-tentially offer testing and training options that areunavailable with the use of conventional neuropsycholog-ical methods. It is proposed that computer-generated in-teractive simulated environments can be used to assessand rehabilitate cognitive abilities, much like an aircraftsimulator tests and trains piloting abilities.

Second Life is a social virtual environment entirely builtand owned by its residents. Since opening to the public in2003, it has grown explosively, and today over 12 millionunique accounts have been created world-wide (Sec-ondlife.com, 2008). Second Life has the capacity to con-tain game content, but it is not a game, rather, it is a socialvirtual world within itself. It is also a representation of thefirst generation of this type of free open source technology.Unlike games, it is a VE without a back story and educa-tors. Also, users have the opportunity to write their ownnarratives in a social virtual world. Through the willingsuspension of disbelief, users initially enter the virtualworld and experience it as visually appealing in a passive

sense. However, through continued participation, the usertransitions from feeling like an outsider or a viewer intoan active “resident” who is “living” in the virtual world,performing social positions and role play.

The purpose of this study is to explore the possibilities of-fered by virtual worlds such as Second Life as a tool forunderstanding gender roles. Virtual worlds have manyuses for testing users’ experiences about and understand-ing of other people, recognition of gender roles, and howtheir experiences in these virtual worlds may change theway they think about men and women. Through these ac-tivities, we believe that users will develop positive valuesconcerning gender identification and respect for other peo-ple. At the same time, we can explore the broader possi-bilities of using virtual worlds for education.

seCond life as a CommuniCaTion enVironmenT To

undersTand opposiTe gender roles

All societies and cultures have unique expectations andrules about men and women. Because of sociocultural fac-tors, the performance of gender roles has a tremendous in-fluence on an individual's life. Gender roles areinternalized through the socialization process, many timesunconsciously. Gender roles also determine many socialexpectations of men and women, such as family and oc-cupation roles, political roles, self-efficacy, and psycho-logical factors. As social customs have changed,present-day gender roles require a deeper understandingabout men and women. In modern times, the meaning ofgender roles has been shown to be far more independentof physiological and anatomical differences than previ-ously believed. This permits individuals to utilize interac-tive social technology within a controlled environment toexplore the complicated patterns of behavior that modernsociety has adapted in response to both men and women’straditional gender roles.

According to psychologists (Chodorow, 1978; Dinnerstein,1977; Johnson, 1988), gender identity results from distin-guishing gender identity differences between males and fe-males since birth. Also, Whiting and Edward (1988) statedthat gender identity is a result of biological difference.

Nood and Attema (2006) said that Second Life is a VEwhere one can interact with the environment, made up ofa realistic graphic representation of our physical world.The first thing a new visitor sees is a modifiable puppet,called an "avatar" that enables the user to move throughthe virtual world. With this avatar, the user can fly, tele-

Communication in Virtual Worlds

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port, or walk to practically any place within Second Life.Moreover, the user can meet others, create objects, go toparties, buy kitchens, and, through the introduction ofcommerce, earn money in a currency called the "LindenDollar"(L$), and perform many other activities.

Virtual worlds can supplement education, modeling ideasthat are abstract and making them interesting, relevant,and concrete (Williamson & Facer, 2004). Virtual worldsmight also provide safe places where children can interactand socialize, without worrying about unknown dangersin an educational context (Alvarez, 2006). However, theystill include some physical dangers, predator behavior, re-sulting negative emotions and so on. Another main appealof Second Life is that new activities can be tried in an al-most risk-free environment. This can encourage experi-mentation in a way that is not possible in the real world.There can be some very real, human aspects to this, suchas people with social disorders practicing talking to othersbehind the safety of a computer screen (Johnson, 2007).We need to change our teaching methods to enhance theskills that future citizens will need in a digital society.Children and young people are introduced to virtualworlds via video games, and the ways that they interactwith technology may change methods of learning, and theaccumulation of knowledge (Gros, 2007).

At the same time, Garau (2003) commented about the roleof virtual worlds that recent works of cyber fiction havedepicted, in a not-so-distant future where the Internet hasdeveloped into a fully three-dimensional and immersivedata-scope, simultaneously accessible by millions of net-work users. This virtual world is described as having spa-tial properties similar to the physical world and its virtualcities are populated by digital proxies of people.

Slater et al. (2000) argues that practical applications of VRare normally in the realms of engineering, product design,and skill rehearsal. Users can enter into a VE such as Sec-ond Life in order to learn something new about a real sit-uation, to which the simulation corresponds, or to improveor learn a new skill. Participants can create their avatarand explore, meet other people, own land, play games orsports, have discussions, dance, create, run a business, en-hance their education and so on, through a VR such asSecond Life. Users can perform actions in real life as wellas something that is impossible in real life. In fact, the cul-ture in Second Life is characterized by its combination ofreal actions as well as virtual life representations and ac-tivities.

researCh meThods

researCh QuesTions

For this research, we had to consider the following ques-tions:-Do virtual worlds provide a learning environment for roleplaying to understand the opposite gender?-Do users change their recognition of gender roles via vir-tual worlds?The research questions are formed to reflect the main ob-jectives of this research and they are statistically tested inthis study.

parTiCipanTs of The sTudy

The sample for this study was drawn from university stu-dents consisting of one hundred twenty female students inthe author's three classes titled, "Instruction Method andTechnology." The the sample consisted of thirty partici-pants. Most of the students are women, with just threemale students. The men were excluded in this research toavoid biases. The students’ ages ranged from 21-23 yearsold. Participants did not meet prior to the experiment toavoid the possibility of any first impressions influencingtheir thoughts on gender in the conversation of the virtualworld. The experiment took place for twelve weeks to giveparticipants ample opportunity to develop an awarenessof gender roles in the virtual environment.

design

The study took place at the school of the participants. Theinstructional interventions were divided into three mainphases–pre-testing, treatment, and post-testing. Treat-ments were carried out over three months based on the3rd-4th grade female students since a pre-service teacherwas taking "Instruction method and Technology" at theuniversity. Participants experienced their gender role fortwo hours per day in a controlled environment within Sec-ond Life. Assessment methods were the same for all stu-dents who participated in the three groups. The first groupserved as a control group, performing a female gender rolein the real world. The other groups performed in the virtualworld of Second life as male and female roles, respec-tively. Gender roles were set as dependent variables. Inorder to answer the research questions, we calculatedANOVA to examine the statistical effect.

researCh proCedure and aCTiViTy

During the sessions, four experimental tasks were em-ployed in order to evaluate the degree of gender role ex-perienced by the participants as they engaged in the virtualworld of Second Life. The Second Life allows a user to

Park

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select their personalized avatar, either male or female,when the account was created for the study. Also, partici-pants engaged in discussions related to social topics suchas gender equality, and employment of males and females.They also visited the male "places" in second life duringthe session as cyber characters. The sessions consisted oftwo hours a day for three months.

Grouping according to random assignment↓

Pre-test on the Learner’s BSRISF↓

Activity in Second Life via interaction with other peoplerelated on discussion and visiting the land

↓Reflection activity via reflection paper about opposite

gender↓

Post-test on the Learner’s BSRISF

insTrumenT

The questionnaire was based on the adults Bem SexRole Inventory Short Form (BSRISF) by Bem (1981,

2007). The test is comprised of 30 item adaptations ofBem’s original inventory designed to investigate mas-culinity and femininity as independent dimensions ofsex role identity. Respondents are asked to rate them-selves as to how well ten stereotypically masculine ad-jectives, ten stereotypically feminine adjectives and tenneutral adjectives describe themselves. In this study, weused the masculinity and femininity items. Respondentswere also asked to specify ratings on a 5-point scale,with 1 meaning "never" to 5 meaning "always." Scoreson the BSRISF are purported to measure the respon-dents’ degree of masculine and feminine identification(Singh & Agrawal, 2007).

resulTs

Table 1 and Table 2 summarize the overall ANOVA re-sults for each of the three group’s pre-test analyses, list-ing the response variable, explanatory variables withp-values, the means value and standard deviation foreach group’s analysis. As you can see in the ANOVATable 1 and Table 2, between the groups there is no sig-nificant difference for masculine adjectives (F=.115,p>.05) and feminine adjectives (F=.050, p>.05). In otherwords, participants had the same group for masculineadjectives and feminine adjectives.

Figure 2. Fig 1. Research Procedure

Measure Women-Women(Real World) n=30

Women-Women(Virtual World) n=30

Women-Men(Virtual World) n=26

As you can see in Tables 3 and 4, differences between thegroups did occur. According to results, studying the recog-nition of gender roles shows that virtual worlds offer a mu-tual understanding via the ability to choose other genderroles for their avatar. In this way, we can recognize the im-portance and potential of virtual worlds such as SecondLife. After the experimental session, groups which chosea male avatar in the virtual world increased their post-test

mean square of masculine adjectives (M=5.18) comparedto the pre-test mean square (M=4.49). Also, there weresignificant differences within masculine adjectives via themean square (F=6.320, p=0.003). At the same time, pre-feminine adjectives of this group decreased after experi-encing activities in the virtual world as a male avatar(M=3.89). As shown in Table 4, there were differences be-tween the groups.

Table 1Result of pre-test recognition of gender role of between real world and virtual world

Masculine Adjectives

Feminine Adjectives

M

SD

M

SD

4.58 4.51 4.49

.75 .73 .72

4.82 4.80 4.76

.60 .76 .72


Table 2Analysis of variance

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measure ss df Ms f p


Feminine Adjectives

Between Group

Within Group

Total

Between Group

Within Group

Total

.123 2 .062 .115 .892

44.674 83 .538

44.798 85

.048 2 .024 .050 .951

40.028 83 .482

40.077 85

Table 4Analysis of variance

measure ss df Ms f p


Feminine Adjectives

Between Group

Within Group

Total

Between Group

Within Group

Total

8.039 2 4.019 6.320 .003

52.786 83 .636

60.825 85

7.830 2 3.915 5.773 .004

56.286 83 .678

64.115 85

Measure Women-Women(Real-Real) n=30

Women-Women(Real-Virtual) n=30

Women-Men(Real-Virtual) n=26

Table 3Result of posttest recognition of gender role between real world and virtual world


Feminine Adjectives

M

SD

M

SD

4.57 4.47 5.18

.68 .89 .82

4.51 4.58 3.89

.65 .81 1.00

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Enforced post multiple comparisons were calculated usingTukey methods to determine whether differences whichwere kept in mind between any groups were concrete. Asa result, there were differences between the groups whichhad chosen other gender roles in the virtual world thantheir own, such as women choosing male avatars. Asshown in the table, gender role recognition of experimen-tal groups (women-men) had significantly increased.Mean square of pre-masculine adjectives of the experi-mental group (woman-man) who chose a male avatar inthe virtual world significantly increased. On the otherhand, feminine adjectives decreased.

In general, the results of this study show that VR inter-actions can be an important factor in developing a mutualunderstanding of gender roles. Through activities in vir-tual worlds, especially through role-playing in a genderrole other than one’s own, individuals can develop adeeper understanding of the special characteristics andadvantages of their own gender, as well as increaserecognition of characteristics of the opposite gender.Also, in this context, VR can become an important learn-ing environment and tool for developing increased un-derstanding, respect for, and comfort interacting with theopposite gender.

ConClusion

In recent years, there has been a rapid increase in the ca-pability of VR technology. VR technology has beenwidely promoted as a major technological advancement


Women-Women Women-Men

*

**

* **

*

**

* **

Group (real World-Virtual World)


Feminine Adjectives

Women-Women

Women-Women

Women-Men

Women-Women

Women-Women

Women-Men

Result of post hoc multiple comparisons by Tukey

Figure 1. Masculine adjectives’ change

Figure 2. Feminine adjectives’ change

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that can offer significant support for education. There areseveral ways in which VR technology is expected to fa-cilitate learning. One of its unique capabilities is the abilityto allow students to visit environments and to interact inevents that real-life distance, time, or safety factors makeunavailable. The type of activities supported by this capa-bility facilitate current educational thinking that studentsare better able to master, retain, and generalize new knowl-edge when they are actively involved in constructingknowledge through learning by doing.

Learners are represented in the virtual world by their char-acters, called an “avatar.” In graphic-based virtual worldenvironments, like Second Life, it is possible for a user tochoose an avatar that is the opposite gender from their reallife gender. Thus, this opens up many possibilities for re-search and exploration. Indeed, the way gender shapesbasic human interaction in virtual worlds is often noticedand reflected upon, and has been studied in game-basedvirtual worlds. According to Svatos (2007), during gameplay a user’s character gains experience points through ac-tivities he or she does in the virtual world, and these ex-perience points drive the character’s evolution andexternal form. Though Second Life is not a game, thereare many similarities between these virtual worlds andvideo games, just as a video game character gains “expe-rience” that changes their avatar’s evolution and form. Itmay be possible for learners to gain “experiences” aboutgender in virtual worlds in ways that can change their per-ceptions of gender in the real world.

The analytical statistical results of this study indicate thatvirtual world environments offer the possibility of a clearunderstanding of gender roles and their placement andfunctionality within the context of a social environment.This in itself further provides opportune foundational cri-teria for such information to become the building blocksof further educational processing analyses. This researchanalysis provides concrete and useful data pertaining tothe functionality of gender roles' impact and variationwhen it comes to formal educational values, strategies,methods, measurable results and treatments. This researchprovides a measure of gender recognition, and shows thatsuch target placement can be variable with a users’ variantactivity experience within the context of a virtual worldin an educational context. Furthermore, it demonstratesthe capability and capacity for educational virtual worldsto be accurate means of promoting practical and theoreti-cal data which is key to understanding the time-worn, in-finite complexities of male/female social relations andeducational placement within a given social context.

This study has the limitation that can also reflect the char-acteristics of gender role in the real world–during the ses-sion, females in the real world had to have a male orfemale avatar in a virtual world such as Second Life. Toreduce this point, we explained to the participants that theyhad to focus on understanding the opposite gender. Also,given the topic for discussion, they had to come up with asolution through rational decision making and positivethinking activities during the session.

referenCes

Alvarez, M. (2006). Second Life and School: The Use of

Virtual Worlds in High School Education. Re-trieved June 13, 2008, from http://www.trin-ity.edu/adelwich/worlds/articles/trinity.manny.alvarez.pdf.

Bem, S. L. (1981). Bem Sex Role Inventory: Professional

Manual. Palo Alto, CA: Consulting Psycholo-gists Press.

Bem, S. L. (2007). Sex role inventory test. Retrieved Au-gust 9, 2007, from http://www.okcupid.com/tests/take?testid=9417365772332679709.

Chodorow, N. (1978). The reproduction of mother-

ing. Berkeley: University of CaliforniaPress.

Foreman, N., Wilson, P., & Stanton, D. (1997). VR andspatial awareness in disabled children. Commu-

nications of the ACM, 40(8), 76-77.

Garau, M. (2003). The Impact of Avatar Fidelity on Social

Interaction in Virtual Environments. Ph D the-sis, University College London.

Gros, B. (2007). Digital Games in Education: The Designof Games-Based Learning Environments. Jour-

nal of Research on Technology in Education,

40(1), pp. 23-38.

Johnson, M. (1988). Strong mothers, weak wives. Berke-ley: University of California Press.

Johnson, N. (2006). The educational potential of Second

Life. Ohio State University. Digital Union.

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Jonassen, D. H., Peck, K. L., & Wilson, B. G. (1999).Learning with technology: A constructivist per-

spective. NJ: Phoenix Color Corp.

Ken, P., & Teixeira, K. (1995). Virtual Reality: Through

the New Looking Glass, second edition, Wind-crest Books.

Nood, D., & Attema, J. (2006). The Second Life of Virtual

Reality. EPN REPORT. Retrieved June 24,2008, from https://docs.rice.edu/confluence/download/attachments/5111868/EPN-RE-PORT-The_Second_Life_of_VR1.pdf?ver-sion=1.

Pugnetti, L., Mendozzi, L., Motta, A., Cattaneo, A., Barbi-eri, E., & Brancotti, B. (1995), Evaluation andretraining of adults’ cognitive impairments:Which role for virtual reality technology?, Com-

puters in Biology and Medicine, 25(2), 213- 227.

Reiter, R. (1975) ed. Toward and Anthropology of Women.

Monthly Review Press: New York.

Rizzo, A. A., Buckwalter, J. G., & Neumann, U. (1997).Virtual reality and cognitive rehabilitation: Abrief review of the future. The Journal of Head

Trauma Rehabilitation, 12(6), 1-15.

Rose, F. D. (1996). Virtual reality in rehabilitation follow-ing traumatic brain injury. Proceedings of the

European Conference on Disability, Virtual Re-

ality and Associated Technology (pp. 5-12).Cognitive, Clinical, and Methodological Issues

in Assessment and Rehabilitation (G. Riva,Ed.), IOS Press, Amsterdam, 123-146.

Savtos, O. (2007). The Potential of Online Virtual Worlds.Retrieved Oct. 9, 2007, from http://almorea.com/papers/PotentialofVW.pdf.

Singh, K., & Agrawal, P. (2007). Perceived Sex Role and

Fear of Success: A Study on Urban Working

Women. Journal of Social Sciences, 15(1), 65-69.

Slater, M., Howell, J., Steed, A., Pertaub, D-P., Garau, M.,& Springel, S. (2000). Acting in Virtual Reality.Proceeding of the Third International Confer-

ence on Collaborative Virtual Environments,San Francisco, U.S.A.

Terdiman, D. (2003). SL Intrudes On First One. RetrievedMarch 9, 2008, from http://www.wired.com/news/games/0,2101,59675,00.html.

Thorne, B. (1999). Gender play: Girls and boys in school

(6th ed.). New Brunswick: Rutgers UniversityPress.

Whiting, B., & Edward, C. (1988). Children of difference

worlds. Cambridge: Harvard University Press.

Williamson, B., & Facer, K. (2004). More than ‘just agame’: the implications for schools of chil-dren’s computer games communities. Educa-

tion, Communication & Information, 4,255-270.


IN THIS FEATURE, we will try to describe the char-acteristics of current cyberpsychology and rehabilitationresearch. In particular, CyberProjects aims at describingthe leading research groups and projects, actually run-ning around the world, with a special focus on Europeanresearch.

geTTing families and friends

TogeTher again–VirTually

A fireside chat, sharing photos with granddad, a family

get-together to play Monopoly on a Sunday afternoon…

Digital media designed for the individual has hastened

the demise of collective social events, but it could also

enable their revival.

By marrying state-of-the-art video and audio communi-cations technology with digital media, interactive de-vices and ambient intelligence, a team of Europeanresearchers hopes to give people of all ages the opportu-nity to get together, play games, share experiences andgenerally communicate, interact and have fun together,even if they are thousands of kilometers apart. Their goalis to break down the barriers between people – techno-logical and social.

“E-mail, the Internet, cellphones, Internet video calls…they are all designed for one person using one machine.They are not designed to support families or groups ofpeople communicating,” suggests Nikolaus Färber, a re-searcher at the Fraunhofer Institute for Integrated Cir-cuits IIS in Germany. “People have become isolated bytechnology,” he adds.

Coupled with people moving and traveling more fre-quently for work and study, it is a situation that has ledfamilies and friends to spend less time together. Even inthe same home many people now tend to entertain andeducate themselves alone, whether it is the teenager play-ing computer games in her room, the father listening tomusic on his MP3 player in the lounge or the motherstudying on her laptop in the kitchen. Technology hasencouraged this isolation, but advances in that same tech-nology could now reverse this trend.

TelepresenCe and more

Working in the EU-funded TA2 (Together anywhere, to-gether anytime) project, Färber and a team of researchersfrom seven European countries are aiming to turn the ta-bles on technology by simply and affordably bringingtelepresence into normal households. Their vision con-sists of groups of friends and family members seeingeach other on their TVs, hearing each other through theirstereo systems, sharing photos and videos and playinggames almost as naturally as if they were in the sameroom.

“My brother lives in Switzerland and we have kids aboutthe same age, but they only get to see each other twice ayear. With the system we are developing they would beable to play together whenever they wanted to withouthaving to leave their homes,” Färber notes.

To make that possible, the TA2 researchers are develop-ing the components necessary to build an affordable andeasy to install in-home telepresence system. The compo-nents can then be used to build complete telepresencesystems without the need for special rooms or bigscreens to bring people together virtually. A televisionset, sound system, cameras and microphones placed in aliving room suffice to create a sufficiently interactive andimmersive experience, while state-of-the-art software,which is transparent to the end user, manages the com-munications backbone.

“Audio and video quality is of essence… it needs to besharp and responsive,” Färber says. “At the same time,TA2 is aware that high audiovisual quality is not the onlything that matters. Applications like games, photo shar-ing, or virtual pin boards are necessary to frame and trig-ger the communication.”

Fraunhofer IIS has developed an Audio CommunicationEngine to provide low-delay, hi-fi quality sound thatvastly improves upon current shaky and echo-prone In-ternet calls. Other project partners, among them Philips,BT and Alcatel-Lucent, are working on enhancing videocommunications, linking interactive devices together andimplementing ambient intelligence.

CyberproJeCTs

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Two or more families playing a board game, for exam-ple, would be able to see and hear each other over theirTV sets, with artificial intelligence used to focus in-homecameras on the person speaking or whoever's turn it is.A touch screen embedded in a table might serve as aboard game interface, while ambient intelligence fromin-home sensors will let the system and other playersknow where participants are and what they are doing.

“Ambient intelligence could also improve communica-tions by letting friends and family know when someoneis available for a call or if they are busy, depending ofcourse on how much information the person wants to dis-close,” Färber says.

Children and the elderly, who often find themselves moreisolated than other social groups in the modern world,could particularly benefit from the technology. One sce-nario, which will be used as a demonstration to highlightthe project results, envisions a grandparent and grand-child playing a picture-matching game called "pairs" inwhich old photos could be used to trigger conversationsand pass stories down through generations.

“At IFA in Berlin (the world’s largest consumer electron-ics fair) we set up a demonstration consisting of tworooms, two TV screens and two tables with integratedtouch screens on which people could play games. People

were playing with each other as if they were really to-gether in the same room… Many people were interestedin the system, particularly those with families and friendsin different parts of the world,” notes Matthias Rose, thehead of marketing communications for audio and multi-media at Fraunhofer IIS.

Fraunhofer is already working on integrating its audiotechnology into commercial products, and commercialapplications are also likely to stem from other areas ofresearch in the TA2 project, which is being funded bythe EU’s Seventh Framework Programme.

“Obviously, once the project ends, it would be interestingto find investors and partners to create a commercialproduct out of the whole system that would allow every-one to incorporate telepresence into their homes andbring families and friends closer together,” Färber says.

For more information visit http://www.ta2-project.eu/.

Compiled by Giuseppe Riva, Ph.D. and Simona Raspelli, Ph.D.

Istituto Auxologico Italiano

Data provided by ICT Results(http://cordis.europa.eu/ictresults).

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CyberfoCus

New technologies are developing at a rapid pace. To help you stay abreast of the latest trends in advanced technolo-gies and healthcare, this feature showcases upcoming, 2009- 2010 events, which will provide you with the oppor-tunity to connect with leading experts worldwide and remain on the cutting edge of the most recent developments.

The CyberFocus column welcomes your contributions. To supply relevant information for this feature, please sendan e-mail to: [email protected].

Cyberpsychology & CyberTherapy 15

June 13 - 15, 2010Seoul, Koreawww.interactivemediainstitute.com

The Journal of CyberTherapy & Rehabilitation is the official journal of the CyberTherapy Conference. The 15th An-nual International CyberTherapy Conference (CT15) brings together researchers, clinicians, policy makers and fundingagencies to share and discuss advancements in the growing discipline of CyberTherapy & Rehabilitation, which in-cludes training, education, prevention, rehabilitation, and therapy. The focus of this year’s conference is two-fold–first,“Technologies as Enabling Tools” will explore the use of advanced technologies in diagnosis, assessment and pre-vention of mental and physical disorders. In addition, attention will be drawn to the role of interactive media in training,education, rehabilitation and therapeutic interventions. Secondly, CT15 will investigate the “Impact of New Tech-nologies” and how they are influencing behavior and society through cyberadvertising, cyberfashion and cyberstalking,among others. Technologies featured at the conference include VR simulations, video games, telehealth, the Internet,robotics, brain-computer interfaces, and non-invasive physiological monitoring devices. Conference attendees havethe opportunity to play a role in designing the future of mental healthcare. CT15 features interactive exhibits at theCyberarium allowing participants to experience the technologies firsthand as well as the opportunity to display theirexhibits in a forum-type setting.

2010 Conferences

raVe 2010 - real actions in Virtual environments

March 3Barcelona, Spainwww.raveconference.com

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The World of health iT Conference & exhibition

March 15 - 18Barcelona, Spainhttp://www.worldofhealthit.org/

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ieee Vr 2010

March 20 - 24Waltham, Massachusetts, USAhttp://conferences.computer.org/vr/2010/

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applied psychophysiology & biofeedback 2010

March 24 - 27 San Diego, California, USAhttp://www.aapb.org/

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2010 haptics symposium

March 25-26, 2010 Boston, Massachusetts, USAhttp://www.hapticssymposium.org/

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spie defense, security, and sensing

April 5 - 9Orlando, Florida, USAhttp://spie.org/x1375.xml

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society of behavioral medicine: 2010

April 7 - 10Seattle, WAhttp://www.sbm.org/meetings/

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laval Virtual 2010: 12th Virtual reality international Conference

April 7 - 11Laval, Francehttp://www.laval-virtual.org/

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The 7th annual World health Care Congress

April 12 - 14Washington D.C., USAhttp://www.worldcongress.com/events/

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med-e-Tel

April 14 - 16Luxembourghttp://www.medetel.lu/index.php

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19th international World Wide Web Conference: WWW2010

April 26 - 30Raleigh, North Carolina, USAhttp://www2010.org/www/

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human systems interaction Conference

May 13-15Polandhttp://hsi.wsiz.rzeszow.pl/

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american Telemedicine association 2010: 15th annual international meeting and exposition

May 16 - 18San Antonio, Texas, USAhttp://www.americantelemed.org/i4a/pages/index.cfm?pageID=3629

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The 6th annual World health Care Congress – europe

May 19 - 20Brussels, Belgiumhttp://www.worldcongress.com/events/HR10015/

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The xii symposium on Virtual and augmented reality – sVr 2010

May 24 - 27Rio Grande Do Norte, Brazilhttp://www.dimap.ufrn.br/svr2010/

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WCbCT 2010-World Congress of behavioral and Cognitive Therapies

June 2 - 5Boston, Massachusetts, USAhttp://www.wcbct2010.org/

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Cyberpsychology & CyberTherapy 15

June 13 - 15Seoul, Koreawww.e-therapy2010.org

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siggraph 2010

July 25 - 29Los Angeles, California, USAhttp://www.siggraph.org/s2010/

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3rd international symposium on intelligent interactive multimedia: systems and services

July 28 - 30Baltimore, Maryland, USAhttp://iimss-10.kesinternational.org/

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2010 american psychological association Conference

August 12 - 15San Diego, California, USAhttp://www.apa.org/convention/

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8th iCdVraT with artabilitation

August 31 - September 2Valparaiso, Chilehttp://www.icdvrat.rdg.ac.uk/

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The 5th international Conference on interactive mobile and Computer aided learning

September 16 - 17Hasselt University, Belgiumhttp://www.imcl-conference.org/

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10th international Conference on intelligent Virtual agents (iVa 2010)

September 20 -22Philadelphia, Pennsylvania, USAhttp://iva2010.org/

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40th european association for behavioural and Cognitive Therapies annual Conference

October 7 - 10Milan, Italyhttp://www.eabct2010-milan.it/

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association for behavioral and Cognitive Therapies (abCT 2010)

November 18 - 21San Francisco, California, USAhttp://www.abct.org/dMembers/?m=mMembers&fa=Convention

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manusCripT submissions

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To submiT

Please submit electronic copies of your manuscriptby visiting www.vrphobia.eu and clicking on the“Submit Paper” link on the right.

manusCripT sTyle. The language of the journal isAmerican English. Submissions should follow Ameri-can Psychological Association (APA) format. Formatquestions not addressed in the checklist below can besent to the Managing Editor at [email protected].

CopyrighT. Submission of a manuscript will be heldto imply that it contains original unpublished work andis not being submitted for publication elsewhere at thesame time. If selected for publication, authors mustsign and return a Copyright Transfer Form (availableon the Web site or from the Publisher.) Submitted ma-

terial will not be returned to the author, unless specif-ically requested.

reVieW. Papers will be evaluated anonymously bymultiple members of the Editorial Board. They will bereviewed based on scientific merit, originality, read-ability, and interest to the readership.

furTher informaTion. Typeset proofs will be sent tothe author for review. This stage is only for correctingerrors that may have been introduced during the pro-duction process. Prompt return of the corrected proofs,preferably within 48 hours of receipt, will minimizethe risk of the paper being held over to a later issue.Two complimentary copies of the issue will be pro-vided to the corresponding author, unless otherwise in-dicated. Further copies of the journal may be ordered.

formaT. The original manuscript should be double-spaced and formatted for A4 paper (.27in. x 11.69 in.;21cm. x 29.7cm.) with adequate and consistent mar-gins on all pages.

The title page, abstract, references, appendixes, authornote, content footnotes, tables, figure captions, and figuresmust be on separate pages (with only one table or figureper page.) They should be ordered in sequence, with thetext pages between the abstract and the references.

Is the author note typed on the title page, which is re-moved by the journal editor before review? Are all otherpages free of author identification? Does each page havethe paper title at the top?

All pages (except figure pages) should be numbered insequence, starting with the title page.

CoVer leTTer. A cover letter must be included withthe manuscript. The letter should include the author's

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postal address, e-mail address, telephone number, andfax number for future correspondence and a statementthat the manuscript is original, not previously pub-lished, and not under concurrent consideration else-where.

This letter needs to inform the journal editor of the ex-istence of any similar published manuscripts writtenby the author.

TiTle page and absTraCT. The title should be 10 to12 words in length. The byline should reflect the insti-tution or institutions where the work was conducted.The abstract must be between 100-150 words and upto five keywords may be included after the abstract.

headings. The levels of headings should accuratelyreflect the organization of the paper, and all headingsof the same level must appear in the same format.

abbreViaTions. Any unnecessary abbreviationsshould be eliminated and any necessary ones must beexplained when they first appear.

Abbreviations in tables and figures need to be ex-plained in the table notes and figure captions or leg-end.

referenCes. References must follow APA format.Please be sure references are cited both in text and inthe reference list.

Text citations and reference list entries should agreeboth in spelling and in date, and journal titles in thereference list must be spelled out fully.References(both in the parenthetical text citations and in the ref-erence list) are to be ordered alphabetically by the au-thors' surnames.

Inclusive page numbers for all articles or chapters inbooks must be provided in the reference list.

noTes and fooTnoTes. The departmental affiliationshould be given for each author in the author note. Theauthor note includes both the author's current affiliationif it is different from the byline affiliation and a currentaddress for correspondence.

The author note must disclose special circumstancesabout the article. This includes any portions pre-sented at a meeting, whether a student paper wasused as basis for the article, any report of a longitu-dinal study and any relationship that may be per-ceived as a conflict of interest.

Footnotes should be avoided unless absolutely neces-sary. Check to make sure essential footnotes are indi-cated by superscript figures in the text andexplanations are collected on a separate sheet at theend of the manuscript. In the text, all footnotes are tobe indicated and correctly located.

Tables and figures. Every table column must have aheading. Make sure the elements in the figures are largeenough to remain legible after the figure has been re-duced to no larger than 11 cm.

Lettering in a figure should not vary by more than 4point sizes of type. Each figure must be labeled with thecorrect figure number, caption, and short article title.

Minimum file resolution (dots per inch) for printing:• line art (graphs, drawings) = 1,200 dpi• halftones (photos) = 300 dpi• combo line/halftone = 600 dpi

CopyrighT and QuoTaTions

Written permission to use previously published text, testsor portions of tests, tables, or figures must be enclosed withthe manuscript.

Page or paragraph numbers need to be provided in textfor all quotations.

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Journal of CyberTherapy & RehabilitationISSN: 1784-9934GTIN-13 (EAN): 9771784993017

Journal of CyberTherapy & Rehabilitation is publishedquarterly by the Virtual Reality Medical Institute, Ruede la Loi, 28/7, B-1040 Brussels, Belgium. The journalexplores the uses of advanced technologies for therapy,training, education, prevention, and rehabilitation. Areasof interest include, but are not limited to, psychiatry, psy-chology, physical medicine and rehabilitation, neurology,occupational therapy, physical therapy, cognitive reha-bilitation, neurorehabilitation, oncology, obesity, eatingdisorders, and autism, among many others.

publishing house

Virtual Reality Medical InstituteRue de la Loi, 28/7 B-1040 Brussels, BelgiumTelephone: +32 2 286 8505Fax: +32/2/286 8508E-mail: [email protected]: www.vrphobia.eu

publisher

Brenda K. Wiederhold, Ph.D., MBA, BCIA

subsCripTion informaTion

Rates for subscription are for a volume of four issues.PrintEurope: €115International: €145

Online and PrintEurope: €135International: €165

Online OnlyAll locations: €75

Subscriptions begin with the first issue of the current vol-ume. No cancellations or refunds are available after thevolume’s first issue is published. There are also no re-funds on single issue purchases.

adVerTising

For advertising information, rates, and specificationsplease contact Virtual Reality Medical Institute, Rue dela Loi, 28/7, B-1040 Brussels, Belgium, Telephone: +322 286 8505; Fax: +32/2/286 8508; E-mail: [email protected].

reprinTs

Individual article reprints are available from correspon-ding authors. Please contact the publisher for rates onspecial orders of 100 or more.

manusCripTs

Please submit electronic copies of your manuscriptby visiting www.vrphobia.eu and clicking on the“Submit Paper” link on the right. Information aboutmanuscript submission requirements and formattingcan be found at the back of each issue or on the Website.

CopyrighT

Copyright © 2010 by Virtual Reality Medical Institute.All rights reserved. Journal of CyberTherapy & Reha-bilitation is owned by Virtual Reality Medical InstituteBVBA and published by the Virtual Reality Medical In-stitute BVBA. Printed in Hungary.

With the exception of fair dealing for the purposes ofresearch or private study, or criticism or review, no partof this publication may be reproduced, stored, or trans-mitted in any form or by any means without prior per-mission in writing from the copyright holder.

For permission to photocopy an article for internal pur-poses, please request permission and pay the appropri-ate fee by contacting [email protected].

The accuracy of contents in Journal of CyberTherapy& Rehabilitation are the responsibility of the author(s)and do not constitute opinions, findings, conclusions,or recommendations of the Publisher or editorial staff.In addition, the Publisher is not responsible for the ac-curacy of claims or information presented in advertis-ing portions of this publication.

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general informaTion

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The Journal of CyberTherapy & Rehabilitation is indexed in PsycINFO, Gale and EBSCO, and

is currently under review with SCOPUS, EMBASE and Medline.

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insTruCTions for ConTinuing eduCaTion Quiz

The quiz is an open-book exam. Clearly mark answersby circling the correct letter. You may photocopy theexam or work directly on the journal page. Mail thecompleted exam and appropriate payment (see fees,

next page) to Interactive Media Institute, 6155 Corner-stone Court East, Suite 210, San Diego, California92121, U.S.A. If you wish to receive a receipt of pay-ment or a copy of the correct quiz answer, please in-clude a self-addressed, stamped envelope.

eValuaTion

Please rate this article, “The Sense of Olfaction: Its Characteristics and Its Possible Applications in Virtual Envi-ronments” (Baus & Bouchard, pg. 31), on a scale of 1 to 5 (1=true, 5=false). _____The information in this article was presented well_____The information is applicable to my line of work _____The article covered all relevant aspects of the topic _____I read this article because it addresses my work _____I read this article to gain the CE credits _____I would recommend the article to colleagues

To judge your responses to the previous article, please evaluate a second article as well, on a scale of 1 to 5 (1=true,5=false).The article title is:____________________________________________________________________ _____The information in this article was presented well_____The information is applicable to my line of work _____The article covered all relevant aspects of the topic _____I read this article because it addresses my work _____I read this article to gain the CE credits _____I would recommend the article to colleagues

The CE credit quiz is open for one year after the issue’s publication date. The Interactive Media Institute is approvedby the American Psychological Association to offer continuing education and is solely responsible for the contentof articles and the examination process.

Please print clearly and mail with payment to the address listed above:

Name________________________________________

Address______________________________________

City______________________________________State and Zip Code (if in U.S.)__________

Country______________________________________

I certify that I have read the article and completed the test without receiving any outside help.

Signed_________________________________________________________Date_____________

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ConTinuing eduCaTion Quiz

The sense of olfaction: its Characteristics and its possible

applications in Virtual environments (baus & bouchard, pg. 31)

If you answer 10 out of 12 questions correctly, you will be awarded one CE credit.

Prepared by Alessandra Gorini, Ph.D.

1. Olfactory sense has been considered of minor inter-

est in VR applications because:

a)the incorporation of olfaction stimuli in the VR expe-rience would not enhance itb)the odor perceived by each subject is highly subjec-tive, and thus, generalization involving one particularodorant is likely to be difficult c)due to their complex composition and transient char-acter, controlled exposure to olfactory stimuli is morecomplex than that to visual or acoustic stimuli d)all of the above

2. Up to date, the rare VR applications that include

some forms of olfaction stimulation regard:

a) the treatment of specific phobiasb) the treatment of eating disordersc) drug addiction researchd) the treatment of psychotic disorders

3. When exposed to multi-sensory alcohol related cues

presented in virtual environments, individuals with al-

cohol use disorders:

a) increase their level of presenceb) become more relaxedc) report significantly higher cravings for alcohol thannon-binge drinkersd) both A and C

4. One of the differences between the olfactory system

and the other senses is that:

a) the olfactory bulb projects without being mediatedby the thalamus onto the amygdalab) the olfactory bulb projects crossed onto the amyg-dalac) the olfactory bulb goes through a series of cortical

relays before reaching the limbic systemd) none of the above

5. Which of the following cerebral structures are in-

volved in the olfactory system:

a) the olfactory bulbb) the amygdalac) the orbitrofrontal cortexd) all of the above

6. Compared to other animals, humans:

a) have a poor ability to localize the source of an odor-antb) have an olfactory acuity inferior to that of most ani-mal speciesc) use olfaction for socializationd) none of the above

7. In order to be effective, the presentation of an odor

in a virtual environment should be:

a) provided using many remote sources to release theolfactory cuesb) supported by a visual cue related to the odorc) randomly providedd) none of the above

8. In a VR experience including odor stimulation:

a) the hedonicity of an odor contributes to the determi-nation of its intended virtual sourceb) the level of familiarity leads to a more rapid associa-tion with the cues presented via other modalitiesc) varying odorant intensities may be useful in cueingthe user about the position, and rate of position change,relative to the intended virtual source of that odord) all of the above

ConTinuing eduCaTion CrediTs

To qualify for CE credits, readers will need to do thefollowing:• After reading an article, answer the questions above.• Send the completed answer sheet, along with pay-ment, to Interactive Media Institute, 6155 Corner-stone Court East, Suite 210 San Diego, CA 92121,U.S.A.

• If you wish to receive a receipt of payment or a copyof the correct quiz answer, please include a self-ad-dressed, stamped envelope. • The fee is $20 for iACToR members or subscribers and$40 for non-subscribers. • All CE exams are open-book. • Credits assigned are based on the length of time re-quired to read each article.

9. The presence of an odorant in the environment can

be associated with:

a) positive affects and increased arousal, if the odor ispleasantb) an alteration in the level of pain perceived by an in-dividualc) negative affects and decreased arousal if the odor isunpleasant d) the pleasantness of the experience

10. Contrary to congenitally blind, mute or deaf peo-

ple, individuals with congenital anosmia:

a) experience less pain b) are more prone to illnessc) do not have intact reproductive–social behaviord) all of the above

11. Clinical scenarios for treating PTSD utilize odors to:

a) make the virtual experience more fascinatingb) make the experience more realisticc) facilitate the processing of traumatic memoriesd) none of the above

12. In training scenarios, olfactory stimulation could

be useful to:

a) trigger appropriate responses to emergency situa-tionsb) establish an association between a distinct odorantand “virtually-evoked” positive emotionsc) enhance the virtual experienced) all of the above

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The Journal of CyberTherapy & Rehabil itation (JCR) is the off icial journal of the International Association of CyberPsychology, Tra in ing & Rehabil itation ( iACToR). Its miss ion is to explore the uses of advanced technolog ies for educat ion, tra in ing , prevention, therapy, and rehabil itat ion .

Please v i s i t www.vrp ho b ia .eu for more i nformat ion .

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