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Volume 3, Issue 1, Spring 2010

Adolescent Internet Depression Prevention: Preferences for Intervention and

Predictors 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 Negative

Mood, Pain Coping, and Recommending Medical Help

The Effect of Activities in Virtual Worlds as a Communication Environment

to Understand Each Other

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Journal of CyberTherapy

Volume 3, Issue 1, Spring 2010

San Diego, California - Brussels, Belgium


Journal of
& Rehabilitation

ediTor-in-Chief assoCiaTe ediTors

Brenda K. Wiederhold, Ph.D., MBA, Cristina Botella, Ph.D. Luciano Gamberini, Ph.D.
BCIA Jaume I University University of Padova
Virtual Reality Medical Institute Castelló de la Plana, Spain Padova, Italy
Brussels, Belgium
Virtual Reality Medical Center Stéphane Bouchard, Ph.D. Giuseppe Riva, Ph.D., M.S., M.A.
San Diego, California Université du Québec en Outaouais Istituto Auxologico Italiano
Gatineau, Québec, Canada Verbania, Italy
managing ediTor

Emily Butcher
Interactive Media Institute
San Diego, California

ediTorial board

Mariano Luis Alcañiz Raya, Ph.D. Tom Furness, Ph.D. Paul Pauli, Ph.D.
Universidad Politécnica de Valencia University of Washington University of Würzburg
Valencia, Spain Seattle, Washington Würzburg, Germany

Rosa M. Baños, Ph.D. Charles Hughes, Ph.D. Heidi Sveistrup, Ph.D.

University of Valencia University of Central Florida University of Ottawa
Valencia, Spain Orlando, Florida Ottawa, Ontario, Canada

A.L. Brooks Wijnand IJsselsteijn, Ph.D. Richard M. Satava, M.D., F.A.C.S.

Aalborg University Eindhoven University of Technology University of Washington
Esbjerg, Denmark Eindhoven, Netherlands Seattle, Washington

Julian Dooley, Ph.D. Linda A. Jackson, Ph.D. Mark D. Wiederhold, M.D.,

Edith Cowan University Michigan State University Ph.D., FACP
Mount Lawley, Australia East Lansing, Michigan Virtual Reality Medical Center
San Diego, California
Paul M.G. Emmelkamp, Ph.D. Sun. I. Kim, Ph.D.
University of Amsterdam Hanyang University XiaoXiang Zheng, Ph.D.
Amsterdam, Netherlands Seoul, South Korea Zhejiang University
Hangzhou, P.R. China
Uri Feintuch, Ph.D. Dragica Kozaric-Kovacic, M.D., Ph.D.
Hadassah-Hebrew University University Hospital Dubrava
Medical Center Zagreb, Croatia
Jerusalem, Israel
José Luis Mosso, M.D.
Joshua Fogel, Ph.D. Regional Hospital No. 25 of the
University of New York IMSS
Brooklyn, New York Mexico City, Mexico
Journal of CyberTherapy & Rehabilitation

Spring 2010
Vo l u m e 3 , I s s u e 1

7 editorial
B. Wiederhold

9 “adolescent internet depression prevention: preferences for intervention and

predictors of intentions and adherence”
M. Marko, J. Fogel, E. Mykerezi & B. W. Van Voorhees

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

Virtual environments”
O. Baus & S. Bouchard

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

K.F. Hsiao

63 “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

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

understand each other”
H. Park

83 Cyberprojects
G. Riva

85 Cyberfocus
D. Stevens

95 Continuing education Quiz

A. Gorini

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Journal of CyberTherapy & Rehabilitation 7
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Welcome, readers and researchers, to the Spring 2010 pret others’ pain, pain coping skills, related mood, and
issue of the Journal of CyberTherapy & Rehabilitation other factors.
(JCR). Our peer-reviewed quarterly academic journal
continues to explore and support the uses of advanced Lastly, Park discusses the use of Second Life as an ex-
technologies for therapy, training, education, preven- ample of how activities in virtual worlds might be used
tion and rehabilitation. JCR is unique in the fact that it as a communication environment to better understand
focuses on the rapidly expanding worldwide trend of each other, with an emphasis in this study on gender.
applying ground-breaking technology towards the field
of healthcare, with an emphasis on the fields of psychi- As well as continuing to provide our readers with the
atry, psychology, physical medicine and rehabilitation, latest studies presented in an informative and engaging
neurorehabilitation, oncology, obesity, eating disorders medium, we will be offering one Continuing Education
and autism. quiz per issue as a further added service to our sub-
scribers and others interested in supporting their educa-
With a growing international base of readers and sup- tion. For more information, see page 95.
porters driven by a similar goal of advancing the use
of technology in the healthcare sector, JCR has re- I would like to sincerely thank the contributing authors
ceived positive attention from peers, international in- for their inspiring work and dedication to this field of
stitutions and international conferences. To keep research. I also want to thank JCR’s Associate Editors
readers abreast of new developments, within this issue – Professor Botella, Professor Bouchard, Professor
of JCR we present comprehensive articles submitted Gamberini and Professor Riva for their leadership and
by preeminent scholars in the field, featuring such top- hard work, as well as or internationally renowned Edi-
ics as combining physical activity with learning in an torial Board for their contributions. I would also like to
augmented reality setting, including the sense of ol- take this opportunity to welcome new Board members –
faction more commonly in VR, and how communica- Linda A. Jackson of Michigan State University, Julian
tion is used in virtual worlds like Second Life. Dooley of Edith Cowan University, Wijnand IJsselsteijn
from the Eindhoven University of Technology, Joshua
In the first article Voorhees et al. study the relationship Fogel from the University of New York, and XiaoXiang
between attitude and adherence to treatment in adoles- Zheng of Zhejiang University – whose diverse back-
cents with sub-threshold depression in order to improve ground and placement around the globe will bring added
public health strategies to prevent depressive disorders. richness to our board. We encourage readers and sub-
scribers to contact us with ideas and we welcome sub-
Next, Baus and Bouchard address the sense of olfaction missions. Your input continues to enrich our publication.
and ways in which it can further and enrich VR any ad-
vocate the growth of the field while discussing possible With the start of a new year, new possibilities abound
applications in virtual environments. and we will continue to promote the growth of the di-
verse field of advanced technologies for healthcare in
In an attempt to merge learning and physical activity in Europe and worldwide. We are happy to count you as a
the classroom, Hsiao next looks at using augmented re- part of this movement and thank you for your continued
ality and VR applications to provide more effective support.
teaching methods and increase retention, while provid-
ing much-needed exercise to the younger population at
the same time. Brenda K. Wiederhold, Ph.D., MBA, BCIA
In the fourth article, Alquda et al. use Virtual Humans Journal of CyberTherapy & Rehabilitation
to look at how race and sex can affect how people inter- Virtual Reality Medical Institute


Journal of CyberTherapy & Rehabilitation 9
S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1
© Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

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) symptoms
may 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 interventions
and 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 participate
in depression prevention. The most important significant predictors of adherence were beliefs about
the intervention. Careful attention to the specific beliefs and attitudes of users toward intervention
should be incorporated into intervention design as well as evolving public health strategies to prevent
depressive disorders.

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

inTroduCTion for greater than one week) are associated with consider-
Twenty-eight percent of adolescents in the United States able cost and impairment of social and academic func-
report their current mood as depressed, while only 2-5% tions (Asarnow et al., 2005). Early or preventive
meet the symptom threshold for major depressive disor- interventions targeting individuals with sub-threshold
der at any given time (Kessler & Walters, 1998; Rushton, symptoms (20% of primary care attendees) (B. W. Van
Forcier, & Schectman, 2002). The great majority have Voorhees et al., 2005, 2006) have been recommended to
sub-threshold depression symptoms, which do not cur- reduce the burden of depressive disorders (Garber, 2006;
rently meet criteria for major depression but often will B. W. Van Voorhees et al., 2009). Unfortunately, some
progress to major depressive disorder (Andrews, 1994). individuals with mild depressive symptom levels, who
By the age of 24, one-quarter of adolescents in the U.S. are the primary targets of indicated prevention strategies,
will develop a depressive disorder, with a substantial ad- demonstrate negative attitudes and beliefs toward de-
verse impact on the individual and society and with costs pression, which make them reluctant to consider an in-
in excess of 100 billion dollars per year (Cicchetti & tervention (Druss, Hoff, & Rosenheck, 2000; Fortney,
Toth, 1998; Kessler & Walters, 1998; Weissman et al., Rost, & Zhang, 1998; Jaycox et al., 2006; Leaf, Bruce,
1999). However, even sub-threshold depressive symp- Tischler, & Holzer, 1987; Lin & Parikh, 1999; Sihvola
toms at the levels of minor depression (two symptoms et 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:

Department of Medicine, The University of Chicago, Chicago, Illinois, USA
Department of Economics, Brooklyn College of the City University of New York, Brooklyn, New York, USA
Department of Applied Economics, University of Minnesota, Twin Cities, St. Paul, MN, USA
Department of Psychiatry, The University of Chicago, Chicago, Illinois, USA
Department of Pediatrics, The University of Chicago, Chicago, Illinois, US
10 Adolescent Internet Depression Prevention

Pediatricians and family physicians are taking on an ex- on physician authority of recommendation (BA) (B. W.
panded role in screening for depressed mood, and also in Van Voorhees, 2009). In this trial, both groups actively en-
identifying and treating adolescents with depressive disor- gaged in exploring the Internet site and demonstrated fa-
ders (Christensen, 2009; Grant, 2009; Kaltenthaler, 2008; vorable changes in vulnerability and protective factors for
Waller, 2009). The Internet offers a potentially more ac- depressive disorder. However, the MI group demonstrated
ceptable form of intervention in primary care settings for higher levels of adherence to the Internet intervention and
early intervention or prevention of mental disorders (Gar- fewer depressive episodes (B. W. Van Voorhees, Fogel, J.,
ber et al., 2009; B. Van Voorhees et al., in press). Motivated Pomper, B. E., & Domanico, R., 2009; B. W. Van Voorhees
adolescents visit self-improvement Web sites to manage et al., 2008).
alcohol use, smoking, obesity, sexual risk and HIV/AIDS
related issues, and show positive behavior change as a re- A variety of predictors has been identified for adherence
sult(Kirk et al., 2003; Lou, Zhao, Gao, & Shah, 2006; C. to Internet-based interventions. We know that females,
A. Patten et al., 2006; Ybarra, 2006). For adults, Internet school-based settings, living in a rural area and lower
interventions may be helpful in increasing levels of exer- pretest anxiety scores predict greater adherence to Internet
cise, adopting a more favorable diet, stopping smoking, based depression interventions in youth (Neil, Batterham,
and reducing depressed mood (Van den Berg, Schoones, Christensen, Bennett, & Griffiths, 2009). We also know
& Vliet Vlieland, 2007; Walters, Wright, & Shegog, 2006; that, for older adults, psycho-education is the least pre-
Wantland, Portillo, Holzemer, Slaughter, & McGhee, ferred option for preventing depression compared to exer-
2004). However, only 20% of the general population ap- cise or vitamin supplementation (Grant, 2009). A few
pears interested in Internet-based lifestyle changes, and as studies have reported varied levels of acceptability and sat-
few as 10% actively visit such Web sites (Evers, 2005; Ver- isfaction with computer-based cognitive behavioral psy-
heijden, Jans, Hildebrandt, & Hopman-Rock, 2007). The chotherapy (Kaltenthaler, 2008), but little is known
use of mental health related Web sites by adolescents is regarding the influence of specific attitudinal factors on
similarly low (G. Clarke et al., 2002; S. B. Patten, 2003; adherence (Waller, 2009). In contrast, we do know what
Santor, Poulin, LeBlanc, & Kusumakar, 2007) Determin- adolescents in primary care think about depression preven-
ing preferences for intervention, and which attitudes and tion interventions and how such attitudes might influence
beliefs are associated with motivation to use a depression- motivation and adherence. The use of theoretical models
prevention Web site, could facilitate the development of of behavioral change has been proposed as a method to de-
more acceptable public health interventions to prevent de- velop a more systematic understanding of motivation and
pression in community settings. adherence to Internet-based mental health interventions
(Christensen, 2009).
The Competent Adulthood Transition with Cognitive-be-
havioral, Humanistic, Interpersonal Training (CATCH-IT), Organizing items according to the theory of planned behav-
(B. W. Van Voorhees et al., 2007) primary care based pre- ior framework has been previously demonstrated to predict
ventive intervention was developed to target adolescents adolescent and emerging perceived need for treatment and
with sub-threshold depressive symptoms and provide an intention in order to accept a physician’s diagnosis of major
acceptable, low-cost, and broadly available depression (B. W. Van Voorhees et al., 2005, 2006). The
intervention/prevention model of depressive disorders Theory of Planned Behavior provides a theoretical frame-
(Garber et al., 2009). This intervention/prevention model work for understanding motivation, intention and adher-
sought to overcome barriers to deployment of preventive ence. According to this theory intention is the closest
interventions for depression by offering the intervention precedent of behavior, which is directly influenced by atti-
within the framework of primary care with an initial en- tudes and beliefs toward a behavior (e.g., attitudes toward
gagement interview by the primary care physician (Land- intervention), subjective norms (e.g., concerns with regard
back, 2009; B. W. Van Voorhees et al., 2007). A to family, peer or employer opinions) and perceived behav-
randomized clinical trial was conducted, comparing two ioral control (e.g., self-efficacy), as a probability that one
forms of physician engagement (both groups having access can perform the specific behavior (e.g. adhering to the in-
to the Internet site), a motivational interview (MI) versus tervention) (Ajzen, 2002). In these analyses, beliefs and at-
brief advice (BA) to determine whether the “patient cen- titudes toward the intervention and behavior, rather than
tered” MI approach (adolescents develop their own ration- social norms, were the most important predictors of inten-
ale for participation) was superior to the one which relies tion (B. W. Van Voorhees et al., 2005, 2006). Primary care

Voorhees et al. 11

physicians, health policy planners, and prevention re- the passive and active adherence to the Web site, are the
searchers would benefit from a sound understanding of subject of our analysis. The passive and active adherence
preferences for intervention and the attitudinal predictors of of the intervention was approximated by time spent on the
greater motivation for prevention and adherence to a pri- Web site and number of characters typed in, respectively.
mary care/Internet-based intervention. Both measures were obtained by using simple algorithms
in the Web site. The randomized controlled trial methods
The purpose of this study is to provide an attitudinal de- have been fully described in prior publications (B. W. Van
scription and to identify predictors of passive and active Voorhees et al., 2009; B. W. Van Voorhees et al., 2008).
adherence within a sample of adolescents with sub-thresh- The University of Chicago Institutional Review Board, as
old depressed mood enrolled in a randomized clinical trial well as those with responsibility for each site ,approved
of a primary care/Internet-based depression intervention this study.
(B. W. Van Voorhees et al., 2009; B. W. Van Voorhees,
Fogel, J., Pomper, B. E., & Domanico, R., 2009). We focus sTudy sample and eligibiliTy
on adolescents with sub-threshold depressed mood in pri- Participants were adolescents (N=83) between the age of
mary care because are the likely targets of preventive in- 14-21, recruited from 13 primary care sites throughout the
terventions for major depression (Garber, 2006; Garber et Southern and Midwest U.S., and reported at least one core
al., 2009; Landback, 2009). We provide an attitudinal de- symptom of depression at both the initial screening and the
scription of this sample in the study and explore how spe- at the full eligibility assessment administered one to two
cific attitudes, measured at baseline, within the framework weeks after the initial screening. Potential participants were
of the theory of planned behavior may influence motivation identified by completing a two-item screening question-
and adherence. Based on the framework of the theory of naire based on the Patient Heath Questionnaire Adolescent
planned behavior, we hypothesize that (1) attitudes/beliefs (PHQ-A-2) core depression symptom items in the routine
about intervention effectiveness would be the most impor- process of care (all adolescents visiting the clinic) (John-
tant predictors of motivation for preventive intervention son, Harris, Spitzer, & Williams, 2002). Adolescents re-
and participation in such an intervention in primary care. porting any core depressive symptom lasting longer than a
We also hypothesize that (2) adolescent primary care pa- few days in the two weeks prior to the screening were con-
tients with sub-threshold depressive symptoms would ex- sidered “positive.” Those with “positive” screens and who
hibit ambivalence toward established traditional consented to be contacted by study staff were called by
interventions (medications, group and individual counsel- phone for eligibility assessment. Inclusion criteria included
ing) similar to earlier studies of adolescents and adults with aged between 14-21, presence of one core symptom of de-
major depressive disorder (Cooper-Patrick et al., 1997; Jay- pression, but below the level of major depression (four or
cox et al., 2006). fewer symptoms, “sub-threshold depressed mood”). Ex-
clusion criteria included meeting criteria (or getting treat-
meThods ment) for minor or major depression, expressing frequent
sTudy design suicidal thought or intent, bipolar disorder, conduct disor-
This study is based on a survey of adolescents enrolled to der, substance abuse, generalized anxiety disorder, or any
participate in a randomized controlled trial in primary care type of eating disorder. Consent from adolescents and par-
of an Internet-based depression intervention and prevention ents (if adolescents were under 18 years old) was collected
program (CATCH-IT). We conducted a phase-2 clinical by study staff at the clinic. A full description and the criteria
trial of a primary care/Internet-based depression prevention of the recruiting method have been previously reported
intervention for adolescents at 13 U.S. primary care sites (Johnson et al., 2002).
(B. W. Van Voorhees et al., 2009; B. W. Van Voorhees et
al., 2008). Eligible adolescents were assigned randomly to demographiCs
either a primary care physician (PCP) motivational inter- Information on age, gender, race/ethnicity, and education
view plus the use of a Internet Web site or to PCP brief ad- level was recorded. Furthermore, family’s history of de-
vice and use of a Internet Web site. Those eligible and pression or any depressive disorder pertaining to the indi-
willing to enroll completed a baseline questionnaire relat- vidual was assessed by asking, “Have you ever been
ing to attitudes and beliefs, as well as motivation for pre- treated for depression (via medication or counseling)?” and
vention before they received their randomization “Have any of your family members (mother, father,
assignment. The responses to these questions, together with sister(s), brother(s)) ever been treated for depression that

12 Adolescent Internet Depression Prevention

lasted at least four weeks?” For the participant’s dimen- indicated a level of agreement based on a Likert-type scale
sional measures of depressed mood we report Center for ranging from “1=strongly disagree” to “5=strongly agree.”
Epidemiologic Studies Depression Scale 10 items Beliefs about the intervention were defined by such state-
(CESD10), scored as double to create the 60-point scale. ments as “depression intervention makes sense to me,”
“protecting yourself from depression through interven-
preferenCes for inTerVenTion tion,” “participating in intervention is important,” “if de-
Preferences for treatment (get over it naturally, medication, pression is found early it can be prevented,” “depression
one-on-one or group counseling) were developed from the intervention could prevent further depression,” “depression
Quality Improvement in Depression study, which showed intervention will help me to get healthy,” and “would be
that among primary care adult patients viewing treatments better off without the intervention.” Attitudes toward the
as unacceptable, there is an association with a lower like- behavioral intervention were measured by the statements
lihood of seeking treatment (Rost, Nutting, Smith, & “going through depression intervention is too much trou-
Werner, 2000). Responses were recorded in a Likert-type ble,” “the benefits of the prevention outweigh any diffi-
scale ranging from “1=definitely acceptable” to “4=defi- culty,” and “going through a depression intervention is too
nitely not acceptable,” where participants rated statements embarrassing.” Subjective social norms were measured by
such as “I will wait and get over it naturally,” “Use anti- such statements as “members of my family support me
depressant drugs,” “Seek one-on-one counseling from a going through intervention,” “I want to please family,” “I
mental health specialist,” and “Seek group counseling… want to do what the doctors want me to do about depres-
led by a mental health specialist.” We added several options sion,” “I think physicians want me to do a depression in-
that were not included in the original scale, represented by tervention,” “my close friends support my going through
statements such as “Talking with primary care physician a depression intervention,” and “I want to please my close
(PCP) about what you can do to prevent depression,” friends.” Perceived behavioral control was measured by
“Talking with PCP and agreeing to set up a regular sched- self-efficacy and had items of “going through this depres-
ule,” “Talking with PCP about your feelings and situation,” sion intervention would be easy” and “arranging the sched-
“Talking with PCP and agreeing to complete an e-pro- ule for the intervention will be easy.” We had previously
gram,” “Talking to a counselor through the phone about administered this questionnaire in a pilot study and found
your feelings,” “Complete a questionnaire with your PCP,” it acceptable and easily understood.
“Complete a questionnaire Online,” “Start an exercise pro-
gram with thirty minutes of aerobic activity, individually,” moTiVaTion ToWard preVenTiVe inTerVenTion
“Start an exercise program with thirty minutes of aerobic These items were adapted from Miller and Rollnick’s
activity with a group,” “Participate in a religious youth three-item assessment of motivation (Miller & Rollnick,
group,” “Take a health class to learn about feelings and 1991). The measures of motivation toward treatment or in-
coping skills,” and “Group meeting with 6-10 peers from tervention were constructed from the responses to the fol-
your school.” All items were scaled in accordance to the lowing statements measured with a Likert-type scale
original scale, as mentioned above. ranging from “1=not important” to “10=very important”:
“rate your ability to learn coping skills to reduce your risk
depression preVenTion iTems based upon Theory of of clinical depression,” “rate your readiness to reduce your
planned behaVior risk of clinical depression by learning coping skills,” and
We adapted the items from a previous questionnaire, which “rate the importance of preventing an episode of clinical
was modified based on the preventive health model (Myers depression over the next year.”
et al., 1996; B. W. Van Voorhees et al., 2006). The original
instrument, developed for prostate cancer, was adapted to ouTCome Variables
primary care based depression prevention. The reliability BEhavioral iNtENtioN
(Cronbach alpha =0.89) and validity of the instrument was Behavioral intention was measured by the stage of chang-
evaluated during a pilot study of the CATCH-IT interven- ing ways to deal with problems in order to prevent depres-
tion in 2004. Validity is supported by several items demon- sion. It was measured by the response to the question,
strating a trend toward predicting intervention performance “Please indicate which statement best fits your current po-
(predictive validity) and post-study qualitative interviews sition with regard to changing the way you think about and
suggested that the concerns/themes identified were consis- solve everyday problems to reduce your risk of developing
tent with items on the scale (face validity). The participants clinical depression.” Participants indicated their responses

Voorhees et al. 13

using a Likert-type scale, consisting of “1=I have not given ence, and active adherence. As passive adherence and ac-
any thought to changing...”, “2=I am giving some thought tive adherence were both skewed data, they were logarith-
to changing...”, “3=I am preparing to change...”, “4=I have mically transformed to allow for a normal distribution.
decided to change...but do not have a plan...” and “5=I have There were four models for each analysis. Model 1 was a
decided to change...and I have a plan...” where higher univariate analysis. Model 2 adjusted for age, race/ethnic-
scores indicate a more active adherence towards changing ity (white/non-white), and gender. Model 3 adjusted for the
the behavior. items from the same category/block. Model 4 simultane-
ously adjusted for all items that were significant or ap-
PassivE adhErENcE proached significance for each outcome (p-value<0.10) in
We measured passive adherence on the Web site by calcu- model 3 in order to understand the strongest correlates from
lating the total amount of time participants spent online the category/block in a multivariate framework. Motivation
throughout the intervention. This variable was constructed items were added as predictors to the passive adherence
by a simple algorithm, which subtracted the first page load and active adherence outcome analyses. They were not in-
timestamp from the last page load timestamp in a given cluded for the intention outcome analysis, as the theory of
session. The length of time for each session was capped at planned behavior does not typically include motivation as
seven minutes, since that is the approximate maximum a predictor for the intention outcome. STATA 10 was used
amount of time required to review the materials on each to conduct the analyses ("Stata Statistical Software: Re-
page. In cases when sessions lasted more then seven min- lease 10," 2009).
utes, we assumed the participant was not reviewing mate-
rial and the page was still loading. The length of all sessions resulTs
was then added together to generate the total amount of demographiCs
time spent online. We chose to calculate time spent on the The total number of participants screened reporting at least
Web site because this is a broad measure of willingness to one core depressive symptom in the two weeks prior to the
at least review material related to depression prevention screening comprised 21% (N=293) of the entire sample,
and its ease of measurement (B. W. Van Voorhees et al., with participants aged from 14-21 years. One hundred and
2009). Visitation of the Internet Web site was done entirely sixty-two participants were contacted to participate in the
at the adolescents’ discretion and occurred completely sep- full assessment, (N=131 were not able to be contacted). Of
arate from the physician encounter. the 162 participants, 71.6% (N=116) agreed to a full assess-
ment and 13 were ruled ineligible (i.e., due to major depres-
activE adhErENcE sion, conduct disorder, or suicide intent). The remaining 103
Active adherence was measured by a proxy measure of the participants were found eligible and 80.6% (N=83) en-
total number of characters typed throughout the interven- rolled. Fifty-seven percent were females (N=47). Race/eth-
tion. The variable was constructed by counting the total nicity varied and included, 61% (N=49) whites and 24%
number of characters typed by each participant as a part of African American (N=19), followed by 6% Asians (N=5),
completing exercises and writing notes at the end of each 5% Hispanics (N=4), and 4% of other racial composition
module, and then adding the characters together across all (N=3). Average age was 17.5 years old (SD=2.04). Twenty-
modules to generate the total number of characters typed. seven percent of the adolescents (N=20) sampled were cur-
This outcome variable was used to measure the active be- rently attending college, with one individual who had
havior of the participants. It was selected because of its already completed college, while over half of the teens had
ease of measurement and its relationship to choosing to ac- finished at least 10 years of education (N=43) and 14%
tively participate in a behavior change process (B. W. Van (N=10) had completed 12 years of education. The mean
Voorhees et al., 2009). This is similar to “homework” in household income of the sample measured by zip code in-
cognitive behavioral psychotherapy. formation obtained from the U.S. Census 2000 was $40,249
(SD=$14,500). More than half of the screened adolescents
statistical aNalysEs in the sample had a family history of depression (N=43),
Descriptive statistics were calculated for the demographic while 31% (N=21) of the adolescents had received prior
variables, preferences for treatment variables, and depres- counseling, and 18% (N=13) had been previously treated
sion prevention items based upon the theory of planned be- with medication. The demographic profile of this sample
havior. Separate linear regression analyses were performed has been reported in greater detail in the primary clinical
for the three outcome variables of intention, passive adher- trial publication (B. W. Van Voorhees et al., 2009).

14 Adolescent Internet Depression Prevention

preferenCes for inTerVenTion (86.95%, N=60 chose definitely acceptable and probably
As shown in Table 1, most adolescents preferred primary acceptable). Other popular preferences endorsed by more
care based interventions, such as talking to their primary than 75% included talking with PCP and agreeing to set up
care doctor about what to do to prevent depression a regular schedule of pleasurable activities, starting an in-

Table 1
Preferences for Treatment

Note. ** Adjusted for similar items in the block

Voorhees et al. 15

dividual aerobic exercise program for thirty minutes a day, group meeting with 6-10 peers from your school. Almost
talking with PCP about feelings and situation, completing three-fifths endorsed “waiting and getting over it naturally”
Internet questionnaires, seeking one-on-one counseling (i.e., no treatment) as acceptable.
from a mental health specialist, starting a group aerobic ex-
ercise program for thirty minutes a day, and completing depression preVenTion iTems based upon Theory of
questionnaires with a PCP. The least preferred preferences planned behaVior
for treatment that were endorsed by less than 40% included As shown in Table 2, most adolescents endorsed favorable
talking to a counselor by phone about their feelings, and a beliefs toward a primary care Internet-based depression

Table 2
Depression Prevention Based on Theory of Planned Behavior

16 Adolescent Internet Depression Prevention

Table 2 cont.

Voorhees et al. 17

Table 2 cont.

prevention intervention program, indicating that it makes through a depression prevention program” in Models 1 and
sense to them (68%, N=53 chose strongly agree and agree) 3. No self-efficacy items were significant. The demograph-
and believing it will help them be healthy (70%, N=53 ics item of male gender significantly predicted lower inten-
chose strongly agree and agree). Additional beliefs favored tion in Model 1 and 3, but depressed mood (CES-D score)
by more than 64% (N=50) included beliefs that depression, did not predict intentions. In Model 4, only the social norms
if detected early, can be prevented, prevention intervention item of family was significantly associated with intentions.
could prevent further depression (65% N=51), and strongly
disagree/disagree with being better off without a depression prediCTors of passiVe adherenCe
prevention intervention (68% N=54). For the attitude As shown in Table 4 with regards to beliefs, the belief of
items, 60% (N=46) favored that the benefits of a depression “participating in an intervention like this is important” and
prevention program outweigh any difficulty. Similarly, “a depression prevention intervention could prevent further
adolescents (62.83% N=49) generally disagreed with the depression” all significantly predicted total time spent on-
concept that the intervention was “too much trouble” but line as a measure of passive adherence to prevent depression
only a minority reported favorable social norms toward the for Models 1 and Model 2. Also, there was a significant
intervention. In terms of self-efficacy, while most felt it negative association with “being better off without a depres-
would be easy to arrange their schedule to participate (59% sion prevention intervention” and total time spent online in
N=45) only less than half the adolescents in the sample felt Models 1, 2, and 3. The attitude item of “the benefits of a
that completing such an intervention would be “easy” depression prevention intervention outweigh any difficulty”
(42% N=32). significantly predicted total time spent online in Models 1
and 2. None of the perceived social norms significantly pre-
prediCTors of inTenTions dicted total time spent online. The perceived behavioral
As shown in Table 3, with regard to beliefs, the belief of control item of “arranging my schedule for depression pre-
“participating in an intervention like this is important” sig- vention intervention will be easy” significantly predicted
nificantly predicted intentions for changing ways to deal total time spent online in Model 3. Motivation item of “rate
with problems in order to prevent depression for Models 1 your ability to learn coping skills to reduce your risk of clin-
and 3 and approached significance in Model 2. Also, the ical depression” significantly predicted total time spent on-
belief of “a depression prevention intervention could pre- line for both Models 1 and 2 and the motivation item of
vent further depression” was significant in Model 1 and ap- “readiness” approached significance in Model 1 and was
proached significance in Model 2. None of the attitudes significant in Model 2. The motivation item of “preventing
significantly predicted intentions. Social norms had signif- an episode” approached significance in Model 2. Depressed
icance in Model 3 for the family item of “I want to please mood did not predict total time spent online in any of the
my family,” the physician item of “I want to do what the models with which it was included. In Model 4, only the
physicians want me to do about depression prevention” in belief about “being better off without a depression preven-
Model 1 and Model 3, and approached significance for tion intervention” was significant with a negative associa-
friends for the item of “My close friends support my going tion with total time spent online.

18 Adolescent Internet Depression Prevention

prediCTors of aCTiVe adherenCe numbers of characters typed, as a measure of active adher-

As shown in Table 5 with regards to beliefs, the beliefs of ence in preventing depression in Models 1 and 2. The belief
“protecting myself from depression through a depression of “depression prevention intervention could prevent fur-
prevention intervention,” “participating in an intervention ther depression” for Models 1 and 2, and also “depression
like this is important,” and “when depression is found early prevention intervention will help me to be healthy” for
it can be prevented” all significantly predicted the total Model 1, all approached significance. With regard to atti-

Table 3
Predictors of Intention

Voorhees et al. 19

Table 3 cont.

tudes, the item of “the benefits of a depression prevention and approached significance in Model 3. Also, there was a
intervention outweigh any difficulty” significantly pre- negative association of “immediate family support” for sig-
dicted number of characters typed in Models 1, 2, and 3. nificantly predicting number of characters typed in Model
The social norm item of “I want to do what the physicians 3. None of the perceived behavioral control items were
want me to do about depression prevention” significantly significant predictors. Male gender approached signifi-
predicted the dependent variable only in Models 1 and 2 cance for a negative association with number of characters

20 Adolescent Internet Depression Prevention

Table 3 cont.

Self efficacy


typed in Model 3. The motivation item of “readiness” sig- ment, 46 answered the phone for the follow-up study. Of
nificantly predicted the total number of characters typed in those who answered the phone, the most common reason
Models 1, 2, and 3. Depressed mood did not predict num- for declining an interview was that they were not interested
ber of characters typed in any of the models with which it (50.0%, N=23), followed by being too young (21.7%,
was included. In Model 4, only the belief item of “protect- N=10). There was no significant difference in the level of
ing myself from depression through a depression preven- depressed mood between those who participated in the
tion intervention” significantly predicted total numbers of study and those who chose not to participate.
characters typed.
missing daTa ConCerns Adolescents endorsed favorable attitudes and prefer-
Participants and those eligible to participate did not differ ences toward primary care Internet-based interventions
based on PHQ-A -2 scores. Similarly, participants did not and more ambivalent attitudes toward more traditional
vary based on PHQ-A-2 scores from those we identified delivery forms such a group counseling program. While
in screening but whom we either did not reach or did not the majority of the sample participants found conven-
consent to a phone interview. We examined reasons for tional approaches to depression prevention, such as talk-
non-participation in the phone assessment (N=177). Of ing to their primary care doctors about depression
those who did not participate in the initial phone assess- prevention and feelings and setting up a regular schedule

Voorhees et al. 21

with their family practitioners acceptable, a great number could help prevent further depression. The most impor-
of the adolescents found novel forms of intervention ac- tant predictors were family social norms for intentions,
ceptable, such as completing an Internet questionnaire disagreeing with the belief about “being better off with-
and starting an individual exercise program. Further- out a depression prevention intervention” for passive ad-
more, most of the adolescents we assessed agreed that herence, and the belief of “protecting myself from
intervention programs were important and relevant and depression through a depression prevention intervention”
more than half believed that an intervention program for active adherence.

Table 4
Predictors of Passive Adherence

22 Adolescent Internet Depression Prevention

Table 4 cont.

preferenCes for inTerVenTion (43%) are new and important. The most effective preven-
This is the first study to consider preferences for interven- tive intervention to date have used the group counseling
tion of adolescents with sub-threshold symptoms. As hy- approach (G. N. H. Clarke, M., Lynch, F., et al., 2001; Gar-
pothesized, (hypothesis 2) we found that adolescents with ber et al., 2009). This is consistent with preference ex-
sub-threshold symptoms in primary care preferred novel pressed by older adults for less psychologically-oriented
approaches such as personal exercise or completing Inter- approaches such as those including exercise and vitamins
net questionnaires. The preference for primary care and In- (Grant, 2009). In contrast, Jaycox and colleagues demon-
ternet-based approaches might be congruent to the strated that most adolescents in primary care settings diag-
preference reported for an autonomous-supportive envi- nosed with major depressive disorder preferred active
ronment from patients’ health practitioners (Sheldon, 2003; treatment (72%) with face-to-face counseling or anti-de-
Vansteenkiste & Sheldon, 2006; Wisdom, Clarke, & pressants, rather than watchful waiting (28%) (Jaycox et
Green, 2006) and methods under personal control such as al., 2006). This difference might be explained by the find-
exercise or vitamin supplementation (Grant, 2009). The ings that symptom severity substantially predicts perceived
findings that a majority of adolescents preferred no treat- need for intervention and willingness to accept treatment
ment (57%) (“Waiting and getting over in naturally”) and (B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et
preferred individual counseling (79%) to group counseling al., 2005, 2006) and in our study participants had low levels

Voorhees et al. 23

Table 4 cont.

of depression symptom severity. Our study findings in an with prior work demonstrating that the lay public and ado-
adolescent sample may differ due to the greater concern of lescents view primary care physicians as their first source
adolescents with regard to opinions of peers compared to for care (Highet, Hickie, & Davenport, 2002; Joffe, Radius,
adults. & Gall, 1988) and that they desire psychosocial interven-
tions despite the reported growing acceptance of the “bio-
aTTiTudes ToWard depression preVenTion logical model” for treating depression (Blumner & Marcus,
Prior studies have assessed the influence that attitudes and 2009).
beliefs of adolescents with varying levels of symptoms
have on their intent to seek treatment (B. W. Van Voorhees prediCTors of inTenTions
et al., 2007; B. W. Van Voorhees et al., 2006) or preferences The significant relationship for both beliefs about the in-
for treatment (Jaycox et al., 2006). However, to our knowl- tervention and perceived social norms with the intentions
edge this is the first study that reports specific attitudes and outcome is a new finding consistent with prior work that
beliefs towards depression prevention on adolescents with shows attitudes/beliefs toward an intervention predict both
sub-threshold depressive symptoms (Christensen, 2009; intention and service use (Jaycox et al., 2006; Leaf et al.,
Neil et al., 2009). Our study also departs from the previous 1987; Lin & Parikh, 1999; B. W. Van Voorhees et al., 2003;
studies in that it assesses perceived behavioral control in B. W. Van Voorhees et al., 2005, 2006). However, the rel-
accordance with the theory of planned behavior framework atively greater importance of social norms for predicting
(Ajzen, 2002). The participants appeared to endorse pri- intention to prevention surprised us because our prior work
mary care/Internet-based prevention, which is consistent with predicting treatment suggested that beliefs toward the

24 Adolescent Internet Depression Prevention

Table 5
Predictors of Active Adherence

Voorhees et al. 25

Table 5 cont.

intervention demonstrated a primacy in decision-making when the perceived need for treatment is low since these
(B. W. Van Voorhees et al., 2005, 2006). Similarly, self-ef- individuals had sub-threshold depressive symptoms, an
ficacy and/or attitudes toward the behavior did not predict adolescent turns to family, such as parents, and friends for
intention or use as it has in other studies (Leaf et al., 1988; guidance (DeBar, 2009). The inverse relationship between
B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al., males and intention is consistent with prior work demon-
2005, 2006). Perhaps for new or novel preventive inter- strating greater use by females of the Internet-based pro-
ventions such as our Internet-based intervention and also grams (Christensen, 2009; Neil et al., 2009).

26 Adolescent Internet Depression Prevention

Table 5 cont.

prediCTors of passiVe and aCTiVe adherenCe tivational interviewing before Web site use increases both
The findings that beliefs about the intervention, attitudes time on the Web site and also number of characters typed
toward behavior, self-efficacy and motivation predict pas- (B. W. Van Voorhees, Fogel, J., Pomper, B. E., & Doman-
sive and active adherence for the prevention intervention ico, R., 2009). Neil and his team have previously demon-
is a new finding. Conversely, demographic factors such as strated that symptom severity influences adherence (Neil
age, gender, depressed mood severity or non-white ethnic- et al., 2009). We were surprised that symptom severity did
ity, did not influence adherence as has been noted in prior not influence adherence in our study. This may reflect that
studies (Christensen, 2009; Neil et al., 2009). The findings the perceived need for “intervention” was deliberately con-
that beliefs concerning the intervention were the most im- structed around a “prevention and resiliency model” rather
portant predictors support our first hypothesis that beliefs than an illness model (B. Van Voorhees et al., in press). Per-
about intervention effectiveness would be the most impor- haps the adolescents discounted their current symptoms
tant predictors of motivation for preventive intervention. when determining whether or not to engage in the Internet
These findings are consistent with an extensive amount of Web site activities (B. Van Voorhees et al., in press; B. W.
literature linking attitudes to help seeking and/or intentions Van Voorhees et al., 2007).
(Jaycox et al., 2006; Leaf et al., 1987; Lin & Parikh, 1999;
B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al., limiTaTions
2005, 2006). These findings are also consistent with the The primary strength of this study was the recruitment of
theoretical models of the Theory of Planned Behavior a sample of adolescents in varied primary care settings in
(Hagger, Chatzisarantis, Biddle, & Chatzisarantis, 2002) two U.S. regions, which resulted in a diverse sample (40%
and Transtheoretical Model of Change (Miller & Rollnick, ethnic minority). Limitations of this study include the
1991). Similarly, we have previously established that mo- small sample size and possible selection bias toward ado-

Voorhees et al. 27

lescents who may be more favorably disposed toward pri- ConClusion

mary care, Internet-based interventions and possibly all Adolescents in primary care are open to the idea of early
mental health interventions than adolescents who chose not preventive intervention to avert developing depressive
to respond to the study after the initial screening identified episodes. They seem to prefer novel forms of intervention
them as “at risk.” Similarly, we omitted individuals who such as Internet-based types and primary care-based pre-
did not visit the Internet site from the adherence analyses scriptions for exercise. Clinicians should recognize that ado-
in order to convert the outcome variable to a natural log lescents might be persuaded to take more proactive
and attain a normal distribution. Also, the small sample size approaches to preventing depression based on their recom-
limited the capacity to complete multivariate analyses and mendations. Clinicians should consider the potential value
consequently may have underestimated the number of po- of novel interventions such as adherence to daily exercises
tentially significant relationships in the multivariate mod- or use of cognitive behavioral therapy through Internet Web
els. Conversely, the adolescent participants that consented sites. Researchers should consider the value of embedding
to a relatively “low burden” study and were found eligible interventions into the normative framework of primary care
to participate in the study were not originally “seeking” where physicians’ persuasive influence can be exercised and
treatment for depression or any other mental-health related controlled. Policy makers should consider primary care as
disease. As such, they might have represented a “snap shot” an acceptable environment to intervene to prevent depres-
of primary care attendees in these practices. Given the lim- sive disorders in adolescents and consider how such efforts
itations of the sample size, we must characterize these find- can be supported with adequate reimbursement from the
ings as exploratory in nature. healthcare and health insurance systems.

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Journal of CyberTherapy & Rehabilitation 31
S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1
© Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

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 Virtual
Reality (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 stimuli
used in clinical applications, as well as the interaction between odors, the other senses, and various
psychological processes. Presently, smells are mostly integrated in VR applications for post-traumatic
stress 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 the owski (1999), these factors include the perception that in-
brain, the olfactory system is the most ancient and perhaps corporating olfaction stimuli would neither enhance the
the least understood” (Ratey, 2001, p. 62). The sense of virtual experience, nor be useful in concrete applications.
smell is believed to have been a major catalyst in the evo- Most importantly, the primary obstacle to a generalized
lution of the primitive brain, and it is suspected that the integration of olfactory stimuli in VEs may be the diffi-
entire limbic system actually evolved from its original culty in dispensing and controlling the odorants in the en-
function of interpreting odorants and emitting pheromones vironment (Sadowski, 1999).
(Ratey, 2001). Its significance for animals is readily rec-
ognized (Ache & Young, 2005). It plays a role in their To date, relaxation techniques (Kawai & Noro, 1996),
search for food, navigation and orientation, reproductive posttraumatic stress disorder (PTSD) treatment (Gerardi,
behavior, and social organization (Albrecht & Wiesmann, Rothbaum, Ressler, Heekin, & Rizzo, 2008), and drug ad-
2006). Although many of these aspects also apply to hu- diction research (Bordnick et al., 2008; Ryan, Kreiner,
mans (Albrecht & Wiesmann, 2006), many tend to con- Chapman, & Stark-Wroblewski, 2009) belong to the rare
sider olfaction of minor importance (Shepherd, 2006). applications integrating olfactory cues in clinically perti-
nent VR scenarios. More specifically, Kawai and Noro
The relatively minor interest in the olfactory sense is also (1996) coordinated olfactory cues with the content of
reflected in the field of virtual reality (VR), and various stereoscopic 3-D images, for example, using the fragrance
factors may contribute to the underutilization of olfactory of a forest with 3-D images of a green forest, in order to
stimuli in virtual environments (VE). According to Sad- experiment 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:

University of Ottawa, Ottawa, Ontario, Canada
Université du Québec en Outaouais, Gatineau, Quebec, Canada
Laboratory of Cyberpsychology, Gatineau, Quebec, Canada
32 The Sense of Olfaction

tions. The results of this experiment suggest that such as- clinical applications. To this end, the information is struc-
sociations can lead to a psychological effect as measured tured into six sections, the first of which briefly addresses
in three psychological factors–depressive mood, anxious the neuroanatomy of the olfactory system. The next two
mood, as well as tension and excitement–that differs ac- sections cover the capabilities of the olfactory sense, and
cording to the type of fragrance (forest, marine, or laven- the characteristics of odors. Next, the potential interactions
der). In the field of PTSD treatment in VR, Gerardi and involving the olfactory sense are covered. The fourth sec-
colleagues' (2008) protocol calls for exposure to visual, tion presents various factors that influence olfactory pro-
auditory, tactile (i.e., vibration), and olfactory stimuli cessing and the fifth section presents some of the
(burning rubber, diesel fuel, weapons fire and spices). influences of odors on physiological state, perception and
During treatment, the patient is exposed to multi-sensory mental processes. Lastly, the present status of the research
combat zone stimuli while driving a Humvee in either involving the sense of olfaction, and the use of olfactory
urban or non-urban "Iraq-like" scenes. The intensity of stimuli in VEs will be discussed. This discussion will in-
these stimuli increases gradually across sessions. The re- troduce some of the present, and some of the potential, ap-
sults of this brief, single case VR exposure treatment in- plications of exposure to olfactory stimuli in VEs.
cluded clinically and statistically significant changes in
scores on the Clinician Administered PTSD Scale (Blake neuroanaTomy of The olfaCTory sysTem
et al., 1990) and the PTSD Symptom Scale Self-Report Olfaction is the “sensation of odors that results from the
(Foa, Riggs, Dancu, & Rothbaum, 1993), thereby suggest- detection of odorous substances aerosolized in the envi-
ing preliminary promise for this type of intervention (Ger- ronment” (Simpson & Sweazy, 2006, p.377), and thus, it
ardi et al., 2008). In the field of substance abuse and is categorized as a chemical sense, as in the sense of taste.
addictions, Bordnick and colleagues' (2008) VR alcohol In addressing olfaction, it is important to distinguish be-
cue reactivity assessment system incorporated visual, au- tween the terms “odor” and “odorant” (e.g., Hudson, 2000;
ditory and olfactory stimuli. These stimuli included the Hudson & Distel, 2002a,b). While an odorant, or olfactory
scents of vanilla, pizza, coffee, the preferred drink of the stimulus, is a physicochemical entity of molecules in the
participant (such as whiskey, beer, brandy, tequila, gin, environment (Hudson & Distel, 2003), an odor is the per-
scotch, red wine or white wine), beer, cigarette smoke, and cept created by a subject’s nervous system, in reaction to
pine trees. During trials involving non-treatment seeking the contact between the olfactory receptors and the mole-
individuals with alcohol use disorders, the exposure of the cule patterns of the odorant (Hudson & Distel, 2003).
subjects to multi-sensory alcohol related cues generated
higher subjective alcohol cravings than when these cues An odorant commences its transformation into an odor ei-
were absent. Furthermore, the multi-modal VE appears to ther from the outside (orthonasal) or from the inside
be associated with high levels of presence in VR (Bord- (retronasal) of the subject’s body. Whereas orthonasal
nick et al., 2008). In an interesting variation on the previ- stimulation results from sniffing the ambient air, retronasal
ous experience, Ryan et al. (2009) found that, when stimulation results when the odorants of ingested food
exposed to multi-sensory alcohol related cues, binge travel up from the back of the oral cavity and through the
drinking college students reported significantly higher nasopharynx into the nasal cavity (Shepherd, 2006). In ei-
cravings for, and thoughts of, alcohol than non-binge ther case, the odorant ends up in the olfactory mucosa, it-
drinkers. self located in the superior and posterior part of the nasal
cavity (Mackay-Sim & Royet, 2006). There, the odorant,
Yet, considering that the sense of smell plays a significant which must be hydrophilic or lipophilic in order to dis-
role in everyday human life (Drummond, Douglas, & solve in the mucus (Stockhorst & Pietrowsky, 2004),
Olver, 2007), and that its loss or impairment has signifi- comes into contact with the olfactory receptors of the ol-
cant chances of adversely affecting an individual’s quality factory epithelium (Ratey, 2001). The axons of the sensory
of living and emotional experience (Pollatos et al., 2007), neurons fasciculate to form the fila olfactoria (Mackay-
it would seem that the successful integration of olfactory Sim & Royet, 2006), which traverses the skull base
stimuli in VEs should be pursued more actively. Thus, the through the cribriform plate, to then enter the olfactory
purpose of this paper is to provide VR researchers an bulb. The left and right olfactory bulbs are interconnected
overview of the olfactory system, and its involvement in via the anterior commissure (Mackay-Sim & Royet,
psychological reactions, in the hope that this information 2006), and axons leave the olfactory bulb via the olfactory
may contribute to an increased use of olfactory cues in VR tract, to then project onto a group of structures collectively

Baus and Bouchard 33

referred to as the primary olfactory cortex (Mackay-Sim as a whole entity (Zucco, 2007). Unlike vision or hearing,
& Royet, 2006). These structures include the amygdala olfaction needs to be activated (Köster, 2002), and its ol-
which seems to play critical roles in odor processing factory bulb-produced “images” are subconscious (Shep-
(Jones-Gotman & Zatorre, 1993; Zald & Pardo, 2000), herd, 2006). This latter point is supported by the absence
conditioned fear and attention (Bremner et al., 1999), as of a significant relay in the thalamus (Shepherd, 2006).
well as aversive and negative emotional states (Hamann Furthermore, it seems impossible for a subject to conjure
& Mao, 2002). There exist important differences in neu- up an olfactory image (Moeran, 2007). Concerning this dif-
roanatomical connections between the olfactory sense and ference form the other senses, Zucco (2003) offers the ex-
other senses. The various connections of the olfactory sys- planation that, unlike olfactory representations, visual and
tem are illustrated at Fig.1. While other senses go through verbal representations are conceptual, and thus, can give
a series of cortical relays before reaching the limbic sys- rise to conscious representations. Alike the other sensory
tem, the olfactory bulb projects uncrossed (Ratey, 2001), modalities, the olfactory system habituates to a prevailing
and without being mediated by the thalamus (Simpson & stimulus (Morean, 2007). This phenomenon is observable
Sweazy, 2006), onto the amygdala. There seems, however, through a rapid decline in the pyriform cortex activation
to exist an additional indirect and less prominent link be- during constant exposure to a particular olfactory stimulus
tween the primary olfactory cortex and the secondary ol- (Poellinger et al., 2001; Sobel et al., 2000).
factory area via the thalamus, (Djordjevic &
Jones-Gotman, 2006). In addition, the connection to the In humans, the development of different cognitive
orbitofrontal cortex provides olfaction with the “fastest processes for socialization seems to have led to loss of
route between perception and action” (Malaspina et al., function mutations in the olfactory receptor genes
2006, p. 222). (Rouquier, Blancher, & Giorgi, 2000), and the human’s ol-
factory acuity is inferior to that of most animal species
In summary, an odor is the result of complex interactions (Malaspina et al., 2006). A person’s ability to localize the
between the molecular pattern of an odorant, the olfactory source of an odorant–based on olfaction alone–is relatively
receptors, the olfactory bulb, the primary olfactory cortex poor (Kobal, Van Toller, & Hummel, 1989), and humans
and the secondary olfactory area. Most importantly, when are anomic to certain odorants (Albrecht & Wiesmann,
compared to the other senses, the sense of olfaction enjoys 2006). Nevertheless, an individual can detect up to 10,000
a more direct, and thus, faster and less filtered, uncrossed odorants (Albrecht & Wiesmann, 2006) with less than
connection with the amygdala. It is this privileged relation 10,000 receptors (Ratey, 2001). Hudson and Distel (2003)
with the limbic system, as well as that with the or- propose three ways the olfactory system is able to meet this
bitofrontal cortex, that speak in favor of the use of olfac- challenge: the combination of wide spectrum receptors and
tory cues in VR. Indeed, many of these brain regions are neurons, the ability to learn, and the ability to adjust the
involved in the processing of virtual stimuli used in clin- sensitivity of the receptors according to the environment,
ical applications, including anxiety disorders (Phillips, the individual experience and the situation. However, de-
Drevets, Rauch, & Lane, 2003), addictions (Everitt & spite its still impressive detection spectrum, the human is
Robbins, 2005) and eating disorders (Beckman, Shi, only able to discriminate between up to four separate com-
Levine, & Billington, 2009). ponents of an odorant (Laing & Francis, 1989). Further-
more, unless it is exposed to certain odorants early in
CapabiliTies of The olfaCTory sense development, the olfactory system may never develop the
Differentiable behavior and physiological changes ex- ability to recognize them. Conversely, one’s olfactory sense
pressed by newborn in reaction to odorants suggest that, can be improved through training (Ratey, 2001).
unlike the visual system, the olfactory system is remark-
ably mature at birth (Schaal, Marlier, & Soussignan, 1998, An odor incorporates a potentially great number of
2000). However, other than “an aversion to decaying, pu- odorants into a single percept, for example, about 800
trid or bitter things” (Morean, 2007, p. 157), the only in- in the case of coffee (Deibler, Acree, & Lavin, 1998).
born olfactory preference seems to be that for the mother’s According to Albrecht and Wiesman (2006), each indi-
amniotic fluid (Schaal, Marlier, & Soussignan, 1998). It vidual is equipped with a different set up of receptors,
seems that the right hemisphere is involved in the elabo- and they qualify one’s olfactory world to be as individ-
ration of odors (Zatorre, Jones-Gotman, Evans, & Meyer, ual as a fingerprint. It also appears that individual sub-
1992; Zucco & Tressoldi, 1989), and that they are acquired jects encode one same odorant differently during

34 The Sense of Olfaction

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

consecutive presentations (Engen, 1983). In addition, it utive presentations, and its resulting odor is influenced
seems that the individuality of one’s olfactory world is by a variety of contextual contributions and personal ex-
further defined by contextual contributions. Indeed, periences. Of particular interest to the integration of ol-
Hudson and Distel (2003) suggest that individuals shar- factory cues in VEs is the finding that the localization
ing the same sensory-chemical niche–the home, the of the source of an odorant, based on olfaction alone (i.e.
neighbourhood, the city, etc.–will respond to an olfac- without the support of the other senses), is relatively
tory stimulus in a more similar manner than those not poor. For the purpose of integrating odors in a VE, the
sharing that same olfactory niche. In support of this sug- implication of this characteristic could be three-fold. For
gestion, Stockhorst and Pietrowsky (2004) found that one, it allows, within certain limits, the use of a single
the perceived intensity of an olfactory stimulus de- remote source to release the olfactory cues (instead of
pended on its concentration, as well as on the level of using multiple sources and activating one, or the other,
everyday experience with the odorant. Hence, an odor depending on the position and/or orientation of the
is a subjective percept produced by the combination of user). The second implication may be that, in order to
an olfactory stimulus and a context, it is modulated via trigger the user's association between the odor and the
the nervous system (Hudson & Distel, 2003), its mean- intended virtual source of that odor, the visual (and po-
ing is probably acquired by individual experience (Hud- tentially auditory as well as haptic) details need to "sup-
son, 1999), its perceived intensity depends on port" the intended odor. For example, the odor of a
interpretation and cognitive appraisal, and therefore, it lemon should be matched with a virtual object that looks
can be modified through learning (Stockhorst & and, if applicable, feels like a lemon. Lastly, the syn-
Pietrowsky, 2004). chronization between the user's virtual position and the
timing of the releases of the olfactory cues need to con-
In summary, the olfactory sense is remarkably mature trolled precisely, perhaps through a three dimensional
at birth. It can detect up to 10,000 odorants, but the non- model creating an increasing odorant intensity as one
exposure to some odorants in early development may approaches the intended virtual source.
lead to an inability to detect them. Olfaction must be ac-
tivated, habituates to prevailing stimulus, and it is im- CharaCTerisTiCs of odors
possible for a subject to conjure up an olfactory image. dimensions of an odor
An odorant may be encoded differently during consec- Hedonicity, or the measure of pleasantness, familiarity and

Baus and Bouchard 35

intensity are the dimensions mostly used to qualify an via other modalities. For example, the level of presence in
odor, and they are not totally independent of another a virtual kitchen may differ between users, depending on
(Delplanque et al., 2008). Hedonicity, also referred to as their familiarity with the type of food odorant use, which
valence (Schiffman, 1974), is the most salient (Engen & in turn, may be associated with cultural background. Fi-
McBurney, 1964; Harper, Land, Griffiths, & Bate-smith, nally, varying odorant intensities may be useful in cueing
1966) of these dimensions. Hedonicity is not quantified the user about the position, and rate of position change,
via a continuum of pleasantness, but via two opposing relative to the intended virtual source of that odor.
clusters of pleasantness and unpleasantness (Godinot,
Sicard, & Dubois, 1995; Schiffman, 1974), and the effect faCTors influenCing olfaCTory proCessing
of a pleasant olfactory stimulus seems to be more persist- gender
ent than that of an unpleasant one (Weber & Heuberger, Herz (2004) reports that women are more sensitive to ol-
2008). As proposed by the mere exposure effect (Cain & factory stimuli than men, and although the results are not
Johnson, 1978; Sulmont, Issanchou, & Köster, 2002), unequivocal, consistent replications suggest that women
pleasantness and familiarity of odors seem to be positively outperform men in olfactory tests (Good & Kopala, 2006;
correlated (Engen and Ross, 1973; Bensafi, et al., 2002). Pause, Sojka, Krauel, Fehm-Wolfsdorf, & Ferstl, 1996).
While Henion (1971) had suggested that, generally, an in- These differences appear at an early age (Dorries,
crease in intensity leads to decreased pleasantness, Schmidt, Beauchamp, & Wysocki, 1989), and apply more
Moskowitz, Dravnieks, and Kiarman (1976) later sug- specifically to discrimination, recognition and identifica-
gested that, depending on the odorant used, the correlation tion abilities (Doty, 1997; Wysocki & Gilbert, 1989), as
could be positive, negative, complex or nonexistent. It has well as the accuracy of higher order olfactory processing,
also been suggested that the path for neutral or pleasant such as naming or memory tasks (Good & Kopala, 2006).
odors is slower, and cognitively more complex, than that The effect size of this difference increases with age (Ship
for unpleasant odors (Rouby & Bensafi, 2002). As the for- and Weiffenbach, 1993), and is consistent across cultures
mer would be associated with higher order associations, (Barber, 1997; Doty et al., 1985). Although women detect
it may also be more influenced by familiarity (Royet et pleasant and unpleasant odors faster than neutral ones, this
al., 1999; Larsson, 2002). As proposed by Delplanque and is not the case for men (Pollatos et al., 2007). Neither Chen
colleagues (2008), the existence of two distinct paths for and Dalton (2005), nor Pollatos et al. (2007) found a dif-
pleasant and unpleasant odors is in line with models sug- ference in perceived pleasantness and arousal between
gesting the existence of different evaluative channels for men and women. In general, women are more sensitive to
the processing of positive and negative stimuli (Cacioppo, biologically relevant olfactory stimuli, such as the
Garner, & Bernston, 1999; Sander, Koenig, Georgieff, pheromone androsterone (Wysocki & Gilbert, 1989). This
Terra, & Franck, 2005). Furthermore, the existence of last point, when combined with women’s peak sensitivity
these two distinct paths is supported by neuroimaging to olfactory stimuli during the pre-ovulatory period (Good
(Fulbright et al., 1998; Zald & Pardo, 1997) and electro- & Kopala, 2006), and the passive communication of mate
physiological (Hummel & Kobal, 1992) results of cerebral quality through body odor (Sergeant, Davies, Dickins, &
activations during odor processing. Griffiths, 2005), supports the biological relevance of the
superior sensitivity of the woman’s olfactory system.
The dimensions qualifying an odor are hedonicity, famil-
iarity and intensity and certain correlations seem to exist emoTional sTaTes
between these dimensions. In order to improve the VR ex- Current emotional states also seem to influence olfactory
perience, it may be useful to consider each of these three processing (Pollatos et al., 2007). While an individual’s
dimensions. For example, it is conceivable that the hedo- current emotional state does not seem to affect olfactory
nicity of an odor could contribute to the determination of discrimination, it seems that across both sexes, negative
its intended virtual source (e.g., during immersion, the de- emotional states are associated with an increase in judged
tection of a pleasant but non-specific odor, while the user odor intensity. For men, this increase in judged odor in-
is positioned equidistantly from an overflowing garbage tensity is observed across all emotional conditions (Chen
can and a bouquet of flowers, is likely to result in an as- & Dalton, 2005; Pollatos et al., 2007). Viewing pleasant
sociation between the pleasant odor and the flowers). Fur- and unpleasant pictures, respectively, increases and de-
thermore, the level of familiarity is likely to lead to a more creases the pleasantness ratings of a neutral suprathreshold
rapid, and stronger, association with the cues presented odor judged according to intensity and pleasantness (Pol-

36 The Sense of Olfaction

latos et al., 2007). The viewing of unpleasant pictures is In summary, women’s olfactory processing seems more
followed by significantly reduced olfactory sensitivity sensitive than that of men, and negative emotional states
(Pollatos et al., 2007). This result is congruent with the ef- are associated with an increase in judged odor. Although
fect of negative emotional states on the ”primary sensory the gender-related difference in olfactory processing may
level of stimulus processing as measured by threshold not necessarily warrant the development of gender-spe-
tasks” (Pollatos et al., 2007, p. 587-588), as previously cific olfactory environments, it may need to be taken into
demonstrated with depressive patients (Serby, Larson, & consideration during the analysis of the effect of odorants
Kalkstein, 1990; Pause et al., 2003). Song and Leonard during immersion. Most importantly for the integration of
(2005) suggest that, considering the projection of the ol- olfactory cues in VEs, visual stimuli seem to influence and
factory system onto the limbic system (in particular, the enhance olfactory processing.
orbitofrontal cortex and the amygdala), there could be a
link between the dysfunction of a depressed patient’s lim- The influenCe of odors on
bic system and the reduced olfactory sensitivity. Interest- perCepTion and menTal proCesses
ingly, Vasterling, Braily, and Sutker (2000) found that A variety of studies demonstrate that olfactory cues can
patients with PTSD suffered from olfactory identification exert a cross-modal influence on the judgement of a vari-
deficits–an observation which Doop, Mohr, Folley, ety of non-olfactory stimulus attributes or qualities (De-
Brewer, and Park (2006) report as consistent with PTSD mattè, Österbauer, & Spence, 2007).
related dysfunction of the fronto-limbic system. These
findings could be considered contradictory to the use of odors, emoTions, and arousal
olfactory cues in the treatment of PTSD. This apparent Pleasant and unpleasant odor cues have the power to lead
contradiction will be addressed in the next section. to, respectively, positive and negative affective states
(Ehrlichman & Halpern, 1988) and moods (Alaoui-Ismaïli
Visual sTimuli et al., 1997; Goel & Grasso, 2004). Specifically, it has
Multisensory integration is a “process by which inputs been demonstrated that pleasant odors decrease arousal,
from one sensory modality influences processing of infor- whereas unpleasant odors have the opposite effect
mation from another modality and leads to either en- (Knasko, 1992; Alaoui-Ismaïli et al., 1997). Furthermore,
hanced or dampened neural responses depending on the arousal seems to be positively correlated with the strength
variety of factors, such as context and temporal or spatial of an odor (Royet et al., 2003; Heuberger, Hongratana-
concordance” (Small, 2004, p. 120). This process implies worakit, & Buchbauer, 2006).
that “when two or more sensory cues occur at the same
time and in approximate spatial correspondence, the firing odors and pain
rate of a multisensory neuron to a stimulus in one modality Odors seem to have the potential to increase and decrease
can be measurably altered by the presence of a second perceived pain. Familiar odors, such as maternal milk
stimulus in another modality” (Österbauer et al., 2005, p. odorant (Mellier, Bézard, & Caston, 1997; Rattaz, Gou-
3434). Anatomical and physiological evidence suggests bet, & Bullinger, 2001), can soothe up to moderate pain
that the multisensory integration of olfactory and visual in infants, thereby limiting or even preventing crying and
stimuli involves the orbitofrontal cortex and the amygdala thus, limit the energy expended during somewhat painful
(Thesen et al., 2004). There seem to exist compelling medical procedures (Goubet, Rattaz, Pierrat, Bullinger,
color-smell associations (Österbauer et al., 2005). Indeed, & Lequien, 2003). Conversely, in the presence of already
color not only facilitates odorant identification, but it can existing pain, certain odors seem to superimpose addi-
also influence judgments of odor intensity and pleasant- tional pain, and slowly increase the level of background
ness (Zellner, Bartoli, & Eckard, 1991). The mere pres- pain (Villemure, Wassimi, Bennett, Shir, & Bushnell,
ence of color in an odorant-less solution increases the 2006). Neurophysiologically, the intensification in per-
likelihood that subjects will report an odor (Engen, 1972), ceived pain can be observed by increased neural activa-
and a seemingly impossible color-smell combination tion in several areas associated with pain (Villemure et
(such as red colored white wine) can create perceptual ol- al., 2006). However, although the unpleasantness of the
factory illusions (DuBose, Cardello, & Maller, 1980; Mor- odor predicts the increase in pain intensity and unpleas-
rot, Brochet, & Dubourdieu, 2001). So far, however, the antness, it is the changes in mood evoked by the odors
literature offers little evidence whether odors can, in turn, that correlates best with the perceived level of pain (Ville-
influence visual perception (Thesen et al., 2004). mure et al., 2006).

Baus and Bouchard 37

odors and soCial inTeraCTion Keverne, 1997; Haberly, 2001). This process permits the
The perceived masculinity/femininity of photographed fine tuning, amplification and storage of the particularly
faces can be influenced by the presence of human sex hor- important odors, thus allowing the subject to distinguish
mone-like chemicals (Kovács et al., 2004). These findings them from the multitude of olfactory stimuli in the envi-
are in line with results suggesting the influence of human ronment (Hudson & Distel, 2003). Learning greatly affects
pheromones on people’s judgements of the written de- the perception and processing of odors, and it allows an
scriptions of others (Cowley, Johnson, & Brooksbank, organism to associate a specific situation with a particular
1977), and on the ratings of the sexual attractiveness of smell (Stockhorst & Pietrowsky, 2004). It may be the
pictures of women (Kirk-Smith, Booth, Carroll, & Davies, processes of amplification and storage of odors (identified
1978; Kirk-Smith & Booth, 1990). Pheromones, which as particularly important through "learning" during a trau-
humans emit in all body fluids (Ratey, 2001), are also matic event) that, despite the previously mentioned find-
processed via the olfactory system (Stockhorst & ings of olfactory identification deficits in PTSD patients,
Pietrowsky, 2004). Even though they may carry no con- make the use of trauma-related odorants pertinent in the
sciously perceptible odor, they can cause measurable treatment of this category of clientele. As demonstrated
changes in the autonomic nervous system and, depending by one trial exploring aversions to smells and tastes asso-
on the pheromone, they can induce mild impressions of ciated with nausea-inducing substances, olfactory learning
contentment or uneasiness (Ratey, 2001). Evidence sug- can take place in the form of one classical conditioning
gests that pheromones affect human sexual behavior, not trial (Stockhorst & Pietrowsky, 2004).
through sexual activity per se (Stockhorst & Pietrowsky,
2004), but through the modification of socio-sexual mat- Olfactory conditioning appears to first have been demon-
ing preference, attractiveness and mood (Cutler, Fried- strated on humans by Kirk-Smith, Dodd and Van Toller
mann, & McCoy, 1998). More specifically, they “facilitate (1983), and by Marinkovic, Schell, and Dawson (1989),
the perception of species members for reproduction (Cow- as well as by Moore and Murphy (1999). Respectively,
ley & Booksbank, 1991; Wyatt, 2003), they lead to an en- these researchers successfully paired an odorant with an
trainment of the menstrual cycle (Stern & McClintock, elevated level of anxiety, physiological arousal, and an
1998), change the physical attraction of possible sexual eye-blink response. Olfactory stimuli may also, by virtue
partners (Kohl, Atzmüller, Fink, & Grammer, 2001; of an association with unconditioned drug stimuli, elicit
Grammer, 1993) and mood (Jacob & McClintock, 2000), conditioned responses in the form of increased craving,
and they are correlated to physical attractiveness skin responses and heart rate changes (Bordnick et al.,
(Rikowsky & Grammer, 1999)” (Stockhorst & 2008). Olfactory conditioning seems to contribute to the
Pietrowsky, 2004, p.5). phenomena of sick building syndrome and multiple chem-
ical sensitivities (Magnavita, 2001). Various investigations
Research results also suggest a tendency to rate other peo- (Van den Bergh et al., 1999) suggest that the somatic neg-
ple more positively when in the presence of a pleasant fra- ative symptoms in reaction to certain chemicals are most
grance (Kirk-Smith & Booth 1990). In turn, there is a likely linked to conditioned increases in olfactory sensi-
significant positive correlation between the rated sexiness tivity to those same chemicals (Chu, 2008), potentially
of a man’s body odor and his facial attractiveness to fe- leading to reactions such as pre-chemotherapy nausea
males (Rikowski & Grammer,1999). However, Demattè (Siegel, 1999). Olfactory conditioning has also emerged
et al. (2007) suggest that odors do not affect the actual per- as an influence in drug administration (Stockhorst et al.
ception of the visual characteristics of a subject, but that 1999) and cigarette smoking behavior (Lazev, Herzog, &
instead, they change the affective reaction to them. Brandon, 1999).

odors, learning, and CondiTioning Herz, Schlanker, and Beland (2004) have suggested that
Indicators supporting the role of learning in olfaction in- ambient odorants, initially paired with seemingly easy but
clude an improving ability to discriminate between two actually impossible to complete tasks, could have an in-
previously unfamiliar odorants with exposure (Rabin, fluence on behavior. In one of their experiments, they ex-
1988; Jehl, Royet, & Holley, 1995), and the ability to ac- posed their participants to an unfamiliar ambient odorant
quire the qualities used to describe an odor (Stevenson, during a frustration mood induction. When the participants
2001). Olfactory learning appears to take place as early as later worked on puzzle tests in a room scented with either
the olfactory bulb and the pyriform cortex (Brennan & the same odorant, a different odorant, or no odorant, par-

38 The Sense of Olfaction

ticipants in the same odorant condition spent significantly memory, more recent sources have suggested that familiar
less time working on the tests than participants in the other odors are easier to remember and discriminate than unfa-
conditions. Herz, Schlanker et al. (2004) suggest the ex- miliar ones (Savic & Berglund, 2000; Schab & Crowder,
istence of an emotional conditioning mechanism–the re- 1995). Royet et al.’s (1999) finding that odor familiarity
duction in the time spent on the task in the presence of the strongly predicted odor naming further supports the link
conditioned odor is the result of a reduced motivation, it- between familiarity and odor memory. Anatomical support
self resulting from the odor-triggered re-emergence of the to this result includes the observation that the judgement
negative emotional reaction initially experienced during of odor familiarity involves the left inferior frontal gyrus
the failure to complete seemingly easy tasks. But the op- (Royet et al., 1999), an area normally linked to semantic
posite also seems to be true. Indeed, Chu (2008) demon- association (Ricci et al., 1999; Vandenberghe et al., 1996).
strated that, by classically conditioning an odorant with Thus, familiar and unfamiliar odors may be mediated by
positive task-related experiences, subsequent perform- separate neuronal circuits (Savic & Berglund, 2004). Fur-
ances of underachieving schoolchildren could be manip- thermore, if familiarity and pleasantness are indeed cor-
ulated to significantly improve on subsequent tasks. An related (as suggested by Bensafi et al., 2002; Sulmont et
olfactory stimulus can also act as a conditioned stimulus al., 2002), then odor pleasantness may also affect odor
in fear conditioning (Engen, 1973), and Chu (2008) sug- memory.
gests that stronger emotions increase the likelihood of ef-
fective olfactory associative links. While the memorization of a new odor seems more diffi-
cult than that of visual and auditory stimuli, if it is suc-
odor and memory cessfully stored, the memory of that odor is particularly
Lehrner et al. (1999) report evidence supporting the exis- persistent (Herz & Engen, 1996; White, 1998). During
tence of a discrete olfactory memory system branching recognition tasks immediately after exposure to stimuli,
into component subsystems. Olfactory memory is inde- visual and auditory stimuli are recognized at a rate of 90%
pendent of, and different from, other modalities of mem- (Zucco, 2007), while olfactory stimuli are recognized at a
ory (Vermetten & Bremner, 2003). Common and complex rate of only 70% (Herz & Engen 1996; Zucco 2003,
odorants are encoded and remembered as poorly as ab- 2005). However, over an entire year, unlike the case for
stract meaningless geometrical shapes (Lawless, 1978); verbal and visual stimuli, the forgetting curve of an ac-
Lawless (1978) and Engen (1991) suppose that the lack quired odor is relatively flat (Engen & Ross, 1973; Nick-
of structural information in olfactory stimuli could con- erson & Adams 1979). In fact, Engen and Ross (1973)
tribute to the poor immediate recognition of odors (in observed that after one year, over and above the 30%
comparison to visual and verbal stimuli). Odor memory recognition rate lost during initial memorization, the
seems strongly affected by proactive interference (Engen, recognition rate of odorants only decreases by an addi-
1987; Lawless & Engen, 1977), barely affected by the ef- tional 5%.
fect of learning strategies (Zucco, 2007), and very resistant
to retroactive interference (Lawless & Engen, 1977; Zucco Odor memory is excellent for odors associated with
2007). As such, it may well be the absence of attributes significant autobiographical experiences (Engen, 1973).
that contributes to its resistance to interference (Schab, This is supported by the ability of certain adults to name
1991). Although Engen and Ross (1973) had proposed that odors they had not smelled since childhood (Goldman &
odors are encoded in relation to perception and independ- Seamon, 1992), and may be influenced by the aforemen-
ent of semantic networks, Royet et al. (1999) found that tioned strong resistance to retroactive interference. Auto-
semantic and perceptual subsystems interacted during biographical memories are “episodic memories:
odor processing (Doop et al., 2006). recollected events that belong to an individual’s past. The
events that are recalled as autobiographical memories are
According to Engen and Ross (1973), there seems to be typically multimodal (involving vision, hearing, smell,
no difference between the recognition rates of intention- taste, touch, and body sense or kinesthesis); they vary in
ally and incidentally learned odor. In addition, the memory spatial, temporal, emotional, and narrative content and
of an odor seems unaffected by higher order abilities context; they have personal relevance” (Rubin, 2005), and
(Danthiir, Roberts, Pallier, & Stankov, 2001). Although they are usually encoded passively (Chu & Downes,
Engen and Ross (1973), as well as Lawless and Cain 2000a). Thus, the systems that play a role in autobiograph-
(1975), had found no link between familiarity and odor ical memory are the individual senses, a multi-modal spa-

Baus and Bouchard 39

tial system that notes the location of people and objects, In addition to being more potent autobiographical memory
emotion, language, a non language narrative system which cues than stimuli presented to other senses (Chu &
tracks causal relations (Rubin, Schrauf, & Greenberg, Downes, 2000), research suggests that olfactory-triggered
2003; Schrauf & Rubin, 2000), and “an explicit memory memories generate a stronger feeling of being brought
system that coordinates or binds information from the back in time than verbally or visually-triggered ones
other systems” (Rubin, 2005, p. 79). When autobiograph- (Herz, 2004; Willander & Larsson, 2006). Indeed, cross-
ical and semantic memory retrievals are compared, the modal laboratory and autobiographical studies of episodic
amygdala, the hippocampus and the right inferior frontal memory have shown that olfactory-triggered memories
gyrus were found to be more active (Rubin, 2005), and are more vivid than memories evoked by corresponding
working more closely together (Greenberg et al., 2005) words (Chu & Downes, 2002), and more emotional than
during the former. those triggered by alternate sensory variants, including au-
ditory stimuli (Royet et al., 2000) of the same item (Herz,
Autobiographical memory retrieval is enhanced by expo- 2004; Herz, Eliassen, Beland, & Souza, 2004). In fact,
sure to events associated with odors (Doop et al., 2006). specific trauma-related olfactory cues can lead to anxiety,
In an autobiographical memory recall task, twice as many fear-related memories, flashbacks (Vermetten & Bremner,
memories were recalled when accompanied with the ap- 2003) and panic attacks (Hinton, et al., 2004) in PTSD pa-
propriate odorant than without (Maylor, Carter, & Hallett, tients. These reactions may, in turn, lead to avoidance be-
2002). Odor-evoked memories seem different from other havior. In the case of PTSD, the conditioned responses
memory experiences (Willander & Larsson, 2006). Al- rooted in the autobiographical memory do not extinguish
though they are no more accurate than those evoked by with time (Vermetten & Bremner, 2003). These observa-
other senses (Herz, 2004), odorant-triggered memories are tions are congruent with the direct synapsing from the ol-
rated as more pleasant, and recalled less frequently factory area to the amygdala-hippocampal complex– the
(Rubin, Groth, & Goldsmith, 1984). Odor representations neural substrate of emotional memory (Cahill, Babinsky,
can be recalled after longer periods of time than verbal or Markowitsch, & McGaugh, 1995; Herz, Eliassen, et al.,
visual ones. While visually and verbally-triggered mem- 2004)–and the greater activation in the amygdala-hip-
ories generate a reminiscence bump between the ages of pocampal complex in reaction to personally relevant odors
10 and 30 years at event (Conway & Haque, 1999; Rubin, (Herz, Eliassen, et al, 2004).
Rahhal, & Poon, 1998), olfactory-triggered memories
have been localized to the first decade of life (Chu & effeCT of sub-ConsCiously proCessed odors
Downes, 2000b; Willander & Larsson, 2006). These re- The research presented above suggests that olfactory
sults are in agreement with research suggesting that asso- processed signals can affect organisms, but it is important
ciative olfactory learning begins very early in life (Schaal, to recognize that these signals need not be consciously
Marlier, & Soussignan, 2000; Van Toller & Kendal-Reed, processed to create an effect. Indeed, subliminal odors, as
1995), and earlier than the formation of autobiographical little as seven ppt, (Shepherd, 2004) can influence implicit
memories consisting of verbal or visual information (Wil- odor memory (Degel & Köster, 1999; Köster, Degel, &
lander & Larsson, 2006). The strength of the relationship Piper, 2002), social likeability judgements, and autonomic
between the olfactory cue and the autobiographical mem- responses in a valence-consistent manner (Li, Moallem,
ory is directly correlated to the emotional charge and sig- Paller, & Gottfried, 2007). In fact, contrary to autonomic
nificance of the remembered event (Vermetten & responses which are independent of the level of awareness
Bremner, 2003). The remarkable ability of olfactory stim- of an odor, the effects on social likeability emerge best when
uli to evoke very old autobiographical memories may be the odor is subliminal (Li et al., 2007). As bottom-up sen-
attributed to weak retroactive interference (Lawless & sory input often induces top-down regulation, thereby re-
Engen, 1977), strong proactive interference and, when sulting in synthesized processes (Schneider & Chein, 2003),
compared to visual or auditory stimuli, a low probability it has been suggested that it is the absence of the conscious
of subsequent exposure interference (Herz, 2004). Conse- awareness of the odor, and thus, the absence of a top-down
quently, the first odor/event association is very hard to un- regulation, that allows the subliminal odor to exert a greater
learn, a subsequent association to the same odor is difficult effect than supraliminal odors (Li et al, 2007).
to form (Herz, 2004), and hence, exposure to event-con-
gruent olfactory information can give access to very old In summary, the presence of an odorant is associated with
personal experiences (Willander & Larsson, 2006). numerous effects, and some of the ways these effects

40 The Sense of Olfaction

could be exploited in VEs will be addressed in the discus- gender (Russel, 1976), as well as certain emotional states
sion section. While pleasant odors seem to lead to positive (Stockhorst & Pietrowsky, 2004). Subconsciously, it affects
affects and decrease arousal, unpleasant ones seem to in- mating behavior (Herz & Inzlicht, 2002; Sergeant et al.,
crease arousal and lead to negative affects. Furthermore, 2005). Specifically, it influences attraction and sexual part-
arousal is inversely related to pleasantness, but positively nering by affecting mood states (Jacob & McClintock,
related to odor strength. The presence of odors can in- 2001), detecting immune system characteristics (Jacob,
crease or decrease the pain perceived by an individual. The McClintock, Zelano, & Ober, 2002; Thornhill & Ganges-
indications that an odor can influence how another person tad, 1999), genetic similarities (Eggert, Müller-Ruchholtz,
is perceived are of particular interest to social presence in & Ferstl, 1999), and female fertility (Poran, 1995). As pre-
a VE. These results seem to speak in favor of assigning sented earlier in this document, research results suggest
individual olfactory signatures to each virtual human in a that through the association of an olfactory cue with an
particular VE. Olfactory learning enables the discrimina- emotion (the more intense the emotion, the stronger the as-
tion of odorants in the environment, and this ability can sociation), that same olfactory cue can later evoke the con-
be improved through exposure. Olfactory conditioning– ditioned emotion, thereby affecting the abilities and
the association between an olfactory stimulus and a par- behavior of the subject. Thus, it could be expected that the
ticular situation–can not only elicit physiological and use of olfactory cues would be common in experimental
physical responses, but it can also affect performance. The as well as in clinical psychology–yet, it isn’t so.
olfactory system seems to have its own memory system,
and although the establishment of the memory of an odor Several factors may have contributed to this situation. First
is more difficult than that of a visual stimulus, if it is suc- and foremost, as olfaction often acts subliminally, its im-
cessfully established, it becomes particularly persistent. portance in day-to-day life may be underestimated (Al-
There seems to be no difference between the recognition brecht & Wiesmann, 2006). Secondly, due to their
rates of intentionally and incidentally learned odors, and complex composition and transient character, controlled
the memory of an odor seems unaffected by higher order exposure to olfactory stimuli is more complex than that to
abilities. Odor memory is excellent for odors associated visual or acoustical stimuli (Stockhorst & Pietrowsky,
with significant autobiographic experiences, and the re- 2004) and it is still impossible, from one exposure to an-
trieval of an autobiographical memory is enhanced by ex- other, to stimulate the exact same combination of olfactory
posure to event-associated odors. The strong resistance to receptors (Hudson & Distel, 2003). Thirdly, the odor per-
retroactive interference allows olfactory cues to trigger ceived by each subject is highly subjective, and thus, gen-
memories originating in the first 10 years of life. These eralization involving one particular odorant is likely to be
memories are vivid, and result in a strong feeling of being difficult. These factors may have contributed to the knowl-
brought back in time. The conscious awareness of the odor edge gap between olfaction and the more researched
is not necessarily required to enable its potential effects. senses such as vision and audition. This knowledge gap
also applies to the technology behind devices reproducing
disCussion and dispensing olfactory stimuli.
The sense of olfaction is used constantly and often subcon-
sciously (Drummond et al., 2007). It contributes to per- More recently, however, due to the potential of this rela-
sonal safety by helping to test the quality of the air tively neglected sense and, in particular, its ability to evoke
(Drummond et al., 2007), detect the presence of food and vivid memories, this trend has begun to change (Chu &
individuals (Drummond et al., 2007), determine the edibil- Downes, 2000a). Today, in the field of scent machines,
ity of food (Holland, Hendriks, & Aarts, 2005), sense the dispensing and controlling odorants in VEs (previously
flavors of food (Ratey, 2001; Shepherd, 2006), to the pleas- identified, as the primary obstacle to a generalized inte-
ures of eating (Simpson & Sweazy, 2006), and thus, it also gration of olfactory stimuli in VEs; Sadowski, 1999) are
influences future consumption. The olfactory sense’s sig- being addressed by a variety odor delivery systems, such
nificant role in human social behavior is supported by the as the SDS100 by Biopac Systems Inc., the Scent Collar
observation that, contrary to congenitally blind, mute or by the Institute for Creative Technologies in collaboration
deaf people, individuals with congenital anosmia do not with AnthroTronix Inc., and the Scent Projector by ATR
have intact reproductive–social behavior (Naftolin, Harris, Media Information Science Laboratories. These systems
& Bobrow, 1971). The olfactory sense contributes to the allow exposure to a variety of orthonasally-delivered ol-
identification of, not only an individual, but also his/her factory stimuli. In the field of applied research, the interest

Baus and Bouchard 41

in aromachology, the study of the influence of odors on heighten sexual arousal (via the release of endorphins)
behavior, now grows annually, and the topics covered by (Ratey, 2001). For example, the natural scent of blooming
this research include the effect of odorants on emotions, plants seems to be able to increase calmness, alertness,
physiology, cognitive abilities and behavior (Chu & and mood (Weber & Heuberger, 2008), while a lemon
Downes, 2000a). It has been suggested that a jasmine scent seems to lead to fewer reports of health symptoms
scent can enhance individuals' performance on problem- (Knasko, 1992).
solving tasks, as well as lead to higher levels of interest
and motivation to a task (Rottman, 1989), and that the Whether in clinical or experimental research, VEs have,
scents of rose and mustard seed differentially modulate at- so far, failed to fully integrate the potential of olfactory
tention to brightness (Michael, Jacquot, Millot, & Brand, stimulation, but there are exceptions. In clinical scenarios,
2003). A stimulating peppermint fragrance seems to con- some interesting VR research utilizing olfactory stimuli
tribute to increased pain tolerance (Raudenbush, Koon, is being pursued in the field of behavioral and physiolog-
Meyer, & Flower, 2002), to enhance athletic performance ical reactivity to drug and alcohol triggers/cues (Bordnick
(Raudenbush, Meyer, & Eppich, 2002; Raudenbush, Cor- et al., 2008). In such scenarios, the power of combining
ley, & Eppich, 2001), to induce physiological arousal visual and olfactory cues to induce drug cravings and un-
(Raudenbush, Koon, et al., 2002), and to enhance attention desired behavior can be employed as a tool for behavior
to visual stimuli. The latter also seems true for muguet modification. Clinical scenarios for treating PTSD utilize
(Warm, Dember, & Parasuraman, 1991). Finally, a rose- the tendency of prevailing olfactory cues to become
mary scent seems to contribute to, at the cost of slower strongly associated to a highly emotional event occurring
performance, increased memory recall accuracy (Moss, at the same time, such the odor of burning human flesh
Cook, Wesnes, & Duckett, 2003), while a cinnamon scent during a Rocket Propelled Grenade attack on a convoy.
seems to contribute to enhanced cognitive performances In these virtual world scenarios, olfactory cues, along
such as attention processes, virtual recognition memory, with visual and acoustic ones, are meant to ease access
working memory, and visual-motor response speed (Zo- to, and thus facilitate the processing of, traumatic mem-
ladz & Raudenbush, 2005). Some of the physiological ories (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo,
changes resulting from pleasant ambient scents may, in 2008).
turn, contribute to behaviors such as increased gambling
in casinos (Hirsch, 1995), increased time spent on a deci- However, the use of olfactory cues in VEs is more often
sion task (Bone & Ellen,1999; Mitchell, Kahn, & Knasko, the exception than the rule, and more extensive applica-
1995), and intentions to visit a store (Spangenberg, Crow- tions of olfactory cues seem possible. For example, VEs
ley, & Henderson, 1996). At the opposite end of the spec- are presently used for pain distraction (Hoffman, Patter-
trum, the persistent scents of air pollution seem to son, & Carrougher, 2000), and odors seem to have the po-
contribute to aggression in school-aged children (Ratey, tential to decrease perceived pain. It would be interesting
2001). Other results indicate that odors can impair the to verify the effect of integrating them in these types of
memory for faces that are presented simultaneously with applications. Furthermore, Kawai and Noro (1996) have
an odorant (Walla et al., 2003), and that when an odor is suggested that odorants, combined with stereoscopic 3-
semantically (Platek, Thomson, & Gallup, 2004) or hedo- D images may, through their ability to affect arousal and
nically (Ehrlichman & Halpern, 1988) congruent with a emotions, be useful in relaxation procedures. It seems
picture or a word, it facilitates the detection of that picture, that, as an extension of this application, the investigation
or the production of that word. Furthermore, stimulating of the use of olfactory cues as an element of treating
odorants seem to have the ability to increase alertness mood disorders in VEs would also be pertinent. In train-
(Goel & Lao, 2006; Weber & Heuberger, 2008). ing scenarios, VR olfactory conditioning could turn out
to be useful in triggering more appropriate responses to
In clinical applications, aromatherapy aims to capitalize emergency situations–for example, the use of the smell
on the ability of olfactory stimuli to elicit specific emo- of smoke during the practice of a fire drill in a VE may
tional responses. It relies on the hypothesis that, due to the lead to more appropriate behavior, including better con-
rapid connection between the olfactory system and the trol of emotions, in the presence of this stimulus during
limbic system, the appropriate olfactory stimulus could an actual fire. Olfactory cues in a VE may also turn out
calm or stimulate an individual, assist sleep, influence eat- to be useful to establish an association between a distinct
ing habits, reduce pain (via the release of enkephalins), or odorant and “virtually-evoked” positive emotions. Such

42 The Sense of Olfaction

an association may possibly find use in relaxation train- suggest that until olfactory cues are properly integrated
ing, or the treatment of certain mood and anxiety disor- in VEs, the gap between real world and virtual world ex-
ders. Furthermore, the ability of a VE to expose a great periences will remain significant. It is likely that the
number of users to a complex, yet perfectly identical sce- proper integration of olfactory cues in VEs will bring sce-
nario, would seem to make it a good tool for investigating nario simulation, whether for training or therapeutic pur-
the fundamental interactions between olfactory cues, per- poses, to a previously unattainable level of realism.
ception, cognition, emotion, and behavior. The results of
such investigations are of major interest, because they Acknowledgement
could reveal whether the integration of olfactory stimuli The writing of this paper was supported by scholarships
in training devices, such as combat simulators, would en- from the Fonds de la Recherche en Santé du Québec
hance the virtual experience, and if so, how and to what (FRSQ) and the Natural Sciences and Engineering Re-
degree. search Council of Canada (NSERC) awarded to the first
author, as well as by grants from the NSERC, the Canada
In sum, research has demonstrated the importance of ol- Foundation for Innovation (CFI) and the Canada Re-
factory stimuli in the human experience, and the results search Chairs awarded to the second author.

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Journal of CyberTherapy & Rehabilitation 51
S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1
© Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

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 for
improved 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 learning
with 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 used
the 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 of
physical activity together with CARLS result in significantly higher academic performance compared
to 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 in
the KMCAI group. An additional benefit of our approach is that students also obtained better physical
fitness while learning.

Keywords: Augmented Reality, Physical Activity,

Information Technology, Academic Achievement, Learning Attitude

inTroduCTion Moreover, students’ body mass index (BMI) was nega-

Numerous researchers have reported the importance of tively associated with their total academic achievement.
physical activity not only for physical and mental health, Therefore, Chomitz et al. pointed out that “promoting fit-
but such studies have also indicated a potential positive ness by increasing opportunities for physical activity dur-
impact on intelligence (Chomitz et al., 2009; Hillman, Er- ing Physical Education (PE), recess, and out of school
ickson, & Kramer, 2008), and cognitive development time may support academic achievement” (Chomitz et al.,
(Neubauer, 2008; Sibley & Etnier, 2003). Further, physical 2009).
activity was even proven to positively correlate to stu-
dents’ academic performance (Hillman, Erickson, & While the importance placed on standardized testing is in-
Kramer, 2008; Castelli et al., 2007; Coe et al., 2006). Re- creasing, many schools in the United States have tried to
cent research done on fourth-eighth grade students re- diminish or even eliminate PE programs, although no em-
vealed that both mathematics and English test scores pirical evidence suggests that this elimination could result
increased as the passed number of fitness tests increased in higher academic performance (Hillman, Erickson, &
(Chomitz et al., 2009). Other research conducted on third Kramer, 2008). A similar situation is also apparent in Tai-
and fifth grade students (Castelli et al., 2007), found that wan. Contrary to the "Health Related Physical Fitness" poli-
"aerobic fitness" was positively associated with total aca- cies of the Ministry of Education in Taiwan (Ministry of
demic achievement, including reading and mathematics. Education, 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:

Department of Information Management, Ming-Chuan University, Taiwan
52 Learning with AR Physical Activity

non-academic programs in order to maximize the time for In addition to creating an AR learning system including
academic programs in order to meet parents’ expectations. exercise, another objective of this study was to compare
In Taiwan, most parents expect their children to spend most the academic performance and learning attitude towards
of their time on academic programs instead of other non- science between high school-age groups using CARLS
academic endeavors, though, as mentioned above, spending and a group using KMCAI. In terms of assessment for ed-
more time on academic programs does not guarantee higher ucational objectives, Bloom classified six categories of
scores. Nonetheless, many Chinese parents are profoundly cognitive domains–Knowledge, Comprehension, Appli-
influenced by the Chinese philosophy that says, “Regardless cation, Analysis, Synthesis and Evaluation (Bloom et al.,
of the result, just throw all your endeavors into studying” 2009). Among these six categories, "Knowledge" was de-
(Hsiao, 2005). Because of their parent’s high expectations fined as “recalling or remembering something without
with respect to studying, students may feel it is inappropri- necessarily understanding, using, or changing it.” The re-
ate to spend time on physical activity instead of studying vised taxonomy of the cognitive domains by Anderson and
academic subjects. This old Chinese philosophy has trig- Krathwohl included Remembering, Understanding, Ap-
gered the innovative idea of "learning while exercising" that plying, Analyzing, Evaluating and Creating (Pickard,
will be discussed in this study. 2007; Anderson & Krathwohl, 2001). The subject special-
ists involved in the research divided the assessment for the
One of the main research objectives of this study was to unit of chemistry in high school science into two cate-
develop a learning system that can facilitate students' gories–memorized type and non-memorized type. The
"learning while exercising." A new information technol- memorized type referred to the content, which students
ogy termed "Augmented Reality" (AR) was employed to only needed to recall or remember without necessarily un-
achieve this objective. Most previous studies involving derstanding. The memorized type corresponded with the
AR learning systems used 3-D features to assist students basic level "Knowledge" in Bloom’s classification of cog-
to learn in a way that is more realistic than 2-D instruc- nitive skills and "Remembering" in Anderson’s & Krath-
tional tools (Yee, Ning, & Lipson, 2009; Chen & Wang, wohl’s Revised Bloom’s Taxonomy (RBT). For the rest
2008). Kaufmann reported that AR is a variation of Virtual of the assessment, the non-memorized type was identified
Reality (VR) (Kaufmann, 2002). Recent research provided with the other five categories of cognition domains except
fruitful results by using VR, MR or AR to help sufferers remembering knowledge. Our final goal in this study was
of mental (Mühlberger et al., 2008; Manzoni et al., 2008) to compare the impact of the three types of physical ac-
or physical health disorders. Regarding mental healthcare, tivity in CARLS on the memorized type and non-memo-
a recent study reported exciting results using VR applica- rized type of knowledge in high school science.
tions for patients with schizophrenia (Kim et al., 2008).
Concerning physical health, Schaik et al. reported that par- meThods
ticipants strongly preferred virtual augmented physical ac- subJeCTs
tivity over traditional physical exercise and the adherence In this study, the participants consisted of 687 seventh and
rate was 100% (Schaik et al., 2008). Wiederhold and eighth grade students, aged between 13-14 years old, from
Wiederhold pointed out that VR has made a significant 22 classes in five high schools located in Northern Taiwan
impact on behavioral healthcare with its multiple effective during the spring term of 2009. Approximately half of the
uses over the past decade (Wiederhold & Wiederhold, participants were male and the other half were female. A
2008). In addition to healthcare by the applications of VR, total of 673 valid data samples were collected. All students
MR or AR, Schaik et al. also found that fitness level was were divided into four groups–Group AR-Jump, Group
not associated with the performance of solving simple AR-Stretch, Group AR-Box and Group KMCAI. In these
puzzles and hitting targets in the game. Further, the corre- four groups, only the first three groups used the AR learn-
lation of preference for type of games with performance ing system. Each group used a different type of AR phys-
in the game was not significant. In this study, a new ap- ical activity. Group AR-Jump practiced aerobic fitness,
proach was taken by creating an AR system for educa- Group AR-Stretch practiced flexibility fitness and Group
tional purposes using the current-day curriculum, not only AR-Box practiced muscle strength. The reference Group
for simple puzzles or simple arithmetic puzzles, together KMCAI used a keyboard and a mouse to operate the com-
with three types of physical activity. Moreover, the poten- puter. The gender distribution ratios, male versus female,
tial of AR environments would be explored for adolescent among the above-mentioned four groups are 84 (53.5%)
high school students. versus 73 (46.5%), 77 (48.4%) versus 82 (51.6%), 79

Hsiao 53

(49.4%) versus 81 (50.6%), and 99 (50.3%) versus 98 to obtain students’ initial academic performance. Students
(49.7%) for Group AR-Jump, Group AR-Stretch, Group from all four groups followed the conventional instruc-
AR-Box, and Group KMCAI respectively. The initial ac- tions, using textbooks and CAI materials to implement the
ademic performance of the students for the subject of sci- first part of the teaching activity, then adopted four differ-
ence or other subjects was not available. Due to the ent approaches to carry out the second part, "practice."
Information Protection Act of students’ personal informa- Table 1 presents the different features of the learning ac-
tion, only the class tutors and students’ parents are allowed tivities for students in the four groups.

Table 1
The 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 CAI textbooks and CAI textbooks and CAI textbooks and CAI
material material material material

practice CARLS- Jump system CARLS- Stretch sys- CARLS- Box system A keyboard and
tem mouse

interactions with By body movement By body movement By body movement By wrist movement
materials like jumping like stretching like boxing

media delivery Text, graphics, sound Text, graphics, sound Text, graphics, sound Text, graphics, sound
effects and AR tech- effects and AR tech- effects and AR tech- effects
nology (with aerobic nology (with flexibil- nology (with muscle
fitness function) ity fitness function) strength function)

insTrumenTs sis in this study, there were 13 items left in the revised
In order to explore academic achievement in high school scale. All items were measured using a five-point Likert-
science, pre-test and post-test paper-and-pencil examina- type scale, ranging from 1 meaning "strongly disagree" to
tions were designed to be used in this study. There were 5 meaning "strongly agree." Regarding the content valid-
eight items pertaining to the memorized type and seven ity, the questionnaire was refined by a pilot study, which
items pertaining to the non-memorized type for each ex- focused on question wording, clarity and validity. In the
amination. Among these 15 items, eight items were the pilot study, the four subject teachers and director men-
same in both of the pre-test and post-test examinations and tioned above provided comments on the questionnaire as
the other seven items were different, but of the same level a basis for revisions. The reliability (alpha) coefficient for
of difficulty. The examination items were identified by the scale was 0.925.
four subject teachers from four high schools and by one
director of Teaching Affairs. In this study, all teachers and students using the AR learn-
ing system received two 50-minute training lessons to be-
In addition, the scale for measuring attitude towards lean- come familiar with the operations of CARLS. During the
ing science was revised from the previous studies of Ger- training week, the students in the three AR groups and the
mann and also of Osborne et al. (Germann, 1988; control group KMCAI spent approximately 20 minutes
Osborne, Simon, & Collins, 2003). After the Factor Analy- for the pre-test and 15 minutes for the pre-attitude test to-

54 Learning with AR Physical Activity

ward learning about science. Afterwards, all students in the five groups. Since the group means differed both pre-
the four groups received one 50-minute lesson for con- test and post-test in academic achievement and learning
ventional instruction using textbooks and CAI materials attitude, covariance analysis was applied to the following
and the other 50-minute lesson for the second part, "prac- statistical analyses. Furthermore, in order to explore a
tice," by using four different approaches in the following richer, in-depth context of students’ learning with AR, ex-
three weeks. After the completion of learning the unit of tensive interviews and observations were also carried out
Elements and Compounds, all students in the four groups in this study.
spent 20 minutes for the post-test and 15 minutes for the
post-attitude test toward learning about science. The post- ChemisTry ar learning sysTem (Carls)
test and post-attitude test were applied a week after fin- In this study, AR technology was employed to facilitate
ishing all activity with AR in order to examine students’ students "learning by exercising." By modifying the con-
learning retention. Thus, in addition to a four-week inter- tent of chemistry for seventh and eighth grade high school
vention with AR, the fifth week was used for the exam students, CARLS was developed as an assisted tool for
and the questionnaire. students’ science learning. Thus, CARLS can be viewed
as another type of a Computer Assisted Instruction (CAI)
In order to avoid anxiety and resistance towards the new tool, but differentiated from conventional KMCAI.
AR technology from parents and teachers, the four-week
intervention using AR technology and one week for the In terms of AR technology, the most well-known defini-
exam and questionnaire in this study were authorized by tion of AR was provided by Milgram and Kishino, who
the schools. Relating to the intervention time of this study, defined it as “a continuum of real to virtual environments
the following realistic and practical problems did exist at in which AR is one area within the general area of Mixed
the beginning stage of designing the experiment: (1) AR Reality (MR)” (Milgram et al., 1994). In Azuma’s work,
is new to most schools in Taiwan so there are a great num- AR was defined as a system with three characteristics: (1)
ber of doubts and resistance towards new technology. (2) a combination of real and virtual environments; (2) inter-
This study involves a large sample of students (n= 673) active in real time; and (3) registered in 3-D (Azuma,
from 22 classes in five high schools. To avoid uncertain 1997). However, Malik et al. argued that AR uses virtual
academic results for students, most schools would not objects, including text, 2-D images or 3-D models, to en-
allow the long-term experiment to be conducted on their hance users' insight into the real world (Malik, Roth, &
students, particularly for the pioneer or exploratory study. McDonald, 2002). Kaufmann reported that AR is a varia-
To examine the differences in students’ academic achieve- tion of VR (Kaufmann, 2002). VR immerses a user in a
ment including both memorized and non-memorized virtual environment but, in contrast, AR allows a user to
types, as well as students’ attitude change towards learn- see the real world combined with virtual objects in the
ing, a series of statistical analyses was conducted among same space at the same time.

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

Hsiao 55

In this study, CARLS adopted a webcam to capture stu- actions according to the students’ intended answers. The
dents’ gestures and body movements from the real world results and feedback from CARLS will be displayed on a
and combined them with designed virtual images to create large screen-wall in the real world.
an interactive image. These virtual interactions were dis-
played onto a screen by a projector (see Figure 1, previous CARLS combined learning with three types of physical
page). In CARLS, when students touch the "answer area" activity–aerobic fitness or jumping (see Figure 2a), flexi-
in the virtual environment, their positions and gestures can bility fitness or stretching (see Figure 2b) and muscle
be captured by the webcam and CARLS will generate re- strength or boxing (Figure 2c).

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

56 Learning with AR Physical Activity

CARLS allowed the students to have direct interactions nent contains interactive communication and discussion
with the system through their body gestures, such as wav- between a teacher and the students. In this study, CARLS
ing their hands to "catch" the answer in the virtual envi- was used for students as an assisted learning tool in the
ronment. For instance, in the boxing physical activity, the second part of teaching activity, "practice." All students
students have to wear "boxing gloves" to hit the correct received conventional instruction using textbooks and
answers a certain number of times instead of only hitting CAI materials on the fundamental concepts of chemistry,
once. The system designer programmed the number of hits in particular the unit dealing with elements and com-
required from the user in order to reach particular physical pounds. The content in the CARLS segment corre-
exercise levels in CARLS. For the other types of physical sponded with the National Curriculum in Science in
activity, like jumping, CARLS can be programmed to re- Taiwan (Ministry of Education, 2003) and consisted of
quest students to jump to reach a certain height, and a cer- 216 items from the elements and compounds unit. All
tain number of times, in order to reach the desired exercise items were identified as memorized or non-memorized
levels. In Taiwan, most high schools have at least one types by four subject teachers involved in this study.
computer and a projector in each classroom, making it is
feasible to implement CARLS in any high school. All that resulTs
is required in addition is a low-cost webcam. In terms of examining the differences in students’ aca-
demic achievement including memorized and non-mem-
With regards to the curriculum design in CARLS, a con- orized types of learning, as well as students’ attitude
ventional high school science teacher in Taiwan would towards learning change, since the group means differed
normally be expected to teach by presenting fundamental both pre-test and post-test in academic achievement and
concepts from textbooks, and then providing practice ex- learning attitude, a series of ANCOVA test analyses
ercises to students. The first part of the teaching activity were applied. Table 2 shows students’ estimated mar-
is a one-way instruction. However, the practice compo- ginal means and standard errors of non-memorized,

Table 2
The descriptive data of non-memorized, memorized science knowledge and learning attitude changes toward sci-
ence for four groups (ANCOVA)

non-memorized memorized learning attitude changes

Mean S.E. n Mean S.E. n Mean S.E. n

group ar-Jump 3.697 0.114 139 3.504 0.144 139 3.391 0.058 97

group ar-stretch 3.726 0.113 141 3.887 0.143 141 3.277 0.059 93

group ar-box 3.649 0.114 139 3.519 0.144 139 3.432 0.060 90

group KmCai 3.246 0.096 197 4.121 0.121 197 3.248 0.048 144

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

pre-test= 3.10 3.48 3.11

Hsiao 57

memorized science knowledge and learning attitude wards science.

changes toward science from four groups (by AN-
COVA). In term of the non-memorized type academic non-memorized and memorized sCienCe
achievement, the students in all three AR groups, AR- KnoWledge
Jump, AR-Stretch, and AR-Box (mean = 3.697, mean = Table 3 presents differences in the non-memorized portion
3.726, and mean = 3.649, respectively), have higher av- of science academic achievement between the four groups,
erage scores than those in the control group KMCAI F (3, 615) =4.921, p<0.01. The table was integrated from
(mean = 3.246). Regarding the memorized science a series of Pairwise Comparisons based on estimated mar-
knowledge, the students in the control group KMCAI ginal means in the ANCOVA test analysis. It revealed there
(mean = 4.121) scored higher than those in the AR- were significant differences in the non-memorized type
Jump, AR-Stretch, and AR-Box groups (mean = 3.504, achievement between the students in Group AR-Jump and
mean = 3.887, and mean = 3.519, respectively). Con- Group KMCAI (p<0.01), Group AR-Stretch and Group
cerning the learning attitude changes towards science, KMCAI (p<0.01), and Group AR-Box and Group
the students in the AR-Box group scored highest on the KMCAI (p<0.01). The results also clearly showed that all
relevance scale (mean = 3.432), indicating that they students in the three AR groups have better academic
have the highest positive learning attitude changes to- achievement in science than those in Group KMCAI.

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

group group group group

ar-Jump ar-stretch ar-box KmCai
(mean=3.697) (mean=3.726) (mean=3.649) (mean=3.246)


group -0.029

group 0.049 0.078


group 0.451** 0.480** 0.403**


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

Table 4 shows the differences in the memorized type aca- in the memorized academic achievement between Group
demic achievement between the four groups, F (3, 615) AR-Jump and Group KMCAI (p<0.01) and between
=5.170, p<0.01. The table was integrated from a series of Group AR-Box and Group KMCAI (p<0.01) after stu-
Pairwise Comparisons based on estimated marginal means dents studied. It revealed that the students in Group
in the ANCOVA test analysis as well. The results shown KMCAI have a better performance than those in both
in Table 4 indicated that there were significant differences Group AR-Jump and Group AR-Box.

58 Learning with AR Physical Activity

Table 4
The differences in memorized science knowledge between four groups

group group group group

ar-Jump ar-stretch ar-box KmCai
(mean=3.504) (mean=3.887) (mean=3.519) (mean=4.121)


group -0.382

group -0.014 0.368


group -0.616** -0.234 -0.602**


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

learning aTTiTude Change ToWard sCienCe KMCAI, F (3, 423) =2.581, p<0.05 (Table 5). The stu-
In terms of the learning attitude change toward science dents in Group AR-Box had a more positive learning atti-
following the course study, there was a significant differ- tude change toward science than those in Group KMCAI
ence between the students in Group AR-Box and Group (p<0.05).

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

group group group group

ar-Jump ar-stretch ar-box KmCai
(mean=3.391) (mean=3.277) (mean=3.432) (mean=3.248)


group 0.115

group -0.041 -0.155


group 0.143 0.028 0.184*


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

Hsiao 59

disCussion pressed their personal experiences about the new ap-

This study developed an AR learning system, CARLS, to proach using AR:
facilitate students learning about science by including
three types of physical activity–aerobic fitness, flexibility “After learning with the use of CARLS, I know the fun-
fitness and muscle strength–at the same time. Further, the damental concepts of Elements and Compounds better
performance in academic achievement in science, includ- now.” (Interviews, June 2009, opinions from Student 2-
ing both memorized and non-memorized types of knowl- 81020-C).
edge and learning attitude change toward science between
the four groups, Group AR-Jump, Group AR-Stretch, “After learning with the use of CARLS, I could clearly un-
Group AR-Box and Group KMCAI, have been com- derstand the differences between Elements and Com-
pared. pounds and the characteristics of Elements and
Compounds.” (Interviews, June 2009, opinions from Stu-
In comparison to the previous research which reported dent 2-81035-A, 3-80332-A, 4-71001-A,2-80215-B, 2-
that "aerobic fitness" was positively associated with total 80426-B, 2-80609-B, 2-81013-C, and 2-80235-C).
academic achievement, including reading and mathemat-
ics (Castelli et al., 2007), the findings derived from this In terms of the change in attitude toward learning about
study support the notion that students combining all three science, this study revealed that the students in Group AR-
types of physical activity in CARLS obtained signifi- Box using the "muscle strength" physical activity obtained
cantly higher scores of the non-memorized type knowl- a significantly more positive attitude change than those in
edge of science than those in the control group KMCAI. the control group KMCAI. Thygerson and Larson (Thyger-
The findings concur with those revealed by previous son & Larson, 2006) suggested that muscle fitness could
studies that there was no negative link between distrac- improve the peoples' ability to manage and function well
tion from physical exercise and performance of cognitive under pressure or anxiety. Further, it also promoted peo-
activity (Schaik et al., 2008). This study also found evi- ple’s intention and willingness to carry out their tasks. The
dence for the benefits of AR physical activity with cog- findings of Thygerson and Larson imply that muscle fitness
nitive activity, irrespective of physical activity type. might improve peoples' attitude toward certain objects or
Meanwhile, the students in the control group KMCAI situations since Loyd and Loyd suggested that attitude in-
tended to attain significantly better performances on the cludes four components–anxiety, confidence, liking and
memorized type of knowledge than those in Group AR- usefulness (Loyd & Loyd, 1985). Moreover, Gibson et al.
Jump and Group AR-Box. These results imply that both defined attitude as the positive or negative mental state to-
conventional KMCAI and our new AR technology ap- ward objects or situations (Gibson, Ivancevich, & Don-
proach were both helpful to students’ learning, but in dif- nelly, 1991). Thus, the findings in this study corresponded
ferent types of knowledge. In terms of memorized with previous studies and also explained why the students
knowledge, based on the revised taxonomy of the cog- in the muscle fitness exercise group had the highest posi-
nitive domain by Anderson and Krathwohl (Anderson & tive learning attitude change toward science.
Krathwohl, 2001), "remembering" is the basic level of
cognitive domain where students "do not need to under- In addition to quantitative evidence on learning attitude,
stand, use or change" knowledge. However, non-memo- the qualitative interviews also provided some clues.
rized knowledge includes other cognitive domains such Among three groups with AR physical activity, the stu-
as understanding, applying, analyzing, evaluating or cre- dents in both Group AR-Box and Group AR-Jump ob-
ating. All of these could be seen as very essential abilities tained higher scores in learning attitude change than
in the field of science. Group AR-Stretch, though only the students in Group AR-
Box obtained significant results in comparison with those
In addition to quantitative evidence on academic achieve- in the control group KMCAI. Based on the analysis of col-
ment, qualitative interviews and observations were car- lected data between the quantitative survey and qualitative
ried out to obtain a better picture of the educational setting interviews, we provide outlines to explain this situation.
and learning process. Relating to higher-level learning be- Firstly, the design of three types of physical activity in
yond memorizing of the concepts of chemistry, especially CARLS might cause students to progress less concerning
the unit dealing with elements and compounds, students learning attitude. The physical activity design for both AR-
from all three types of physical activity in CARLS ex- Box and AR-Jump is quite "simple" and "straightforward."

60 Learning with AR Physical Activity

The students only need to jump a certain height to touch in the AR learning system was taken from a certain unit
the answer, or to box the answer there is only a "short" in high school science so that the findings could not be
distance between their hands and the answer. However, generalized to other fields or subjects. Moreover, the stu-
the physical activity design for AR-Stretch is slightly more dents who were involved in this study only used the
complicated than the other two. Students have to move the CARLS system to specially learn the unit dealing with el-
correct answer from location A to location B carefully and ements and compounds for a relatively short period of
stretch their body in a difficult manner. The students from time. One week of training was used to provide familiarity
Group AR-Stretch which resulted in less progress regard- with the AR system and three weeks were spent learning
ing positive attitude change towards learning stated: with CARLS. There may possibly have been a novelty ef-
fect effecting students’ performances or behaviors, which
“It is a bit difficult to move the answer to the target loca- is partially in response to increased interest in, or attention
tion. Even though I know the answer, I am not able to move to, the AR technology, instead of the curriculum. The find-
the answer to reach the assigned location.” (Interviews, ings might vary when CARLS is used in learning for a
June 2009, opinions from Student 2-81003-B, 3-80322- longer period of time. Therefore, instead of drawing too
B, and 3-80419-B) much attention to the novelty of the new technology, fu-
ture researchers and teachers should be encouraged to em-
“The system should be improved to be easier for user and phasize more valuable characteristics of AR, i.e. exploring
the route for moving should be re-designed.” (Interviews, learning material through the combinations of the real and
June 2009, opinions from Student 2-80831-B and 3- virtual objects in the 3-D space so that it would help to
80110-B) display more concrete demonstrations to learners. Further-
more, students obtain more physical activity while learn-
However, in order to reach the aim of the "stretch" exer- ing compared to the sedentary learning style. Finally,
cise, the route between location A and location B was de- although this study revealed that the students participating
liberately designed to be longer and more winding in in all three types of physical activity in CARLS obtained
comparison with the other two types of physical activity. higher scores on the non-memorized science knowledge,
Future research may look more closely at the relationship this study did not directly prove that any specific physical
between the precise functions of exercise and the effect activity in CARLS promoted any specific students’ abili-
on learning. ties in the above-mentioned five non-memorized cognitive
domains. Future studies might prove fruitful in providing
ConClusions more details of the likely causes of the results by utilizing
This study provides a new approach to increasing students’ more sophisticated medical equipment.
physical activity without diminishing students’ academic
performance since many schools have tried to decrease For teachers adopting the new AR technology in the class-
PE programs in many countries due to a variety of reasons. room, we suggest that they pay close attention to the safety
In addition, better academic achievement in non-memo- of students since physical activity typically takes place in
rized knowledge of science and a more positive attitude the classroom. Further, the amount of physical activity
toward learning about science were also promoted by should be individualized for different students’ health con-
using CARLS. In this study we have shown that by using ditions. Physical activity should ideally take place within
CARLS it is possible to promote better academic achieve- a normal school schedule, however, if student exercise has
ment in non-memorized knowledge in science, and a more been limited by school budgets or any variety of reasons
positive attitude toward science while students also par- as has happened in different countries, an AR learning sys-
ticipated in extra physical fitness exercises while learning. tem with physical activity functions, like CARLS, might
provide an alternative solution.
In spite of the above findings, as the exploratory study that
pioneers in combining learning with AR and physical ac- Acknowledgements
tivity, some suggestions and research constraints are This research work has benefitted from the technical sup-
needed for future researchers and teachers adopting new port by Professor SY Huang and an AR work team in
AR technology in the classroom. First, the content used Ming-Chuan University, Taiwan.

Hsiao 61

referenCes Hillman, C.H., Erickson, K.I., & Kramer, A.F. (2008). Be

Anderson, L., & Krathwohl, D.E. (2001), A Taxonomy for smart, exercise your heart: exercise effects on
learning teaching and assessing: A revision of brain and cognition. Nat. Rev. Neurosci., 9, 58-
Bloom's taxonomy of educational objectives 65.
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Journal of CyberTherapy & Rehabilitation 63
S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1
© Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

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 pain
intensity, 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 analog
scale (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 pain
unpleasantness, a greater number of pain-related negative moods, poorer coping skills, and a greater
need to seek medical help for their pain. Participants of both races rated Caucasian VHs as experiencing
more 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 notable
advantage over other research methodologies in this line of inquiry. Several future research and education
applications of this VH technology are discussed.

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

inTroduCTion ticipants rated female subjects as experiencing greater

Empirical investigations support the presence of sex pain intensity in an experimental pain task compared to
differences in pain (Dao & LeResche, 2000; Ellemeier males (Robinson & Wise, 2004).
& Westphal, 1995; Frot, Feine, & Bushnell, 2004; Sex-specific relationships between pain and negative
Hawthorn & Redmond, 2000; Robinson, Riley, Myers, affect have been reported in both community and clin-
Papas, Wise, Waxenberg et al., 2001; Robinson & Wise, ical samples (Riley, Robinson, Wade, Myers, & Price,
2003; Robinson & Wise, 2004; Unruh, 1996; Vallerand 2001). In the National Health and Nutrition Examina-
& Polomano, 2000). Some studies have shown that fe- tion Survey, pain and depression were more prevalent
males perceive and express higher levels of pain than in females than in males (Magni, Caldieron, Rigatti-Lu-
males in clinical settings (Hawthorn & Redmond, chini, & Merksey, 1990). In clinical pain samples, the
2000). Sex-related differences in pain perception have prevalence of depression and anxiety is typically higher
also been found in experimental pain settings (Frot, et for females (Unruh, 1996). Although little is known
al., 2004). These sex differences extend to the observa- about the differences between males and females in
tion of pain in others, with one study finding that par- coping 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

University of Jordan, Department of Psychology, Amman, Jordan
University of Washington, Department of Rehabilitation Medicine, Seattle, Washington, U.S.A.
University of Florida, Department of Clinical and Health Psychology, Gainesville, Florida, U.S.A.
64 Sex and Race Differences in Rating Pain

found that females use a wider range of coping strate- sible with traditional research methodologies, such as
gies than men do. However, Keogh & Herdenfeldt those that involve historical chart reviews. It was hy-
(2002) suggested that the use of a wider range of strate- pothesized that a VH stimulus would elicit the same sex
gies could reflect the failure of coping strategies to ef- and race differences previously published in traditional
fectively reduce pain. self-report and observational studies.

A number of studies have also suggested that there are meThods

racial differences in pain perception, pain-related neg- parTiCipanTs
ative affect, and pain coping. In one study, African Seventy-five University of Florida undergraduate stu-
Americans with rheumatoid arthritis reported signifi- dents (53 females, 22 males) were recruited through
cantly higher use of distraction and praying/hoping as fliers and posters requesting volunteers to participate
coping strategies, whereas, Caucasians reported greater in this study. The participant sample was 83% Cau-
use of ignoring pain and coping statements (Jordan, casian and 17% African American.
Lumley, & Liesen, 1998). Campbell, Edwards, & Fill-
ingim (2005) examined racial differences in responses inClusion/exClusion CriTeria
to multiple experimental pain stimuli, including heat Eligibility requirements for participation were being at
pain, cold pressor pain, and ischemic pain and found least 18 years old, English speaking, and of African
that African Americans reported greater use of passive American or Caucasian background. Participation was
pain coping. Moreover, research on pain-related mood also contingent upon ability to give consent.
has shown that African Americans with chronic pain
had higher pain-related depression and disability when proCedure
compared to Caucasians (Carmen, Green, Ndao-Brum- Each participant was asked to read a description of the
blay, Nagrant, Baker, & Rothman, 2004). Riley, Wade, study including the time required to complete the study
Myers, Sheffield, Papas, & Price (2002) also found that and a reminder that the study is voluntary. After reading
African Americans experience greater emotional suf- the study description, all participants read and signed a
fering compared to Caucasians with similar levels of computerized consent form acknowledging that the
pain intensity. study procedures were explained and that they could
withdraw, without prejudice, from the study at any
Most research studies investigating sex and race differ- time. Next, they completed a brief demographic ques-
ences in pain perception and evaluation focused on how tionnaire that collected participants’ age, race, and sex.
both sexes and different races perceive and evaluate Participants then read a set of instructions that provided
their own pain. The current study focuses on the differ- information on how to approach the task and how to
ences in perceiving and evaluating others’ pain. Fur- use Visual Analogue Scales (VASs) to give ratings.
thermore, studies investigating differences in
perceiving and evaluating pain in others relied mainly A series of 16 vignettes were produced using comput-
on recorded videos and still pictures of actual pain pa- erized VH technology via a commercially available
tients expressing pain. This methodology, however, is software package (People Puttytm). A novel feature of
not sensitive to the possible variance that might already this approach was the ability to standardize the amount
exist amongst video-taped pain patients. The current of pain expressed in the VH face across different sexes
study controls this possible variance through a novel and races of VHs. This was accomplished by employ-
computerized technology which reduces the variance ing the Facial Action Coding System (FACS). The
to almost zero. The purpose of this study was to employ FACS is based on an anatomic analysis of facial muscle
a novel computer-generated virtual human (VH) tech- movements and distinguishes 44 different action units
nology to investigate sex and racial differences in the (AUs). An abbreviated version of the FACS was used
observation of pain, pain coping, pain-related negative in this study focusing on the four primary action units
affect, and recommendations to seek treatment. The use that are involved in the facial expression of pain and
of a VH technology allows for the standardization of produced validated facial expressions showing pain–
the amount of pain expression independent of the sex brow lowering, tightening of the orbital muscles sur-
and race characteristics that are of interest as dependent rounding the eye, nose wrinkling/upper lip raising, and
variables. This level of experimental control is not pos- eye closure.

Alqudah et al. 65

Each stimulus the participants observed consisted of a analysis

vignette and a VH patient. Each VH contained three All data analyses were performed using SPSS for Win-
cues–sex (two levels: male or female), race (two levels: dows (Version 15). Mixed model ANOVA analyses
Caucasian or African American), and pain (two levels: were performed where sex and race of participants and
low amount or high amount of pain) which was re- VHs served as independent variables, and ratings of
flected on the VHs facial expressions. pain intensity, pain unpleasantness, pain-related nega-
tive mood, pain coping, and the extent to which the
Participants were instructed to completely respond to VHs were recommended to seek medical help for their
VHs in the order presented, complete the ratings for one pain served as dependent variables. We had no a priori
VH before going on to the next, and they were not al- hypotheses regarding a number of the interaction terms
lowed to revisit a previously viewed VH. For each VH, (e.g. sex of participant, by race of participant, by sex
participants used computerized VASs to rate the level of video, by race of video), therefore, we approached
of pain intensity observed, the level of pain unpleasant- the analyses by looking at only the main effects and
ness observed, the level of pain-related negative mood specified two-way interactions for which a priori hy-
observed, how well the observed VH was coping with potheses were available.
the pain experience, and the extent to which they would
recommend the observed VH to seek pain-related med- Willingness to report pain and pain endurance, taken
ical help. Participants also completed a computerized from the GREP, were investigated to determine whether
version of the Gender Role Expectations of Pain ques- they met the criteria to serve as covariates in the analy-
tionnaire (GREP) (see appendix A) using computerized ses involving participants’ ratings of pain intensity and
VASs to assess the degree to which gender role expec- pain unpleasantness.
tations of pain may contribute to their ratings.
The Gender Role Expectations of Pain questionnaire CoVarianCe analysis
(GREP) consists of visual analog scales to assess par- Willingness to report pain and pain endurance are two
ticipants’ view of the typical male and female regarding factors of the GREP that were considered for inclusion
pain sensitivity, pain endurance, and willingness to re- in the models as covariates. Correlation analyses were
port pain. It also assesses the participants’ personal at- conducted on these two factors as well as male and fe-
tribution of his/her pain sensitivity, pain endurance, and male participants’ ratings of pain intensity and pain un-
willingness to report pain relative to the typical male pleasantness for male and female VHs. Results of the
and female. The psychometric properties of the GREP correlation analyses were not significant, thereby indi-
factor structure are close to the theoretical formulation cating that the two GREP factors did not meet the as-
of the scales, accounting for 76% of the variance in sumptions of covariance analysis. Therefore,
scores. The questionnaire has good test–retest reliability willingness to report pain and pain endurance were not
with individual item correlations ranging from 0.53 to included in the following models.
0.93. The sex differences in the endorsement of items
on the GREP were large, with the largest differences assoCiaTions among The dependenT Variables
(46% of variance) shown for willingness to report pain A correlation analysis was conducted between the de-
items. Wise, Price, Myers, Heft and Robinson found pendent variables. All dependent variables in this study
that the GREP was a significant predictor of experimen- (ratings of pain intensity, pain unpleasantness, pain-re-
tal pain ratings in undergraduate males and females, and lated negative mood, pain coping, and recommending
that a significant proportion of sex differences in pain medical help) were significantly correlated. The mag-
report was accounted for by gender role expectations. nitude of the correlations ranged from 0.35 (pain coping
and recommending medical help) to 0.87 (pain intensity
Task duration for the current study was approximately and pain unpleasantness.) See Table 1 below.
one hour. Following the completion of the task, partic-
ipants were asked to respond, in writing, to a task valid- analysis of pain inTensiTy raTings
ity probe, in which they were asked to guess the study sEx EffEcts
hypotheses. Then, participants were briefed regarding Both male and female participants rated pain intensity
the variables of interest and the study hypotheses. for female VHs as significantly higher than that for

66 Sex and Race Differences in Rating Pain

Table 1
Correlations between the dependent variables

pain intensity pain pain-related pain coping recommending

unpleasantness negative mood medical help

pain intensity 1 – – – –

pain 0.87 1 – – –

pain-related 0.72 0.82 1 – –

negative mood

pain coping 0.68 0.75 0.71 1 –

recommending 0.53 0.51 0.42 0.35 1

medical help

male VHs, F (1, 73) = 4.92, p < 0.05. Both Caucasian racE EffEcts
and African American participants rated pain intensity There was no main effect of race of VHs on ratings of
for female VHs significantly higher than that for male pain intensity. Table 2 below summarizes the results of
VHs, F (1, 73) = 6.93, p < 0.05. the pain intensity ratings.

Table 2 analysis of pain unpleasanTness raTings

Means and standard deviations of pain intensity sEx EffEcts
ratings Both male and female participants rated pain unpleas-
antness for female VHs significantly higher than that
Vh pain intensity for 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 higher
than that for male VHs, F (1, 73) = 4.17, p < 0.05.
male 38.65* (14.54)
These results mirrored the pain intensity effects pre-
sented above.

female 41.14* (13.87) racE EffEcts

There was no main effect of race of VHs on ratings of
pain intensity. Table 3 below summarizes the results of
the pain unpleasantness ratings.
Caucasian 39.94 (13.98)
a nalysis of pain -r elaTed n egaTiVe
mood r aTings
african american 39.72 (14.45) sEx EffEcts
Both male and female participants rated pain-related
negative mood for female VHs as significantly higher
* < .05 significant difference between participants on
than that for male VHs, F (1, 73) = 6.76, p < 0.05. A
pain intensity ratings

Alqudah et al. 67

Table 3 Table 4
Means and standard deviations of pain unpleasantness Means and standard deviations of pain-related nega-
ratings tive mood ratings

Vh pain unpleasantness Vh negative mood

male 32.42* (15.17) male 37.87* (15.44)

female 44.77* (14.54) female 40.23* (15.11)

Caucasian 44.30 (14.28) Caucasian 39.84* (14.97)

african american 42.90 (15.27) african american 38.12* (16.02)

* < .05 significant difference between participants on * < .05 significant difference between participants on
pain unpleasantness ratings pain-related negative mood ratings

main effect was found for race of participants where race Effects
Caucasian participants’ ratings for both male and female Both Caucasian and African American participants
VHs pain-related negative mood (M=40.59, SE=1.84) viewed Caucasian VHs as coping more poorly with
were significantly higher than African American partic- their pain (M=34.47, SE=13.56) than African American
ipants’ ratings (M=31.75, SE=4.02), F (1, 73) = 3.99, p VHs (M=32.79, SE=14.07), F (1, 73) = 6.86, p < 0.05.
= 0.05. An interaction of the sex of the VHs by race of Table 5 below summarizes the results of the pain-cop-
participants was also found–Caucasian participants' rat- ing ratings.
ings for female VHs (M=42.17, SD=14.28) were signif-
icantly higher than African American participants' ratings Table 5
for female VHs (M=31.02, SD=16.16), F (1, 73) = 4.11, Means and standard deviations of pain-coping ratings
p < 0.05.
Vh Coping
racE EffEcts
Both Caucasian and African American participants
viewed Caucasian VHs as having significantly higher male 32.47* (13.63)
levels of pain-related negative mood (M=39.84,
SD=14.97) compared to African American VHs
female 34.76* (13.80)
(M=38.12, SD=16.02), F (1, 73) = 5.34, p < 0.05. Table
4 above summarizes the results of the pain-related neg-
ative mood ratings.
Caucasian 34.47* (13.56)
analysis of pain-Coping raTings
sEx EffEcts
Both male and female participants viewed female VHs african american 23.79* (13.07)
as coping more poorly than male VHs, F (1, 73) = 6.37,
p < 0.05. No significant main effect for sex of VHs on * < .05 significant difference between participants on
the race of participants was found. pain-coping ratings

68 Sex and Race Differences in Rating Pain

analysis of reCommending mediCal help raTings American participants’ ratings for female VHs were higher
sEx EffEcts than that for male VHs only on pain intensity and pain un-
A main effect for sex of VHs on sex of participants was pleasantness. Caucasian VHs were viewed as having
found. Both male and female participants’ ratings for rec- higher pain-related negative mood and as coping more
ommending medical help were significantly higher for fe- poorly with their pain than African American VHs.
male VHs than that for male VHs, F (1, 73) = 5.98, p < African American VHs’ pain intensity was rated higher
0.05. The sex of participants was also found as a main ef- only by African American participants. Ratings made by
fect, indicating that male participants’ ratings for recom- male participants tended to be higher than ratings made
mending medical help (M=52.86, SE=4.31) were by female participants.
significantly higher than female participants’ ratings
(M=42.50, SE=2.78), F (1, 73) = 4.02, p < 0.05. Race of disCussion
the participant did not have an effect on ratings of recom- Although pain levels–as expressed by the faces of the
mending medical help. VHs–were digitally controlled to be equivalent across dif-
ferent sexes and races, results indicated that participants
racE EffEcts of both sexes and races still viewed female VHs’ pain,
Male participants’ ratings for both Caucasian and African both the sensory (intensity) and affective (unpleasantness)
American VHs (M=52.86, SE=4.31) were significantly components, as significantly higher than that for male
higher than that of female participants (M=42.50, VHs. This is consistent with other research findings. In a
SE=2.78), F (1, 73) = 4.06, p < 0.05. Table 6 below sum- study of experimentally-induced pain, Robinson et al.
marizes the results of recommending medical help ratings. found that viewers rated females’ pain as higher than
males’. One explanation for why female VHs were viewed
Table 6 as having higher pain is the difference in pain expecta-
Means and standard deviations of recommending med- tions. Females are expected to report higher levels of pain
ical help ratings than males in general. Although willingness to report pain
and pain endurance (as measured by the GREP) did not
recommending correlate significantly with pain ratings in this study, a siz-
medical help able literature shows that both males and females expect
females to experience greater amounts of pain (Robinson
male 44.05* (21.16) et al., 2001; Unruh, 1996). Additional research is needed
to determine whether such expectations are also elicited
by computer-generated VH characters.
female 47.15* (20.94)
The International Association for the Study of Pain’s def-
inition of pain highlights the importance of understanding
Caucasian 45.80 (21.35) the emotional experiences of pain. It is important to note
the effects of negative mood accompanying pain. Al-
though all facial expressions of pain were digitally con-
african american 45.28 (20.71) trolled to be similar for males and females in this study,
female VHs’ pain-related negative mood was rated as sig-
* < .05 significant difference between participants on nificantly higher than that for male VHs’ by participants
recommending medical help ratings of both sexes. This result could be explained by the posi-
tive relationship between pain and negative mood and is
consistent with the findings of the National Health and
summary of resulTs Nutrition Examination Survey, where pain and depressive
In summary, male and female participants both rated fe- symptoms were more evident in females than in males
male VHs’ pain intensity, pain unpleasantness, pain-re- (Magni et al.,1990).
lated negative mood, and poorer pain coping, as higher
than male VHs. Male and female participants were also Caucasian VHs were rated by both African American and
more likely to recommend that female VHs seek medical Caucasian participants as experiencing greater pain-re-
help than male VHs. However, Caucasian and African lated negative moods. These results suggest that assess-

Alqudah et al. 69

ment of the pain-related negative mood is, at least, partly medical help showed significant intercorrelations. Rela-
determined by the race of the individual experiencing pain. tionships between these dependent variables have a pattern
Consistent with the pain-related negative mood results, that might add to the explanation of some of the current
participants of both sexes rated female VHs as coping results. For example, the high correlation between pain in-
more poorly with their pain, and participants of both races tensity, pain unpleasantness, pain-related negative mood,
rated Caucasian VHs as coping more poorlywith their and pain coping might add to the explanation of why fe-
pain. These results mirror those for pain-related negative male virtual videos were rated higher on all variables, if
mood, and suggest that when females and Caucasians are pain ratings influenced the other ratings.
viewed as having higher pain than males and African
Americans, respectively, they are also more likely to be The results of this study have several implications that are
viewed as experiencing higher levels of pain-related neg- worth noting. First, the use of computerized VHs with dig-
ative mood and poorer pain-related coping. itally controlled facial expressions of pain across sexes
and races is an innovative technique that enabled greater
When an individual’s pain level, pain-related negative standardization of pain expression than real humans would
mood, and maladaptive pain coping is rated as high, it is allow. This standardization allows for greater confidence
expected that he/she is more likely to be recommended to in interpreting the results as being determined by the sex
seek medical help for his/her pain. In this study, female and race biases that participants brought to the ratings.
VHs were rated higher on all these variables than male Furthermore, the VH technology used in this study has the
VHs. They were also recommended to seek medical help potential to be an educational assessment and intervention
for their pain significantly more often than male VHs. tool. Students, healthcare providers, and other individuals
However, it was not expected for male participants’ rec- can use this technology to assess their own biases in in-
ommendations to be higher than female participants’. terpreting pain or other emotions expressed by others. This
Male participants recommended that VHs of both sexes technology can also be accessible to almost anyone in the
and races should seek medical help for their pain signifi- world via the Internet.
cantly more than female participants. This is consistent
with studies showing sex differences in health-seeking be- This study did have some limitations, however. First, there
haviors. Males have been found to request more drugs was only one African American male participant in the
than females after surgery when given access to patient sample. Future investigations with more diverse samples
controlled analgesia (Macintyre & Jarvis, 1995). Burns, would be necessary to provide additional evidence of the
Hodsman, McLintock, Gillies, Kenny, & McArdle (1989) sex and race findings of the present study. Second, the par-
and Stinshoff, Lang, Berbaum, Lutgendorf, Logan & ticipants in this study were undergraduate students and it
Berbaum (2004) also found that males tend to seek more would be important to replicate these findings in other
medication for their pain compared to females. Based on populations. Finally, the VH characters only showed the
the current findings, it also appears that males are more head region and, thus, did not address the many other non-
likely to recommend that others seek care for their own verbal expressions of pain that are communicated through-
pain complaints. Several other interpretations are possible. out the entire body. Future work could examine whether
For example, perhaps males consider themselves to be less the sex and race effects observed herein are also found
equipped than females to help others with their medical when full body characters are used and other nonverbal
concerns. Males may also be less tolerant of expressions expressions are manipulated.
of distress from others, which results in them being more
likely than females to encourage that medical care be Acknowledgement
sought. These speculations could be investigated in future The present work was supported by grants from the Na-
studies. tional Institute of Dental and Craniofacial Research
(R01DE013208), National Institute of Neurological Dis-
The ratings of pain intensity, pain unpleasantness, pain- orders and Stroke (F31NS049675), and National Center
related negative mood, pain coping, and recommending for Rehabilitation Research (T32HD007424).

70 Sex and Race Differences in Rating Pain

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Journal of CyberTherapy & Rehabilitation 71
S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1
© Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

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 a
tool 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, of
different ethnicities and gender roles, which may allow them to better recognize characteristics of
male/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 explored
the benefits of using virtual worlds for educational applications.

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

inTroduCTion play an increasingly important part of our culture as a

Our future society is an age of knowledge and informa- whole.
tion. In this new period, entrenched stereotypes and prej-
udices may yield to a more balanced sense of social values Different societies reflect cultural values that vary, alter
based on rationality and dignity. This will be a direct result and evolve with given social, political and environmental
of empowering the individual, without the distinction of locations. Male and female gender roles, and the interac-
sexual, ethnic, or class discrimination. Talented individu- tion between the two, have long been a key determinant
als who may otherwise be stifled will have a better chance of social-cultural values. In other words, expectations of
to be realize their own potential and become socially rec- male and female behavior are set according to gender dif-
ognized. ferences and variance. However, such expectant interpre-
tive analysis is within accordance to age modification
Jonassen et al. (1999) argues that technologies can be ap- variants. A gender role is set within a particular social, po-
plications of human knowledge to solve real-world prob- litical, and environmental context shared between male
lems. Such technological tools can support human needs and female subjects. However, such expectant interpretive
and expand the individual’s functional capacities. This analysis is within accordance to age modification variants.
knowledge can be constructive, aid in informational re- This is social science and humanity’s framework for the
source management, and requires producing communica- desired analysis. Gender is the primary component of the
tion connectivity. In the same context, Second Life is a gender system in human society, which refers to the set of
social virtual environment tool and new media for explor- arrangements by which a society transforms biological
ing communication environments may improve mutual sexuality into products of human activity, and in which
understanding between men and women concerning gen- these transformed needs are satisfied (Reiter, 1975).
der roles. Virtual worlds continue to grow as a significant
component of many children’s and adults’ leisure time. Thorne (1999) classified four kinds of meaning for gender
They are being used in education worldwide, and they playing. 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:

Kyonggi University, Republic of Korea, San 94-6 Iui-dong, Paldal-gu, Suwon-si, Gyeonggi-do, 443-760, Republic of Korea
72 Communication in Virtual Worlds

is community activity through role playing with gender sense. However, through continued participation, the user
classifications, gender identities, and gender areas. He ar- transitions from feeling like an outsider or a viewer into
gued that gender role playing is an important activity to an active “resident” who is “living” in the virtual world,
understand one's own gender identity and to understand performing social positions and role play.
the opposite gender role. It has been determined that gen-
der roles are decided by social and cultural factors more The purpose of this study is to explore the possibilities of-
than biological factors. This makes online communities fered by virtual worlds such as Second Life as a tool for
an interesting site to explore how gender is perceived in understanding gender roles. Virtual worlds have many
virtual spaces. The online player community serves the uses for testing users’ experiences about and understand-
function of interaction and socialization for many players, ing of other people, recognition of gender roles, and how
and one virtual world in particular, is the so-called Second their experiences in these virtual worlds may change the
Life. This Second Life is rich in scenery with players in- way they think about men and women. Through these ac-
teracting with other characters through text-based chat, tivities, we believe that users will develop positive values
virtual environment and social activities. concerning gender identification and respect for other peo-
ple. At the same time, we can explore the broader possi-
Virtual Reality (VR) is an emerging computer interface bilities of using virtual worlds for education.
that strives to make simulations believable and realistic.
Highly realistic and believable simulations are accom- seCond life as a CommuniCaTion enVironmenT To
plished using high-speed supercomputers and three-di- undersTand opposiTe gender roles
mensional graphic accelerators (Ken & Teixeira, 1995). All societies and cultures have unique expectations and
The important distinguishing features of VR is that it is rules about men and women. Because of sociocultural fac-
highly immersive, interactive, colorful and visually ori- tors, the performance of gender roles has a tremendous in-
ented, fun and generally exciting. VR technology is in- fluence on an individual's life. Gender roles are
creasingly being recognized as a potential tool for the internalized through the socialization process, many times
assessment and rehabilitation of cognitive and functional unconsciously. Gender roles also determine many social
processes in humans (Foreman et al, 1997; Pugnetti et al, expectations of men and women, such as family and oc-
1995; Rizzo & Buckwalter, 1997; Rose, 1996). Virtual en- cupation roles, political roles, self-efficacy, and psycho-
vironments (VE) allow the creation of dynamic stimulus logical factors. As social customs have changed,
environments in which all responding behaviors can ver- present-day gender roles require a deeper understanding
ifiably be recorded. Such advanced technology could po- about men and women. In modern times, the meaning of
tentially offer testing and training options that are gender roles has been shown to be far more independent
unavailable with the use of conventional neuropsycholog- of physiological and anatomical differences than previ-
ical methods. It is proposed that computer-generated in- ously believed. This permits individuals to utilize interac-
teractive simulated environments can be used to assess tive social technology within a controlled environment to
and rehabilitate cognitive abilities, much like an aircraft explore the complicated patterns of behavior that modern
simulator tests and trains piloting abilities. society has adapted in response to both men and women’s
traditional gender roles.
Second Life is a social virtual environment entirely built
and owned by its residents. Since opening to the public in According to psychologists (Chodorow, 1978; Dinnerstein,
2003, it has grown explosively, and today over 12 million 1977; Johnson, 1988), gender identity results from distin-
unique accounts have been created world-wide (Sec- guishing gender identity differences between males and fe-, 2008). Second Life has the capacity to con- males since birth. Also, Whiting and Edward (1988) stated
tain game content, but it is not a game, rather, it is a social that gender identity is a result of biological difference.
virtual world within itself. It is also a representation of the
first generation of this type of free open source technology. Nood and Attema (2006) said that Second Life is a VE
Unlike games, it is a VE without a back story and educa- where one can interact with the environment, made up of
tors. Also, users have the opportunity to write their own a realistic graphic representation of our physical world.
narratives in a social virtual world. Through the willing The first thing a new visitor sees is a modifiable puppet,
suspension of disbelief, users initially enter the virtual called an "avatar" that enables the user to move through
world and experience it as visually appealing in a passive the virtual world. With this avatar, the user can fly, tele-

Park 73

port, or walk to practically any place within Second Life. researCh meThods
Moreover, the user can meet others, create objects, go to researCh QuesTions
parties, buy kitchens, and, through the introduction of For this research, we had to consider the following ques-
commerce, earn money in a currency called the "Linden tions:
Dollar"(L$), and perform many other activities. -Do virtual worlds provide a learning environment for role
playing to understand the opposite gender?
Virtual worlds can supplement education, modeling ideas -Do users change their recognition of gender roles via vir-
that are abstract and making them interesting, relevant, tual worlds?
and concrete (Williamson & Facer, 2004). Virtual worlds The research questions are formed to reflect the main ob-
might also provide safe places where children can interact jectives of this research and they are statistically tested in
and socialize, without worrying about unknown dangers this study.
in an educational context (Alvarez, 2006). However, they
still include some physical dangers, predator behavior, re- parTiCipanTs of The sTudy
sulting negative emotions and so on. Another main appeal The sample for this study was drawn from university stu-
of Second Life is that new activities can be tried in an al- dents consisting of one hundred twenty female students in
most risk-free environment. This can encourage experi- the author's three classes titled, "Instruction Method and
mentation in a way that is not possible in the real world. Technology." The the sample consisted of thirty partici-
There can be some very real, human aspects to this, such pants. Most of the students are women, with just three
as people with social disorders practicing talking to others male students. The men were excluded in this research to
behind the safety of a computer screen (Johnson, 2007). avoid biases. The students’ ages ranged from 21-23 years
We need to change our teaching methods to enhance the old. Participants did not meet prior to the experiment to
skills that future citizens will need in a digital society. avoid the possibility of any first impressions influencing
Children and young people are introduced to virtual their thoughts on gender in the conversation of the virtual
worlds via video games, and the ways that they interact world. The experiment took place for twelve weeks to give
with technology may change methods of learning, and the participants ample opportunity to develop an awareness
accumulation of knowledge (Gros, 2007). of gender roles in the virtual environment.

At the same time, Garau (2003) commented about the role design
of virtual worlds that recent works of cyber fiction have The study took place at the school of the participants. The
depicted, in a not-so-distant future where the Internet has instructional interventions were divided into three main
developed into a fully three-dimensional and immersive phases–pre-testing, treatment, and post-testing. Treat-
data-scope, simultaneously accessible by millions of net- ments were carried out over three months based on the
work users. This virtual world is described as having spa- 3rd-4th grade female students since a pre-service teacher
tial properties similar to the physical world and its virtual was taking "Instruction method and Technology" at the
cities are populated by digital proxies of people. university. Participants experienced their gender role for
two hours per day in a controlled environment within Sec-
Slater et al. (2000) argues that practical applications of VR ond Life. Assessment methods were the same for all stu-
are normally in the realms of engineering, product design, dents who participated in the three groups. The first group
and skill rehearsal. Users can enter into a VE such as Sec- served as a control group, performing a female gender role
ond Life in order to learn something new about a real sit- in the real world. The other groups performed in the virtual
uation, to which the simulation corresponds, or to improve world of Second life as male and female roles, respec-
or learn a new skill. Participants can create their avatar tively. Gender roles were set as dependent variables. In
and explore, meet other people, own land, play games or order to answer the research questions, we calculated
sports, have discussions, dance, create, run a business, en- ANOVA to examine the statistical effect.
hance their education and so on, through a VR such as
Second Life. Users can perform actions in real life as well researCh proCedure and aCTiViTy
as something that is impossible in real life. In fact, the cul- During the sessions, four experimental tasks were em-
ture in Second Life is characterized by its combination of ployed in order to evaluate the degree of gender role ex-
real actions as well as virtual life representations and ac- perienced by the participants as they engaged in the virtual
tivities. world of Second Life. The Second Life allows a user to

74 Communication in Virtual Worlds

select their personalized avatar, either male or female, 2007). The test is comprised of 30 item adaptations of
when the account was created for the study. Also, partici- Bem’s original inventory designed to investigate mas-
pants engaged in discussions related to social topics such culinity and femininity as independent dimensions of
as gender equality, and employment of males and females. sex role identity. Respondents are asked to rate them-
They also visited the male "places" in second life during selves as to how well ten stereotypically masculine ad-
the session as cyber characters. The sessions consisted of jectives, ten stereotypically feminine adjectives and ten
two hours a day for three months. neutral adjectives describe themselves. In this study, we
used the masculinity and femininity items. Respondents
Grouping according to random assignment were also asked to specify ratings on a 5-point scale,
↓ with 1 meaning "never" to 5 meaning "always." Scores
Pre-test on the Learner’s BSRISF on the BSRISF are purported to measure the respon-
↓ dents’ degree of masculine and feminine identification
Activity in Second Life via interaction with other people (Singh & Agrawal, 2007).
related on discussion and visiting the land
↓ resulTs
Reflection activity via reflection paper about opposite Table 1 and Table 2 summarize the overall ANOVA re-
gender sults for each of the three group’s pre-test analyses, list-
↓ ing the response variable, explanatory variables with
Post-test on the Learner’s BSRISF p-values, the means value and standard deviation for
each group’s analysis. As you can see in the ANOVA
Figure 2. Fig 1. Research Procedure Table 1 and Table 2, between the groups there is no sig-
nificant difference for masculine adjectives (F=.115,
insTrumenT p>.05) and feminine adjectives (F=.050, p>.05). In other
The questionnaire was based on the adults Bem Sex words, participants had the same group for masculine
Role Inventory Short Form (BSRISF) by Bem (1981, adjectives and feminine adjectives.

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

Measure Women-Women Women-Women Women-Men

(Real World) n=30 (Virtual World) n=30 (Virtual World) n=26

M 4.58 4.51 4.49

SD .75 .73 .72

M 4.82 4.80 4.76

SD .60 .76 .72

As you can see in Tables 3 and 4, differences between the mean square of masculine adjectives (M=5.18) compared
groups did occur. According to results, studying the recog- to the pre-test mean square (M=4.49). Also, there were
nition of gender roles shows that virtual worlds offer a mu- significant differences within masculine adjectives via the
tual understanding via the ability to choose other gender mean square (F=6.320, p=0.003). At the same time, pre-
roles for their avatar. In this way, we can recognize the im- feminine adjectives of this group decreased after experi-
portance and potential of virtual worlds such as Second encing activities in the virtual world as a male avatar
Life. After the experimental session, groups which chose (M=3.89). As shown in Table 4, there were differences be-
a male avatar in the virtual world increased their post-test tween the groups.

Park 75

Table 2
Analysis of variance

measure ss df Ms f p

Between Group .123 2 .062 .115 .892

Adjectives Within Group 44.674 83 .538

Total 44.798 85

Between Group .048 2 .024 .050 .951

Adjectives Within Group 40.028 83 .482

Total 40.077 85

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

Measure Women-Women Women-Women Women-Men

(Real-Real) n=30 (Real-Virtual) n=30 (Real-Virtual) n=26

M 4.57 4.47 5.18

SD .68 .89 .82

M 4.51 4.58 3.89

SD .65 .81 1.00

Table 4
Analysis of variance

measure ss df Ms f p

Between Group 8.039 2 4.019 6.320 .003

Adjectives Within Group 52.786 83 .636

Total 60.825 85

Between Group 7.830 2 3.915 5.773 .004

Adjectives Within Group 56.286 83 .678

Total 64.115 85

76 Communication in Virtual Worlds

Enforced post multiple comparisons were calculated using

Tukey methods to determine whether differences which
were kept in mind between any groups were concrete. As
a result, there were differences between the groups which
had chosen other gender roles in the virtual world than
their own, such as women choosing male avatars. As
shown 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 in
the virtual world significantly increased. On the other
hand, feminine adjectives decreased.

Figure 1. Masculine adjectives’ change In general, the results of this study show that VR inter-
actions can be an important factor in developing a mutual
understanding of gender roles. Through activities in vir-
tual worlds, especially through role-playing in a gender
role other than one’s own, individuals can develop a
deeper understanding of the special characteristics and
advantages of their own gender, as well as increase
recognition 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 the
opposite gender.

In recent years, there has been a rapid increase in the ca-
pability of VR technology. VR technology has been
Figure 2. Feminine adjectives’ change widely promoted as a major technological advancement

Group (real World-Virtual World) Women-Women Women-Men

Masculine *
* **
Feminine *
* **
Result of post hoc multiple comparisons by Tukey

Park 77

that can offer significant support for education. There are The analytical statistical results of this study indicate that
several ways in which VR technology is expected to fa- virtual world environments offer the possibility of a clear
cilitate learning. One of its unique capabilities is the ability understanding of gender roles and their placement and
to allow students to visit environments and to interact in functionality within the context of a social environment.
events that real-life distance, time, or safety factors make This in itself further provides opportune foundational cri-
unavailable. The type of activities supported by this capa- teria for such information to become the building blocks
bility facilitate current educational thinking that students of further educational processing analyses. This research
are better able to master, retain, and generalize new knowl- analysis provides concrete and useful data pertaining to
edge when they are actively involved in constructing the functionality of gender roles' impact and variation
knowledge through learning by doing. when it comes to formal educational values, strategies,
methods, measurable results and treatments. This research
Learners are represented in the virtual world by their char- provides a measure of gender recognition, and shows that
acters, called an “avatar.” In graphic-based virtual world such target placement can be variable with a users’ variant
environments, like Second Life, it is possible for a user to activity experience within the context of a virtual world
choose an avatar that is the opposite gender from their real in an educational context. Furthermore, it demonstrates
life gender. Thus, this opens up many possibilities for re- the capability and capacity for educational virtual worlds
search and exploration. Indeed, the way gender shapes to be accurate means of promoting practical and theoreti-
basic human interaction in virtual worlds is often noticed cal data which is key to understanding the time-worn, in-
and reflected upon, and has been studied in game-based finite complexities of male/female social relations and
virtual worlds. According to Svatos (2007), during game educational placement within a given social context.
play a user’s character gains experience points through ac-
tivities he or she does in the virtual world, and these ex- This study has the limitation that can also reflect the char-
perience points drive the character’s evolution and acteristics of gender role in the real world–during the ses-
external form. Though Second Life is not a game, there sion, females in the real world had to have a male or
are many similarities between these virtual worlds and female avatar in a virtual world such as Second Life. To
video games, just as a video game character gains “expe- reduce this point, we explained to the participants that they
rience” that changes their avatar’s evolution and form. It had to focus on understanding the opposite gender. Also,
may be possible for learners to gain “experiences” about given the topic for discussion, they had to come up with a
gender in virtual worlds in ways that can change their per- solution through rational decision making and positive
ceptions of gender in the real world. thinking activities during the session.

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IN THIS FEATURE, we will try to describe the char- TelepresenCe and more
acteristics of current cyberpsychology and rehabilitation Working in the EU-funded TA2 (Together anywhere, to-
research. In particular, CyberProjects aims at describing gether anytime) project, Färber and a team of researchers
the leading research groups and projects, actually run- from seven European countries are aiming to turn the ta-
ning around the world, with a special focus on European bles on technology by simply and affordably bringing
research. telepresence into normal households. Their vision con-
sists of groups of friends and family members seeing
geTTing families and friends each other on their TVs, hearing each other through their
TogeTher again–VirTually stereo systems, sharing photos and videos and playing
games almost as naturally as if they were in the same
A fireside chat, sharing photos with granddad, a family room.
get-together to play Monopoly on a Sunday afternoon…
Digital media designed for the individual has hastened “My brother lives in Switzerland and we have kids about
the demise of collective social events, but it could also the same age, but they only get to see each other twice a
enable their revival. year. With the system we are developing they would be
able to play together whenever they wanted to without
By marrying state-of-the-art video and audio communi- having to leave their homes,” Färber notes.
cations technology with digital media, interactive de-
vices and ambient intelligence, a team of European To make that possible, the TA2 researchers are develop-
researchers hopes to give people of all ages the opportu- ing the components necessary to build an affordable and
nity to get together, play games, share experiences and easy to install in-home telepresence system. The compo-
generally communicate, interact and have fun together, nents can then be used to build complete telepresence
even if they are thousands of kilometers apart. Their goal systems without the need for special rooms or big
is to break down the barriers between people – techno- screens to bring people together virtually. A television
logical and social. set, sound system, cameras and microphones placed in a
living room suffice to create a sufficiently interactive and
“E-mail, the Internet, cellphones, Internet video calls… immersive experience, while state-of-the-art software,
they are all designed for one person using one machine. which is transparent to the end user, manages the com-
They are not designed to support families or groups of munications backbone.
people communicating,” suggests Nikolaus Färber, a re-
searcher at the Fraunhofer Institute for Integrated Cir- “Audio and video quality is of essence… it needs to be
cuits IIS in Germany. “People have become isolated by sharp and responsive,” Färber says. “At the same time,
technology,” he adds. TA2 is aware that high audiovisual quality is not the only
thing that matters. Applications like games, photo shar-
Coupled with people moving and traveling more fre- ing, or virtual pin boards are necessary to frame and trig-
quently for work and study, it is a situation that has led ger the communication.”
families and friends to spend less time together. Even in
the same home many people now tend to entertain and Fraunhofer IIS has developed an Audio Communication
educate themselves alone, whether it is the teenager play- Engine to provide low-delay, hi-fi quality sound that
ing computer games in her room, the father listening to vastly improves upon current shaky and echo-prone In-
music on his MP3 player in the lounge or the mother ternet calls. Other project partners, among them Philips,
studying on her laptop in the kitchen. Technology has BT and Alcatel-Lucent, are working on enhancing video
encouraged this isolation, but advances in that same tech- communications, linking interactive devices together and
nology could now reverse this trend. implementing ambient intelligence.

84 CyberProjects

Two or more families playing a board game, for exam- were playing with each other as if they were really to-
ple, would be able to see and hear each other over their gether in the same room… Many people were interested
TV sets, with artificial intelligence used to focus in-home in the system, particularly those with families and friends
cameras on the person speaking or whoever's turn it is. in different parts of the world,” notes Matthias Rose, the
A touch screen embedded in a table might serve as a head of marketing communications for audio and multi-
board game interface, while ambient intelligence from media at Fraunhofer IIS.
in-home sensors will let the system and other players
know where participants are and what they are doing. Fraunhofer is already working on integrating its audio
technology into commercial products, and commercial
“Ambient intelligence could also improve communica- applications are also likely to stem from other areas of
tions by letting friends and family know when someone research in the TA2 project, which is being funded by
is available for a call or if they are busy, depending of the EU’s Seventh Framework Programme.
course on how much information the person wants to dis-
close,” Färber says. “Obviously, once the project ends, it would be interesting
to find investors and partners to create a commercial
Children and the elderly, who often find themselves more product out of the whole system that would allow every-
isolated than other social groups in the modern world, one to incorporate telepresence into their homes and
could particularly benefit from the technology. One sce- bring families and friends closer together,” Färber says.
nario, which will be used as a demonstration to highlight
the project results, envisions a grandparent and grand-
child playing a picture-matching game called "pairs" in For more information visit
which old photos could be used to trigger conversations
and pass stories down through generations.
Compiled by Giuseppe Riva, Ph.D. and
“At IFA in Berlin (the world’s largest consumer electron- Simona Raspelli, Ph.D.
ics fair) we set up a demonstration consisting of two Istituto Auxologico Italiano
rooms, two TV screens and two tables with integrated Data provided by ICT Results
touch screens on which people could play games. People (



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 send
an e-mail to:

Cyberpsychology & CyberTherapy 15

June 13 - 15, 2010
Seoul, Korea

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 funding
agencies 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 have
the opportunity to play a role in designing the future of mental healthcare. CT15 features interactive exhibits at the
Cyberarium allowing participants to experience the technologies firsthand as well as the opportunity to display their
exhibits in a forum-type setting.

2010 Conferences

raVe 2010 - real actions in Virtual environments

March 3
Barcelona, Spain


The World of health iT Conference & exhibition

March 15 - 18
Barcelona, Spain


ieee Vr 2010
March 20 - 24
Waltham, Massachusetts, USA



applied psychophysiology & biofeedback 2010

March 24 - 27
San Diego, California, USA


2010 haptics symposium

March 25-26, 2010
Boston, Massachusetts, USA


spie defense, security, and sensing

April 5 - 9
Orlando, Florida, USA


society of behavioral medicine: 2010

April 7 - 10
Seattle, WA


laval Virtual 2010: 12th Virtual reality international Conference

April 7 - 11
Laval, France


The 7th annual World health Care Congress

April 12 - 14
Washington D.C., USA


April 14 - 16



19th international World Wide Web Conference: WWW2010

April 26 - 30
Raleigh, North Carolina, USA


human systems interaction Conference

May 13-15


american Telemedicine association 2010: 15th annual international meeting and exposition
May 16 - 18
San Antonio, Texas, USA


The 6th annual World health Care Congress – europe

May 19 - 20
Brussels, Belgium


The xii symposium on Virtual and augmented reality – sVr 2010

May 24 - 27
Rio Grande Do Norte, Brazil


WCbCT 2010-World Congress of behavioral and Cognitive Therapies

June 2 - 5
Boston, Massachusetts, USA


Cyberpsychology & CyberTherapy 15

June 13 - 15
Seoul, Korea



siggraph 2010
July 25 - 29
Los Angeles, California, USA


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

July 28 - 30
Baltimore, Maryland, USA


2010 american psychological association Conference

August 12 - 15
San Diego, California, USA


8th iCdVraT with artabilitation

August 31 - September 2
Valparaiso, Chile


The 5th international Conference on interactive mobile and Computer aided learning
September 16 - 17
Hasselt University, Belgium


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

September 20 -22
Philadelphia, Pennsylvania, USA


40th european association for behavioural and Cognitive Therapies annual Conference
October 7 - 10
Milan, Italy



association for behavioral and Cognitive Therapies (abCT 2010)

November 18 - 21
San Francisco, California, USA

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Ning Network
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joining the discussion between eminent experts in the field today.
Plus get access to the official journal and official voice of the
association, the Journal of CyberTherapy & Rehabilitation and
CyberTherapy & Rehabilitation Magazine!


receive discounted membership to affiliated
conferences, associations and societies


facilitate important dialogue about transforming
health care through technology for free


be updated on the latest news and events

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ConTinuing eduCaTion Quiz

Prepared by Alessandra Gorini, Ph.D.

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.
1. Olfactory sense has been considered of minor inter- relays before reaching the limbic system
est in VR applications because: d) none of the above
a)the incorporation of olfaction stimuli in the VR expe-
rience would not enhance it 5. Which of the following cerebral structures are in-
b)the odor perceived by each subject is highly subjec- volved in the olfactory system:
tive, and thus, generalization involving one particular a) the olfactory bulb
odorant is likely to be difficult b) the amygdala
c)due to their complex composition and transient char- c) the orbitrofrontal cortex
acter, controlled exposure to olfactory stimuli is more d) all of the above
complex than that to visual or acoustic stimuli
d)all of the above 6. Compared to other animals, humans:
a) have a poor ability to localize the source of an odor-
2. Up to date, the rare VR applications that include ant
some forms of olfaction stimulation regard: b) have an olfactory acuity inferior to that of most ani-
a) the treatment of specific phobias mal species
b) the treatment of eating disorders c) use olfaction for socialization
c) drug addiction research d) none of the above
d) the treatment of psychotic disorders
7. In order to be effective, the presentation of an odor
3. When exposed to multi-sensory alcohol related cues in a virtual environment should be:
presented in virtual environments, individuals with al- a) provided using many remote sources to release the
cohol use disorders: olfactory cues
a) increase their level of presence b) supported by a visual cue related to the odor
b) become more relaxed c) randomly provided
c) report significantly higher cravings for alcohol than d) none of the above
non-binge drinkers
d) both A and C 8. In a VR experience including odor stimulation:
a) the hedonicity of an odor contributes to the determi-
4. One of the differences between the olfactory system nation of its intended virtual source
and the other senses is that: b) the level of familiarity leads to a more rapid associa-
a) the olfactory bulb projects without being mediated tion with the cues presented via other modalities
by the thalamus onto the amygdala c) varying odorant intensities may be useful in cueing
b) the olfactory bulb projects crossed onto the amyg- the user about the position, and rate of position change,
dala relative to the intended virtual source of that odor
c) the olfactory bulb goes through a series of cortical d) all of the above


9. The presence of an odorant in the environment can 11. Clinical scenarios for treating PTSD utilize odors to:
be associated with: a) make the virtual experience more fascinating
a) positive affects and increased arousal, if the odor is b) make the experience more realistic
pleasant c) facilitate the processing of traumatic memories
b) an alteration in the level of pain perceived by an in- d) none of the above
c) negative affects and decreased arousal if the odor is 12. In training scenarios, olfactory stimulation could
unpleasant be useful to:
d) the pleasantness of the experience a) trigger appropriate responses to emergency situa-
10. Contrary to congenitally blind, mute or deaf peo- b) establish an association between a distinct odorant
ple, individuals with congenital anosmia: and “virtually-evoked” positive emotions
a) experience less pain c) enhance the virtual experience
b) are more prone to illness d) all of the above
c) do not have intact reproductive–social behavior
d) all of the above

ConTinuing eduCaTion CrediTs • If you wish to receive a receipt of payment or a copy

To qualify for CE credits, readers will need to do the of the correct quiz answer, please include a self-ad-
following: dressed, stamped envelope.
• After reading an article, answer the questions above. • The fee is $20 for iACToR members or subscribers and
• Send the completed answer sheet, along with pay- $40 for non-subscribers.
ment, to Interactive Media Institute, 6155 Corner- • All CE exams are open-book.
stone Court East, Suite 210 San Diego, CA 92121, • Credits assigned are based on the length of time re-
U.S.A. quired to read each article.

JCR The Journal of
& Rehabilitation

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The Journal of CyberTherapy & Re ha bilitation (JCR) is the official journal of the
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Its m ission is to explore the uses of adva nced tech nolog ies for ed ucation, tra i n i ng,
prevention, thera py, a nd reha bil itation .

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