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Using Avatars and Agents to Promote Real World Health Behavior Changes



This chapter reviews the past and current trends of one particularly intriguing aspect of virtual worlds—virtual representations commonly known as avatars—in the context of health behavior change. Despite the growing interest in the influence of virtual representations on health behaviors, there has been a surprising dearth of research exploring the use of virtual representations as a direct and central vehicle of behavior change. State-of-the-art findings on the use of virtual representations to promote behavior change will be discussed first, followed by a more detailed discussion of recent studies that specifically target health behavior change using virtual representations.
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[The Digital Patient: Advancing Medical Research, Education, and Practice], Edited by [C. Donald
Combs, John A. Sokolowski, Catherine M. Banks].
ISBN 0-471-XXXXX-X Copyright © 2015 Wiley[Imprint], Inc.
Chapter 12
Using Avatars and Agents to Promote
Real World Health Behavior Changes
Sun Joo (Grace) Ahn
Fluid, dynamic, and infinitely replicable, virtual worlds have been an enticing yet
prohibitively costly platform for health behavior researchers in the past decade. What
difficulties that the researchers of the past have faced in incorporating virtual worlds in
primary and secondary prevention and intervention programs have dramatically
decreased in the recent years with unprecedented advancement in digital media
technology [1] and virtual worlds are enjoying a newfound surge of popularity in both
academic and clinical environments. Digital devices that simulate vivid sensory
information, allowing users in virtual worlds to experience visceral environmental cues,
have now become much more affordable and accessible, opening up new horizons for
incorporating virtual reality technology in people’s everyday lives, outside of
sophisticated laboratories.
This chapter reviews the past and current trends of one particularly intriguing
aspect of virtual worlds—virtual representations commonly known as avatars—in the
context of health behavior change. Despite the growing interest in the influence of
virtual representations on health behaviors, there has been a surprising dearth of research
Wiley STM / Combs, Sokolowski, Banks: The Digital Patient: Advancing Medical Research,
Education, and Practice Chapter 12/ Ahn / filename: ch12.doc
exploring the use of virtual representations as a direct and central vehicle of behavior
change. State-of-the-art findings on the use of virtual representations to promote
behavior change will be discussed first, followed by a more detailed discussion of recent
studies that specifically target health behavior change using virtual representations.
Avatars and Agents
The word “avatar” originates from the Sanskrit word avatara, which means “descent” to
describe an incarnation or a bodily manifestation of an immortal being in Hinduism. In
much the same way, users interact in the virtual world in the form of embodied virtual
identities that mark their presence in the virtual environment [2]. In the past, avatars
typically served as simplistic and static visual markers (e.g., a simple chat icon on AOL
or Yahoo Messenger), much like the virtual equivalent of horses players use to represent
themselves in board games. Over time, avatars have become significantly more complex,
rendered in three dimensional forms with an extensive range of dynamic movements,
photorealistic appearances, naturalistic language, and even the ability to mimic empathy
when interacting with users. The avatars of today are still works in progress—the
humanoids that have evolved to feel and express naturalistic emotions as are often
depicted in popular media are yet figments of imagination. However, the speed at which
avatars have gained technical sophistication forecasts that more realistic, natural, and
affordable avatars may soon become a reality in the near future.
Agents are another form of virtual representation that shares similar features and
capabilities with an avatar, but the two forms are distinguished by the element of control:
avatars are controlled by human users whereas agents are controlled by computer
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Education, and Practice Chapter 12/ Ahn / filename: ch12.doc
algorithms [3]. Although seemingly similar in their specifications, agents and avatars
yield meaningfully different influences in their interactions with human users [4].
Research studies have demonstrated that the mere perception of interacting with another
human (vs. a computer algorithm) meaningfully affects whether a virtual representation is
successful at influencing an individual’s attitude and behaviors even when the agents and
avatars are performing identical tasks at the same level [5, 6].
A recent meta-analysis examining 32 studies that compared the influence of
agents against avatars concluded that the mere perception of human control elicited
stronger social responses from humans than the perception of machine control [7]. In
particular, this agency effect was stronger when humans were required to form a certain
degree of relationship with the virtual representations by engaging in a competitive or
cooperative task, rather than a neutral task. The effect of agency was also stronger when
the virtual representations were actually controlled by a human rather than a machine,
regardless of perceived agency.
Designing Agents and Avatars for Health Programs
These findings have important implications for the design and implementation of virtual
representations in health prevention and intervention programs. First, avatars that are
controlled by humans are likely to have stronger impacts on health behavior change than
agents that are controlled by machines. Thus, rather than an agent providing a heavily
scripted intervention, an avatar delivering naturalistic responses is likely to be much more
effective in changing health behaviors.
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Education, and Practice Chapter 12/ Ahn / filename: ch12.doc
Having an actual person control a virtual representation may be useful in a variety
of health contexts. For instance, a rich collection of literature points to the fact that
individuals often judge others based on nonverbal cues such as physical appearance or
behavior [8-10]. Indeed, people are often drawn to others perceived as similar to
themselves [11, 12] or simply familiar (e.g., celebrities) [13, 14]. Because virtual
representations afford labor- and cost-effective means of adopting almost a limitless
option of physical appearances and behaviors that may be different from the actual self,
human controllers behind the virtual representation may flexibly adapt to tailor their
avatars for each respective interactant.
Such a scenario is then possible: an Asian female health care provider is
controlling an avatar. A patient of different sex and ethnicity walks in. The health care
provider may then select a male avatar of the patient’s ethnicity and interact with the
patient through the male avatar to elicit positive responses based on perceived similarity.
Similarity is not necessarily confined to physical appearances; the health care provider
may also mimic the behavior of the patient. Behavioral mimicry has been found to
increase a host of favorable attitudes toward the interaction partner, including liking [15].
Alternatively, the avatar could take on the physical appearance of a well-known celebrity
to deliver health messages, and the perceived familiarity triggered by the avatar may
favorably impact persuasion as demonstrated in earlier studies [14].
Despite earlier findings that indicate the superiority of avatars over agents in a
persuasion context, having human controllers positioned for each and every avatar is
likely a costly option. A more labor- and cost-effective solution may be to implement
computer controlled agents. Although the initial development and setup of the agent
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might be costly, once the infrastructure is established, agents can continue to work at the
same speed and efficiency without the need to eat or rest. These agents may be infinitely
replicable, which would allow patients to receive equal and uniform care across all health
care facilities. Also, for sensitive topics of discussion (e.g., sexual history), patients may
prefer to interact with a machine controlled agent rather than a human controlled avatar
for greater perceived privacy.
Thus, both agents and avatars are viable options for incorporation in health
prevention and intervention programs and the choice to use one over the other should be
made after a careful cost-effectiveness analysis [16]. Although research demonstrates
that avatars are more effective in promoting desired behaviors than agents, the associated
costs in employing a human controller may be prohibitive in a large scale program. On
the other hand, if the program calls for strong and impactful interventions that are more
likely to elicit behavior change, avatars may be well worth the costs. The following
section discusses representative case studies on the systematic investigation of using
agents and avatars in the context of health behavior change to consider the costs and
benefits associated with each type of virtual representative.
Using Agents and Avatars to Promote Health Behavior
Virtual representations offer a set of novel characteristics that allow researchers and
practitioners to implement new strategies to approach health behavior change that were
difficult or not possible with traditional tools and platforms. These characteristics
include the virtual acceleration of time [17], wherein agents and avatars are able to
transcend temporal boundaries of the physical world to digitally depict events in the past
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or future from the present point in time. Another major characteristic that distinguishes
virtual representations from traditional media platforms is high interactivity, or the
medium’s capacity that allows users to influence the form and/or content of the mediated
experience in real time [18]. It is generally agreed that the best interactive medium
mimics the interactive dynamics of face-to-face communication [19]. Using interactive
virtual representations that afford naturalistic social interactions is likely to heighten
users’ engagement and involvement [20], as well as foster more positive attitudes or
liking towards the interaction content [21].
The initial scientific foray into using agents and avatars to impact behavior in the
physical world began with the Proteus Effect [22, 23], which found that when individuals
are aware of the visual characteristics and traits of an avatar that he or she is embodying,
and understand what others will expect of their behaviors based on those characteristics
and traits [24], the experience of embodying that particular avatar will encourage them to
continue to engage in the expected behaviors in the physical world. For example, when
individuals were given tall avatars to embody in a virtual world, they were more
aggressive during a negotiation task in the physical world than individuals who were
given shorter avatars. This is likely a result of conforming to normative expectations that
taller people are more confident and more likely to be in positions of power [25].
Combined with the novel media characteristics that afford users some experiences
that were difficult or impossible with traditional media platforms, the ability of agents
and avatars to influence behaviors in the physical world introduces new horizons for
research on the incorporation of virtual representations in health promotion campaigns as
vehicles of behavior change. The implication is that even the most creative and
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fantastical virtual experiences with agents and avatars may yield effects that transfer into
the physical world to affect individuals’ attitudes and behaviors, giving researchers the
freedom to explore any health context of their desires. Despite such potentials, few
studies have systematically investigated agents and avatars in the context of health
behavior change. Among the collection of literature on agents and avatars in the health
realm, the following sections review some of the representative and state-of-the-art
studies that specifically focus on how interactions in the virtual world with virtual
representatives affect health behaviors in the physical world.
Vicariously Experiencing Future Negative Health
Consequences through Agents and Avatars
Individuals are likely to hold a “rosy” view of distant futures, conceptualizing their
futures in a positive light. Kahneman and Lovallo [26] attribute this overly optimistic
assessment of future outcomes to an isolation error: people tend to think of the future as
an isolated event, independent of past and present events, and base their forecasts of the
future on plans and scenarios of success rather than on accurate past results. Greater
temporal distance of an event, relative to the present, enhances the perceived positivity
towards it [27]. Because future negative health consequences may take some time to
manifest following present behaviors, the large temporal distance is likely to encourage
unrealistic and inaccurate levels of optimism in thinking about the health issue. For
instance, smoking a cigarette today will not immediately lead to lung problems the next
day; rather, the detrimental effect of smoking may require years to manifest. The
temporal distance between the cause (smoking) and effect (lung problems) renders this
relationship abstract and opaque, leading individuals to assume an optimistic outlook for
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their own health in the future. Consequently, this “rosy view” phenomenon is one major
barrier to successfully communicating health risks and changing present health behaviors.
One solution to the rosy view phenomenon is personal experience. Studies have
demonstrated that going through the actual experience at the moment reduces the
unrealistic level of optimism that individuals perceive about future events [28] and that
recent experiences are given more weight in deciding one’s susceptibility to risk than
distant experiences [29]. However, with future negative health consequences, it would
be unrealistic to prescribe personal experiences of negative health outcomes (e.g., lung
problems) to reduce overly optimistic future forecasts. These negative health outcomes
are often irrevocable or fatal.
Using agents and avatars to digitally render future negative health consequences
allows individuals to vicariously, but vividly, experience negative outcomes without
having to incur actual damages to their physical and mental health. In the virtual world,
time becomes a more fluid concept; once created, an agent or an avatar may be digitally
manipulated to dynamically shift their appearances. For example, a virtual representation
of an individual in his or her 20s may be created and then rapidly aged to depict the same
person in his or her 60s [30]. Although 40 years has passed in the virtual world, this may
take only a few seconds in the physical world. More importantly, these virtual
experiences are sufficiently realistic to influence behaviors in the physical world.
In one of the first studies to observe how using agents and avatars to virtually
depict future negative health consequences may influence health relevant behaviors in the
physical world, participants were asked to watch a virtual simulation of an agent with
photorealistic resemblance to themselves gain weight by eating candy or lose weight by
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eating carrots [31]. After watching the virtual simulation, participants were subjected to
an unobtrusive measure of candy consumption in the physical world. Candy
consumption was influenced by an interaction of two variables: sex and presence, or the
degree to which participants felt that they were right there in the virtual world [32]. Male
participants who felt high presence ate more candy whereas female participants who felt
high presence suppressed this behavior and ate less candy. The authors posited that this
finding was a result of virtual imitation, wherein participants modeled the behavior he or
has observed from his or her agent, particularly when the perceived presence was high.
However, as the agents were shown to eat both candies and carrots, it was not clear which
observed virtual behavior was affecting candy consumption in the physical world.
Building on these preliminary results, a recent set of studies investigated the
transfer of virtual world effects to physical world behaviors in the context of soft drink
consumption [33-35]. If the earlier study posited that individuals would model and
imitate the behaviors observed by the agent, this set of studies argued that agents and
avatars may be used to reduce two types of psychological distances—temporal and social.
Reducing the perceived temporal distance between the present health behavior and the
future negative health consequence is likely to render the causal relationship concrete
[36]. Also, reducing the perceived social distance between the individual and the given
health issue is likely to promote perceived personal relevance and involvement with the
issue [36].
The results from this set of studies revealed that perceived social distance could
be successfully reduced by tailoring the information to the audience [33]. Tailoring may
be as simple as changing the verbiage in a traditional pamphlet to create the illusion that
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the pamphlet was created specifically to target an individual. In virtual worlds, an agent
or an avatar may be tailored to bear photorealistic resemblance to an individual, so that
the individual may feel as if the vicarious virtual experiences are actually happening to
him or her. Tailoring in both modalities reduced social distances, increased levels of
involvement with the health issue at hand, and ultimately led to greater intentions to
adopt the desired health behavior (i.e., reducing soft drink consumption) immediately
following experimental treatments [33].
The results also revealed that perceived temporal distance could be successfully
reduced by coupling traditional health pamphlets with virtual simulations that feature
agents and avatars depicting future negative health consequences [33]. A virtual
simulation was created to show an agent dynamically gaining weight as it continued to
consume soft drinks in a virtual world, wherein two minutes of virtual time was
equivalent to two years of physical time. By accelerating the passage of physical time in
the virtual world, participants who were exposed to the virtual simulation perceived
shorter temporal distances between their present health behaviors and future health
consequences. The reduced temporal distance, in turn, increased the perceived
imminence of risks related with soft drink consumption, ultimately leading to lower
consumption of soft drinks one week following the experimental treatment compared to
participants who were not exposed to the virtual simulation. At this point, the effect of
tailoring that was observed immediately following experimental treatments dissipated
and only the effect of watching the virtual simulation remained influential.
A following study explored the effect of virtual doppelgängers [37], agents with
photorealistic resemblance to individuals, to investigate the underlying mechanisms
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driving health behavior change in the same context of soft drink consumption [34].
Virtual doppelgängers create an interesting social phenomenon wherein a virtual entity
that has photorealistic resemblance to an individual may look like an individual but not
act like him or her because the agent is being controlled by an algorithm. Participants in
the study were exposed to a virtual simulation showing either virtual doppelgängers or an
unfamiliar agent gaining weight as a result of consuming soft drinks regularly for two
years, depicted in two minutes in the virtual world. Results indicated that virtual
doppelgängers were more effective than unfamiliar agents in increasing the perception of
presence as well as self-relevant thoughts in the virtual simulation. Watching an agent
that looks like the self consume soft drinks and become obese made participants feel as if
he or she were truly undergoing the experience and encouraged them to think about
themselves in the context of soft drink consumption. Heightened presence and self-
relevant thoughts, in turn, led to increased personal relevance to the issue of soft drink
consumption and obesity.
Finally, different modalities used to deliver a health message about soft drink
consumption and obesity were compared to determine the most effective message
modality in the promotion of health behaviors [35]. Results indicated that compared to
strictly statistical information, print narratives, and pictures, the virtual simulation of an
agent gaining weight as a result of soft drink consumption over the years was best able to
highlight the risks involved with soft drink consumption and actually reduce consumption
one week following experimental treatments.
Taken together, these studies indicate that agents and avatars may serve as a
powerful vehicle of health behavior change by depicting future negative health
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consequences. Without incurring actual harm to personal health, individuals are able to
observe sufficiently realistic simulations of what the future might have in store for them
if they were to continue their present health behaviors. The observation of accelerated
changes in the virtual representations’ health is able to meaningfully reduce the temporal
and social distances perceived between the health risk and the self. Consequently,
individuals feel that the risk may be more imminent and more personally relevant than
they had originally thought, and ultimately adopt desirable health behaviors in the
physical world.
Interactive Agents and Avatars for Health Behavior
If merely observing the vicarious experience of future negative health consequences
occurring to agents and avatars are powerful enough to change health behavior, the
ability to directly interact with the agent or avatar is likely to amplify these favorable
effects. In one of the earliest studies looking at how interactions with avatars could lead
to differences in health behaviors in the physical world, participants were given either a
photorealistically similar self avatar or an unfamiliar avatar to interact with in a virtual
world [38]. When the participants exercised in the physical world, the avatar exercised
with them using synchronous head and body movements in the virtual world. Results
indicated that when participants interacted with a self avatar that exercised with them,
they engaged in more exercising than when they interacted with an unfamiliar avatar.
These effects persisted for up to 24 hours following the experimental treatments.
In the past, such studies had to be conducted in a highly controlled laboratory
setting to deliver interactive experiences with a virtual representation because the
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experimental set up required state-of-the-art digital devices to track and render
participants’ movements. Recently, however, the development of consumer grade
electronics, such as video game consoles, has gradually increased the accessibility and
affordability of interactive media, allowing individuals to interact with virtual
representations in the comforts of their own living rooms [39]. The newer video game
consoles such as the Microsoft Kinect Xbox and the Nintendo Wii are equipped with
sensors and accelerometers that allow players to use naturalistic body movements to
control their avatars in the game. This development has introduced a novel genre of
gaming called exergames, which require players to use body movements to progress
through the game [40]. Several recent studies have demonstrated that interacting with the
avatars in these exergames results in increased physical activity [41] as well as weight
reduction [42], particularly when playing with others rather than playing alone. Although
exergames still contribute to the overall number of hours individuals spend in front of
screens, which is positively linked to negative health outcomes [43], they help to
substitute what would otherwise have been completely sedentary screen time with low to
moderate levels of physical activity [44].
Although the bulk of studies looking at agents and avatars fail to reflect this, not
all virtual representations are required to take on human forms. In one of the few studies
that explored the effect of non-human virtual representations on health behaviors in the
physical world, researchers investigated the potential of using a virtual pet to promote
physical activity in children [45]. The American Heart Association released a scientific
statement in 2013 regarding pet ownership and cardiovascular risk [46], noting that
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owing a pet, a dog in particular, significantly increases physical activity levels of the
pet’s owner, thereby reducing the risks for cardiovascular diseases and obesity.
Guided by the framework of social cognitive theory [47], the virtual pet was a dog
designed to systematically promote physical activity in children through goal setting,
vicarious experiences, and positive reinforcement. In the study, children’s physical
activity was measured with an activity monitor that was synchronized with each virtual
dog so that each child was paired with a unique pet displayed on a television screen
mounted on a kiosk. The kiosk set up allows for the virtual pet to be mobile, following
the children wherever needed rather than the children having to come to a specified
location to participate in the program.
The underlying logic was that as children engaged in physical activity in the
physical world, the virtual dog would also stay active with them in the virtual world,
reaping the health benefits. When compared with children in the control group who were
given an identical computer system with the same functionalities but without the virtual
dog, children who interacted with the virtual dog engaged in approximately 1.09 more
hours of physical activity daily. Self-report survey data revealed that interacting with the
virtual dog led children to feel confident about their abilities to set and meet physical
activity goals, which in turn, heightened their beliefs that physical activity is good for
them. The increase in physical activity belief ultimately led to an increase in physical
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In an era of digital media technology, people consume health information in ways that are
very different from the past. For young people, in particular, the Internet is one of the
most sought out sources for health information [48]. Atkin [49] argues that choosing a
channel appropriate for a specifically targeted audience will maximize the effect of health
information. With the increasing ubiquity of interactive and mobile digital technology in
our homes, it may be a timely endeavor to reexamine not just the content of health
information but also how it is being disseminated.
Agents and avatars offer a dynamic yet highly controllable means to deliver
health information in a novel, involving way. Offering a wide range of strategic tools
that take advantage of novel media characteristics, such as the virtual acceleration of time
and interactivity, agents and avatars yield powerful impacts in the virtual world that
transfer to the physical world to change health behaviors. Observing and interacting with
these virtual representations allows individuals to feel as if they are genuinely present in
the situation [31, 34, 35], heightens their confidence about achieving health goals [45],
and encourages them to think of the health risk as a personally relevant, important, and
imminent event [33, 34]. Ultimately, these underlying mechanisms drive desired health
behaviors that persist longer over time than the same health information delivered
through more traditional channels, such as statistical information, print, or pictures [31,
33-35, 38, 45]. These efforts may even be combined with gaming mechanisms to replace
overall sedentary time with physical activity while playing video games [40-42].
As agents and avatars offer different strengths and weaknesses, researchers and
practitioners should administer an extensive analysis of cost-effectiveness to select the
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more appropriate form of virtual representation in the given context. An alternative
option would be to consider an agent-avatar hybrid, which capitalizes the strength of
programmable features and algorithms of agents while still being guided by a human
controller [50, 51]. This crossover design would offer health interventions that have
greater impact on human behavior but remain cheaper to operate and manage.
There is still much work to be done to harness the dynamic flexibility that agents
and avatars offer to implement systematic primary and secondary prevention and
intervention programs. However, the state-of-the-art research introduced in this chapter
confirms the potential of virtual representations to serve as a vehicle of health behavior
change. Health issues often involve an intricate and complex web of individual and
environmental factors, and avatars and agents may not be a panacea for all these issues.
Yet, with the rapid advancement of digital technology transforming our traditional norms
and patterns of communication, these virtual representations, whether they are human or
animal form, hold much potential in the realm of health interventions that has yet to be
Key Terms
virtual representations
acceleration of time
health behavior
physical activity
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... A corpus of studies supports the idea that avatars could reinforce health behaviours through "vicarious experiences" (Fox, 2014;Ahn, 2016) because humanified avatars increase the feeling of similarity in subjects and are leading to higher scores on attractiveness and friendliness (Khan & Sutcliffe, 2014). Avatars are using facial expressions, non-verbal cues, gestures and even a casual communication style, leading to support, understand and knowledge acquisition related to behavioural change in subjects (Wonggom et al., 2020). ...
... Avatars can induce positive outcomes at the emotional level (Johnson et al, 2016), feelings of confidence in maintaining health behaviours and reaching goals related to health. Avatars can even sustain long-term behavioural changes in comparison with the same health messages conveyed through print, pictures or other classic channels (Ahn, 2016;Baylor, 2009). People tend to have the same psychological, neuronal and behavioral activation on the perception of the emotions in humans and in avatars (de Borst & de Gelder, 2015) and one of the best examples is the Proteus Effect (Yee & Bailenson, 2007) which highlights the degree to which an individual could be affected on the emotional level by modifications/threats that could impact their virtual representation . ...
... Это позволяет считать VR экспериментальной коммуникативной средой, технологией разного рода процессов и/или методом исследования, используемым в рамках разных наук (см. подробнее [Ahn 2015;Becker et al. 2019;Dolgunsöz, Yıldırım, Yıldırım 2018;Innocenti 2017;Peeters 2019]). ...
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In this paper, we try to show the features of the speaker’s use of deictic gestures in virtual reality (VR) in terms of the referent’s position. The referent appears in three positions relative to the speaker: prox-imal, medial and distal. We explore how the referent’s position in the VR environment can affect the speak-er’s gestural behavior. For that purpose, a VR experiment with 24 participants was conducted. We obtained 720 reactions, represented as marked phrases, which were further analyzed and processed in the Semograph Information System. The results showed that the speaker, when pointing to the referent in VR, uses upper limbs and their components, as well as head and body. The speaker's use of certain body parts when pointing in VR could be caused by the position of the referent in space. We discuss the patterns that could expand the understanding of the nature of gestures themselves. We also highlight further research prospects and offer recommendations for future experiments.
... Research has also demonstrated a link between a virtual representation of self and real-world behaviours (Wrzesien et al., 2015;Seitz et al., 2014;Behm-Morawitz, 2013;Fox et al., 2013;Bordnick et al., 2011;) as a result of individuals identifying with their avatar (Schultze and Leahy, 2009) and experiencing presence within the computer mediated environment (Parrish et al., 2015;Ganesh et al., 2012). Consequently, immersion in and engagement with, the VR environment may promote changes in health behaviour (Ahn, 2015) and it has been suggested as a potential behaviour modification tool for addressing obesity (Napolitano et al., 2013;. Studies undertaken within an experimental environment have demonstrated that an individual's behaviour conforms to their digital self-representation (Bordnick et al., 2011;Fox et al., 2013;Yee and Bailenson, 2007). ...
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Background: Obesity interventions rely predominantly on managing dietary intake and/or increasing physical activity but sustained adherence to behavioural regimens is often poor. Avatar technology is well established within the computer gaming industry and evidence suggests that virtual representations of self may impact real-world behaviour, acting as a catalyst for sustained weight loss behaviour modification. However, the effectiveness of avatar technology in promoting weight loss is unclear. Aims: We aimed to assess the quantity and quality of empirical support for the use of avatar technologies in adult weight loss interventions. Method: A systematic review of empirical studies was undertaken. The key objectives were to determine if: (i) the inclusion of avatar technology leads to greater weight loss achievement compared to routine intervention; and (ii) whether weight loss achievement is improved by avatar personalisation (avatar visually reflects self). Results: We identified 6 papers that reported weight loss data. Avatar-based interventions for weight loss management were found to be effective in the short (4-6 weeks) and medium (3-6 months) term and improved weight loss maintenance in the long term (12 months). Only 2 papers included avatar personalisation, but results suggested there may be some added motivational benefit. Conclusions: The current evidence supports that avatars may positively impact weight loss achievement and improve motivation. However, with only 6 papers identified the evidence base is limited and therefore findings need to be interpreted with caution.
... Although there have been at least two qualitative reviews on avatars and health behaviour (Ahn, 2015b;Ahn & Fox, 2017a), this study is the first to systematically collect and assess the evidence of avatar appearance on health-related attitudes, beliefs, intentions, and behaviours. These reviews presented preliminary findings on how doppelgängers can influence health behaviours, as well as how these may be integrated with social psychology theories to produce favourable health-related outcomes. ...
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Evidence has suggested that health promotion may be achieved using representations of the self in virtual environments (avatars) to alter self-perception, and model behaviours. This systematic review aimed to assess evidence of the role that the appearance of avatars plays in influencing health-related attitudes and behaviours. Journal databases, author books and websites, grey literature sources were searched. Rehabilitation and mental health outcomes were excluded. A total of 13 articles (14 studies) addressing primary (e.g. exercise, diet, and smoking), and secondary (e.g. body satisfaction) health related attitudes and behaviours were included. Seven studies reported significant main effects of avatar manipulation, which included avatar body type (varied by adiposity or muscularity), and Self Discrepancy Theory-based (SDT; e.g. actual, ideal, ought selves) customisation. The review indicates a dearth of research on avatar appearance and health-related outcomes. The assignment of avatars with varying body types appeared to be the most consistent manipulation for in-game physical activity. The assignment of 'obese' avatars appeared to reduce behavioural outcomes, however the absence of control conditions means the actual direction is unclear. Results from this review indicate a need for a grounded, theory-driven approach to future avatar appearance-based studies.
This paper presents a novel mobile serious game, "Space Vision", which uses a hidden-object mechanic with fiducial marker detection to gamify a clinical test of visual acuity - a key marker of childhood eye disease. For Space Vision to become a credible clinical tool that can facilitate the screening and home-monitoring of children's visual acuity, it must be able to sustain player engagement over the extended durations required to detect vision abnormalities. Hence, we pay particular attention to developing effective game characters - a crucial aspect of children's game design. Using an early prototype with 13 school children (aged 5-6 years), we investigate player experiences through a series of evaluation sessions, involving a single one-to-one observational playtest, semi-structured interview, and ideation activity with each child. Thematic analysis of our session video recordings, written observations, and ideation artefacts, found that future game iterations must: increase resonance between players and game characters by providing aesthetic and behavioural customisation, embrace more anthropomorphic styling, better imbue narratives pertaining to children's life scripts, and feature fantasy character powers as a form of self-expression. Meanwhile, greater physical device support and digital incentivisation of body posture and head position are key to improving the reliability of the visual acuity measurement.
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The article is a preliminary research that examines the methodology of the experiment devoted to the study of the speaker’s behavior in virtual reality (VR) and its results. The purpose of the experiment is to study the specific features of verbal and non-verbal implementation of the role and spatial deixis in VR. Based on the received reactions, the speaker’s coordinate system will be determined and models of the speaker’s communicative behavior in VR will be constructed. The article describes in detail the design of the experiment, which includes: stimulus material on the basis of which the VR scene is created; types of scenes used to determine the type of the speaker’s orientation; description of the tools by means of which VR is created; requirements for the selection of participants in the experiment; methods of recording material and the principles of its decoding. Special attention was paid to correlating the ‘external’ (gesture) and ‘internal’ (verbal) behavior of the speakers, to the principles of gesture fixation and their correlation with the subject’s verbal reactions to the presented scene. Based on the data obtained from the subjects, there was developed a classifier where the categories ‘Structure of the situation’, ‘Type of communication’ and ‘Means of communication’ and their subclasses are used. The data are entered into the Semograph information system and are visually presented in the form of a customizable interactive graph by using the SciVi software. At present, the reactions of two informants (a man and a woman) from the general sample have been processed. Based on the analysis of their reactions, preliminary results were obtained, which made it possible to demonstrate approaches to work with the classifier and to trace the representation of verbal and non-verbal means in the reactions of the subjects. Moreover, preliminary results help to determine the type of orientation and communicative behavior of the speaker depending on their personality and the type of scene. Preliminary analysis allows us to refine the principles of material processing, its annotation and entry into the Semograph system as well as working with the classifier.
Background Closed loop (CL) automated insulin delivery systems are demonstrated to be safe and effective in regulating glucose levels and reducing cognitive burden in people with type 1 diabetes (T1D). However, given the limited market options and the do-it-yourself nature of most systems, it can be difficult for potential users to shape their expectations fitting them into daily lives and management routines. As such, we examined the potential feasibility of a virtual reality (VR) intervention. Methods A four-part VR intervention was created to expose adults with T1D to expected CL system barriers: body image, perceived hassles of using CL, deskilling fears, and unwanted social attention. Goals of the pilot were to assess feasibility and expose patients to CL. Surveys were conducted pre- and postparticipating in the VR experience. Results A total of 20 adults with T1D completed the pilot. Average time to complete the experience was 14.1 minutes (8.8-39.9). Reported VR sickness was low. Willingness to use VR was maintained in 90% ( n = 18) and did not change expectations of CL in 95% ( n = 19). Virtual reality changed perceived hassles of CL in 25% ( n = 5) with four concerned over alarms and one connectivity issues: positive diabetes technology attitudes, confidence in managing hypoglycemia, overall perceptions of appearance, and positive affect maintained after the VR intervention. Negative affect significantly decreased after exposure and perceptions of being overweight trended toward significance. Conclusion This pilot VR intervention demonstrated high potential in addressing expected barriers to uptake and usage of CL systems without decreasing enthusiasm or changing expectations of CL.
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This study explored how health information accessed via a 3D social virtual world and the representation of ‘self’ through the use of an avatar impact physical world health behaviour. In-depth interviews were conducted in a sample of 25 people, across 10 countries, who accessed health information in a virtual world (VW): 12 females and 13 males. Interviews were audio-recorded via private in-world voice chat or via private instant message. Thematic analysis was used to analyse the data. The social skills and practices evidenced demonstrate how the collective knowledge and skills of communities in VWs can influence improvements in individual and community health literacy through a distributed model. The findings offer support for moving away from the idea of health literacy as a set of skills which reside within an individual to a sociocultural model of health literacy. Social VWs can offer a place where people can access health information in multiple formats through the use of an avatar, which can influence changes in behaviour in the physical world and the VW. This can lead to an improvement in social skills and health literacy practices and represents a social model of health literacy.
Conference Paper
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Virtual doppelgängers are human representations in virtual environments with photorealistic resemblance to individuals. Previous research has shown that doppelgängers can be effective in persuading users in the health domain. An experiment explored the potential of using virtual doppelgängers in addition to a traditional public health campaign message to heighten the perception of personal relevance and risk of sugar-sweetened beverages. Both virtual doppelgängers and an unfamiliar virtual human (i.e., virtual other) used in addition to a health pamphlet were effective in increasing risk perception compared to providing just the pamphlet. Virtual doppelgängers were more effective than virtual others in increasing perceived personal relevance to the health message. Self-referent thoughts and self presence were confirmed as mediators. Sugar-sweetened beverages (SSBs) have recently garnered much negative attention with the increasing concern for rising rates of obesity [1]. A flood of health promotion campaigns has been launched in an effort to counteract the prevalence of SSB consumption and some governments have even proposed a ban on large sized soft drinks in an attempt to assist the battle against obesity. Virtual health agents provide us with novel ways to address this health issue. Specifically, this study investigated how the use of virtual doppelgängers, or agents designed to look like the self [2], can be used to effectively change health behaviors.
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Existing research has investigated whether virtual representations perceived to be controlled by humans (i.e., avatars) or those perceived to be controlled by computer algorithms (i.e., agents) are more influential. A meta-analysis (N = 32) examined the model of social influence in virtual environments (Blascovich, 2002) and investigated whether agents and avatars in virtual environments elicit different levels of social influence. Results indicated that perceived avatars produced stronger responses than perceived agents. Level of immersion (desktop vs. fully immersive), dependent variable type (subjective vs. objective), task type (competitive vs. cooperative vs. neutral), and actual control of the representation (human vs. computer) were examined as moderators. An interaction effect revealed that studies conducted on a desktop that used objective measures showed a stronger effect for agency than those that were conducted on a desktop but used subjective measures. Competitive and cooperative tasks showed greater agency effects than neutral tasks. Studies in which both conditions were actually human controlled showed greater agency effects than studies in which both conditions were actually computer controlled. We discuss theoretical and design implications for human–computer interaction and computer-mediated communication.
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Publisher Summary Individuals come to “know” their own attitudes, emotions, and other internal states partially by inferring them from observations of their own overt behavior and/ or the circumstances in which this behavior occurs. Thus, to the extent that internal cues are weak, ambiguous, or uninterpretable, the individual is functionally in the same position as an outside observer, an observer who must necessarily rely upon those same external cues to infer the individual's inner states. This chapter traces the conceptual antecedents and empirical consequences of these propositions, attempts to place the theory in a slightly enlarged frame of reference, and clarifies just what phenomena the theory can and cannot account for in the rapidly growing experimental literature of self-attribution phenomena. Several experiments and paradigms from the cognitive dissonance literature are amenable to self-perception interpretations. But precisely because such experiments are subject to alternative interpretations, they cannot be used as unequivocal evidence for self-perception theory. The reinterpretation of cognitive dissonance phenomena and other self-perception phenomena have been discussed. The chapter highlights some differences between self-perception and interpersonal perception and shift of paradigm in social psychology. It discusses some unsolved problems, such as the conceptual status of noncognitive response classes and the strategy of functional analysis.
Objectives: To systematically review levels of metabolic expenditure and changes in activity patterns associated with active video game (AVG) play in children and to provide directions for future research efforts. Data Sources: A review of the English-language literature ( January 1, 1998, to January 1, 2010) via ISI Web of Knowledge, PubMed, and Scholars Portal using the following keywords: video game, exergame, physical activity, fitness, exercise, energy metabolism, energy expenditure, heart rate, disability, injury, musculosheletal, enjoyment, adherence, and motivation. Study Selection: Only studies involving youth (<= 21 years) and reporting measures of energy expenditure, activity patterns, physiological risks and benefits, and enjoyment and motivation associated with mainstream AVGs were included. Eighteen studies met the inclusion criteria. Articles were reviewed and data were extracted and synthesized by 2 independent reviewers. Main Outcome Exposures: Energy expenditure during AVG play compared with rest (12 studies) and activity associated with AVG exposure (6 studies). Main Outcome Measures: Percentage increase in energy expenditure and heart rate (from rest). Results: Activity levels during AVG play were highly variable, with mean (SD) percentage increases of 222% (100%) in energy expenditure and 64% (20%) in heart rate. Energy expenditure was significantly lower for games played primarily through upper body movements compared with those that engaged the lower body (difference, -148%; 95% confidence interval, -231% to -66%; P = .001). Conclusions: The AVGs enable light to moderate physical activity. Limited evidence is available to draw conclusions on the long-term efficacy of AVGs for physical activity promotion.
The chameleon effect refers to nonconscious mimicry of the postures, mannerisms, facial expressions, and other behaviors of one's interaction partners, such that one's behavior passively rind unintentionally changes to match that of others in one's current social environment. The authors suggest that the mechanism involved is the perception-behavior link, the recently documented finding (e.g., J. A. Bargh, M. Chen, & L. Burrows, 1996) that the mere perception of another' s behavior automatically increases the likelihood of engaging in that behavior oneself Experiment 1 showed that the motor behavior of participants unintentionally matched that of strangers with whom they worked on a task. Experiment 2 had confederates mimic the posture and movements of participants and showed that mimicry facilitates the smoothness of interactions and increases liking between interaction partners. Experiment 3 showed that dispositionally empathic individuals exhibit the chameleon effect to a greater extent than do other people.